A nationwide survey on knowledge, attitude, and practice regarding human papillomavirus (HPV), HPV-related disease, and HPV vaccine among adolescents and their parents in China

ABSTRACT

Although human papillomavirus (HPV) infection constitutes a significant public health challenge, the HPV vaccination coverage remains suboptimal in China. Recent roll-out of new policies calls for an updated evaluation on the knowledge, attitude, and practice on HPV and HPV vaccination among adolescents and their parents. This nationwide cross-sectional survey targeted adolescents aged 9–17 y paired with one of their parents. Sociodemographic factors and the awareness, knowledge, attitude, practice and willingness toward HPV and HPV vaccination were collected for adolescents and their parents. Univariable and multivariable regression analyses were conducted to evaluate the factors associated with the knowledge, attitude, and practice of adolescents and their parents. A total of 1,000 pairs of adolescents and their parents were included. Awareness of HPV and HPV vaccine was 34.2% and 43.9% among adolescents, and 61.0% and 68.0% among parents. Although 77.0% of the adolescents and 78.2% of the parents believed in the benefits of HPV vaccine on adolescents, the vaccination rate remained low among adolescents (7.4%). The willingness toward HPV vaccination was significantly higher among the unvaccinated adolescents whose parents acknowledged the risk of HPV infection on themselves or communicated with their children about reproductive health. The findings underscored critical gaps in knowledge, attitude, and practice toward HPV and HPV vaccination among Chinese adolescents and their parents. To address these challenges, family-oriented, school-based and physician-led educational initiatives, enhancement of the accessibility and convenience of HPV vaccination, expansion of HPV vaccine indications, and evidence to support its inclusion in the National Immunization Program are needed.

Plain Language Summary

Human papillomavirus (HPV) is a very common virus that can cause several cancers and other diseases in both women and men. Vaccination during adolescence, especially before sexual activity begins, is one of the most effective ways to prevent HPV-related diseases. However, HPV vaccination coverage among adolescents in China remains low. This study surveyed 1,000 pairs of adolescents aged 9–17 y and one of their parents from across China to understand their knowledge, attitudes, and behaviors related to HPV and HPV vaccination. We found that awareness of HPV and the HPV vaccine was limited, particularly among adolescents. While most adolescents and parents believed that the HPV vaccine is beneficial, only a small proportion of adolescents had actually received the vaccine. Importantly, parents played a key role in adolescents’ willingness to be vaccinated. Adolescents were more likely to want the HPV vaccine if their parents understood the health risks of HPV, discussed reproductive health topics with them, or recognized the benefits of vaccination. Concerns about vaccine safety and limited access were common reasons for not getting vaccinated. These findings highlight the need for family-based education programs that target both adolescents and parents, improve understanding of HPV and vaccine safety, encourage open family communication and physician engagement in education initiatives, and provide evidence supporting the inclusion of HPV vaccination in the national immunization program, which may increase uptake and reduce HPV-related diseases in the future.

Introduction

Human papillomavirus (HPV) infection constitutes a significant public health challenge in China, with high-risk strains contributing to approximately 150,700 cervical cancer cases and 55,700 deaths in 2022.¹ Additionally, HPV is associated with increasing incidences of anal, oropharyngeal, and genital cancers.^2–4 Globally, HPV vaccination initiatives commenced in 2006 with the introduction of the quadrivalent vaccine, aiming to curb cervical cancer and other HPV-related diseases. Since 2016, HPV vaccine has been approved in China for females aged 9–25 y later expanding to females aged 9–45 y in 2020. Presently, seven HPV vaccines are available in China, including Gardasil® and Gardasil-9®, which have recently received approval for use in males aged 9 to 26 y and 16 to 26 y, respectively. This approval represents a significant public health advancement in China by providing protection to both genders against certain HPV-related cancers and diseases.

Adolescents are a priority group for HPV vaccination as immunization prior to sexual debut significantly enhances vaccine effectiveness.⁵ However, national vaccination coverage is suboptimal, with only 4.0% of adolescent girls aged 9–14 y and 4.7% of girls aged 15–19 y received at least one dose of HPV vaccine in 2022, lagging behind high-income countries like the United States, where 65.5% of adolescents had received at least one dose of HPV vaccine by 2017.^6,7 As a voluntary health behavior, the successful uptake of HPV vaccine largely depends on adolescents’ knowledge and attitudes toward HPV and HPV vaccine.⁸ Besides, adolescents’ decision-making of HPV vaccination is expected to be largely affected by their parents, thus parental knowledge, attitude, and practice (KAP) toward HPV and HPV vaccination should also receive great attention.

Previous studies conducted in Chinese mainland predominantly focused on distinct parent or adolescent cohorts.^5,9,10 Nonetheless, the comprehensive association between parental factors and adolescents’ KAP cannot be precisely captured through a single cohort study, whereas the dyadic information collected from parent–child pairs is warranted for a thorough investigation of this critical association. Moreover, the roll-out of new policies in recent years may have shifted the KAP toward HPV and HPV vaccine for adolescents and parents. For instance, in alignment with the Action Plan for Accelerated Elimination of Cervical Cancer, which aims for 90% HPV vaccination coverage for 15-y-old girls by 2030,^11,12 government-funded HPV vaccination programs have been implemented for school-aged girls in several provinces since 2022 in China¹³ and Chinese government just announced the HPV vaccine would be introduced into National Immunization Program (NIP) in Chinese mainland in 2025. Understanding the current KAP among adolescents and their parents is crucial for the rollout of this public health initiative.

Thus, we conducted a nationwide survey to assess the current status of KAP toward HPV, HPV-related diseases, and HPV vaccine among pairs of adolescents aged 9–17 y and their parents. Besides, the study further explored factors associated with their KAP, especially the influence of parental factors on adolescent KAP. Findings in this study will provide evidence of current HPV vaccination status in China for healthcare practitioners and decision makers, as well as generate insights in directing future HPV vaccine-related interventions to ultimately improve HPV vaccine coverage in this prioritized target group.

Materials and methods

Study design and settings

This nationwide cross-sectional survey targeted adolescents aged 9–17 y paired with one of their parents. A multi-stage non-randomized sampling method was applied in this study, starting with the stratification of sample quota by the seven administrative regions, including northern, eastern, northeastern, central, southern, southwestern and northwestern China, based on the 2020 National Statistics population distribution.¹⁴ In each administrative region, one urban and one rural area were randomly selected, and sample quota was allocated according to the urban-to-rural population ratio of the region. Within each area, the sample quota for adolescents was equally stratified by sex, then evenly divided into three age groups, including 9–12, 13–15, and 16–17 y.

Ethics statement

This study received approval from the Institutional Review Board of the National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College (ID: 23/343–4085) and adhered to the principles outlined in the Declaration of Helsinki. Informed consent was obtained from each participant and parent(s) before the survey began.

Questionnaire

In this study, two sets of self-administered structured questionnaires were designed based on the Health Belief Model and the Behavioral Risk Factor Surveillance System questionnaire, one intended for adolescents and the other for their parents.^15,16 The draft questionnaires were first reviewed and revised through two rounds of expert consultation meetings. The questionnaires then underwent testing through interviews with two Key Opinion Leaders (KOLs), followed by four cognitive interviews with two adolescents and their parents to ensure readability and comprehensibility. After adjusting the content and wording based on the feedback from these interviews, the questionnaires were finalized and then digitalized for completion on electronic devices. The survey was administered using electronic devices provided by the study team, and participants completed the questionnaires on site. The questionnaire for adolescents consisted of five domains: (1) socio-demographic information; (2) knowledge and awareness about HPV and HPV-related disease; (3) knowledge and awareness about HPV vaccine; (4) attitude, willingness and practice toward HPV vaccination; (5) communication about reproductive health between adolescents and their parents. Apart from these domains, three additional domains were included in the adolescent parent questionnaire, including: (6) health management of parents and adolescents; (7) practice toward HPV-related disease; and (8) parental attitude, willingness and practice toward HPV vaccination of their adolescent children. In addition, there was a question “Please select the ‘Wrong’ answer to this question” for quality control purposes.

Data collection

The survey was conducted between July and August 2024. Adolescents and one of their parents were recruited in pairs at the same time. The recruitment took place at multiple sites where a large number of pedestrians could be approached, such as shopping malls, residential areas, and parks in urban areas, and pedestrian main streets and village community squares in rural areas. For pairs of adolescents and parents willing to participate, parents were asked to first sign the informed consent, then complete the screening questionnaire (Supplementary Table S1). Informed consents were then collected from adolescents and their parent(s) who agreed to participant into the study. Subsequently, adolescents and their parents were asked to complete the questionnaire independently to prevent any influence or interference from communication between them. The appropriate ranges and choices for each question, as well as internal logic across questions, were pre-specified during questionnaire design and digitization. The questionnaire also included a quality control question, and failure in it triggered an early termination of the questionnaire. Completed questionnaires were checked for omissions and logical errors including free text, and follow-up calls were made to address any data issues found.

Data analysis

Knowledge scores for HPV and HPV-related diseases, and HPV vaccine were calculated separately. The scoring system awarded one point for each single-answer question and three points for each multiple-answer question. For single-answer questions, participants received one point for each correct answer and no points for incorrect answers or if they selected “I do not know.” For multiple-answer questions, each option was treated as a true/false question, with the score for each option calculated as three points divided by the total number of options, excluding “I do not know.” Points were awarded for each correct answer, either by selecting the correct option or by not selecting the incorrect option. No points were given if the participant selected “I do not know.” The total scores were then calculated by summing the points from contributing questions. These scores were described using mean, standard deviation (SD), interquartile range, median, minimum, and maximum.

Categorical variables, including awareness of HPV and HPV vaccine, attitude, willingness, and practice toward HPV vaccination for both adolescents and their parents were described by frequency and percentage. The seven administrative regions were further grouped into central China (including central and northern China), eastern China (including eastern and northeastern China), and southern and western China (including southern, southwestern, and northwestern China) for analysis. Subgroup analyses were conducted by sex and implementation of free HPV vaccination. Linear regression was used to identify factors associated with the total knowledge score, while logistic regression was conducted to identify factors associated with the attitude and willingness toward HPV vaccination. Univariable regression analysis was initially performed with each candidate covariate to assess crude associations, followed by multivariable regression on selected covariates for adjusted associations. The crude and adjusted coefficients and corresponding 95% confidence intervals (CI) were presented, with statistical significance set as p < .05. The analysis was conducted using R software, version 4.3.1.

Results

Demographics of adolescents and their parents

A total of 1,000 pairs of adolescents and their parents were included in the final analysis (Table 1, Figure 1, and Supplementary Table S2), of whom 28.8% were from central China, 34.2% were from eastern China, and 37.0% were from southern and western China. All questionnaires passed the quality control question. Among all the 1,000 pairs, 64.2% were from urban regions. Adolescents had a mean age of 13.5 (SD: 2.68, ranging between 9 and 17) years, with educational levels almost equally distributed across primary school or lower (31.5%), middle school (33.6%), and high school or higher education (34.9%). The parents had a mean age of 39.5 (SD: 5.25) years, with 98.7% being married and more females (57.3%) than males (42.7%). Most parents had high school or secondary vocational school education (42.3%), followed by middle school or lower (24.3%) and college or higher education (33.4%). Parents were primarily employed in business and services (39.4%) or as manual and industrial workers (30.7%), with 66.3% earning an average monthly income of less than 6,000 CNY (approximately $860 in United States dollars).

Table 1.

Socio-demographic characteristics of adolescents (N = 1000) and parents (N = 1000).

Characteristic	Mean (SD) or n (%)
Adolescents (N = 1,000)
Age (years)	13.5 (2.68)
Sex – male	500 (50.0%)
Educational level
Primary school or lower education	315 (31.5%)
Middle school education	336 (33.6%)
High school, secondary vocational school or higher education	349 (34.9%)
Parents (N = 1,000)
Age (years)	39.5 (5.25)
Administrative region
Central China	288 (28.8%)
Eastern China	342 (34.2%)
Southern and Western China	370 (37.0%)
Type of residence – urban	642 (64.2%)
Sex – male	427 (42.7%)
Educational level
Middle school or lower education	243 (24.3%)
High school or secondary vocational school education	423 (42.3%)
College or higher education	334 (33.4%)
Employment status
Students and Education	65 (6.5%)
Healthcare and Public Services	37 (3.7%)
Business and Services	394 (39.4%)
Manual and Industrial Workers	307 (30.7%)
Homemaker and Unemployed	170 (17.0%)
Other [a]	27 (2.7%)
Average monthly income
<6,000 CNY ($860)	663 (66.3%)
≥6,000 CNY ($860)	312 (31.2%)
I do not want to answer	25 (2.5%)
Marital status – married	987 (98.7%)

CNY = Chinese dollars; SD = standard deviation.

[a] Other includes electronic information technology, military, infant care and freelance.

Figure 1.

Participant disposition flow chart for adolescents and their parents.

Note: a. Eligible for analysis of Knowledge of HPV, HPV-related disease, Awareness of HPV, HPV-related disease.

b. Eligible for analysis of Knowledge of HPV, HPV-related disease, and HPV vaccine.

c. Eligible for analysis of Knowledge of HPV vaccine, Awareness of HPV vaccine, Attitude toward HPV vaccination.

d. Eligible for analysis of Practice toward HPV vaccine for their adolescent children.

e. Eligible for analysis of Practice toward HPV vaccine for themselves.

f. Eligible for analysis of Practice toward HPV-related disease.

g. Eligible for analysis of the influencing factors of willingness toward vaccinating their adolescent children with HPV vaccine.

h. The analysis of “practice toward HPV Vaccine” for the adolescents was based on responses provided by their parents, and the corresponding sample size was described in the flow chart for the parents.

i. Eligible for analysis of the influencing factors of willingness toward HPV vaccination.

j. The group of “never received HPV vaccination” consisted of adolescents who selected “No” or “Not sure” for receipt of HPV vaccination.

KAP of adolescents and their parents

Awareness and knowledge

As summarized in Table 2, 34.2% of adolescents were aware of HPV, and their mean score for the knowledge of HPV and related diseases was 2.5/5 (50.0%). Slightly more adolescents were aware of HPV vaccine (43.9%), and their mean score on HPV vaccine knowledge was 3.2/6 (53.3%). Among adolescents who were aware of HPV, only 33.9% of adolescents knew that HPV cannot be transmitted through eating dirty food or cough/sneezing, and only 43.0% knew that boys can also be infected with HPV. Among adolescents who were aware of HPV vaccine, 57.9% knew that HPV vaccination is also needed for minors, and 56.9% agreed that HPV vaccine should be administered as early as possible. In addition, 88.2% knew that girls need to get HPV vaccination, but only 34.4% believed that boys also need HPV vaccination. Also, only 33.0% of adolescents knew that HPV vaccine cannot treat HPV-related diseases (Figure 2 and Supplementary Table S3).

Table 2.

The knowledge, attitude, and practice toward HPV, HPV-related disease and HPV vaccine among adolescents and parents.

Variable	Adolescent Mean (SD) or n (%)	Parents Mean (SD) or n (%)
Awareness of HPV and HPV vaccine[a]
Awareness of HPV – yes	342 (34.2%)P	610 (61.0%)
Awareness of HPV vaccine – yes	439 (43.9%)	680 (68.0%)
Knowledge of HPV, HPV-related disease, and HPV vaccine
Knowledge construct of HPV and HPV-related disease (points)[b]	2.4 (0.99)	5.2 (1.94)
Knowledge construct of HPV vaccine (points)[c]	3.2 (1.36)	7.5 (1.94)
Knowledge construct of HPV, HPV-related disease, and HPV vaccine (points)[d]	5.8 (1.90)	13.0 (3.07)
Attitude toward vaccinating themselves with HPV vaccine[e]
HPV vaccination will bring me health benefits – agree	338 (77.0%)	561 (82.5%)
Attitude toward vaccinating their adolescent children with HPV vaccine[f]
HPV vaccination will bring the adolescent child with me today health benefits – agree	–	532 (78.2%)
Practice toward HPV vaccine[g][h]
Receipt of HPV vaccination – yes	74 (7.4%)	120 (12.0%)
Willingness toward vaccinating themselves with HPV vaccine[i]
Willingness to receive HPV vaccination – yes	253 (25.3%)	449 (44.9%)
Willingness toward vaccinating their adolescent children with HPV vaccine[j]
Willingness to vaccinate their adolescent children with HPV vaccine – yes	–	417 (41.7%)

HPV = human papillomavirus.

[a] Total N (awareness of HPV and awareness of HPV vaccine) is 1000 for both adolescents and parents.

[b] Total N (knowledge construct of HPV and HPV related disease) is 342 for adolescents, and 610 for parents, respectively.

[c] Total N (knowledge construct of HPV vaccine) is 439 for adolescents, and 680 for parents, respectively.

[d] Total N (knowledge construct of HPV, HPV related disease, and HPV vaccine) is 292 for adolescents, and 559 for parents, respectively.

[e] Total N (attitude toward vaccinating themselves with HPV vaccine) is 439 for adolescents, and 680 for parents, respectively.

[f] Total N (attitude toward vaccinating their adolescent children with HPV vaccine) is 680 for parents.

[g] Total N (practice toward HPV vaccine) is 1000 for both adolescents and parents.

[h] The practice toward HPV vaccine for adolescents was reported by their parents.

[i] Total N (willingness toward vaccinating themselves with HPV vaccine) is 1000 for both adolescents and parents.

[j] Total N (willingness toward vaccinating their adolescent children with HPV vaccine) is 1000 for parents.

Figure 2.

Responses to the questions constituting the knowledge construct toward HPV, HPV-related disease and HPV vaccine.

a. Proportion of adolescents correctly responded to single answer questions constituting the knowledge construct toward HPV, HPV-related disease and HPV vaccine.

b. Proportion of parents correctly responded to single answer questions constituting the knowledge construct toward HPV, HPV-related disease and HPV vaccine.

c. Adolescent parent responses to the question of “Diseases related to HPV.”

d. Adolescent parent responses to the question of “High risk population of HPV infection”

e. Adolescent parent responses to the question of “Recommended age groups for HPV vaccination.”

In contrast to their adolescent children, the parents demonstrated higher awareness, with 61.0% aware of HPV, and 68.0% knowing about HPV vaccine. Their mean knowledge score was 5.2/10 for HPV and related diseases, and 7.5/12 for HPV vaccine. Similar knowledge gaps were identified among parents, with only 33.5% acknowledging that males need HPV vaccination, and 35.1% knowing that HPV vaccine cannot treat HPV-related diseases. While 83.9% of parents understood the link between HPV infection and cervical cancer, only 17.7% were aware of its association with head and neck cancer. Only 23.8% of parents knew that people starting sexual intercourse early are at high risk of HPV infection. For the recommended age groups for HPV vaccination, half of the parents (50.0%) did not know that 9–15 y is the recommended age range. And 31.2% parents did not know that within the recommended age range for HPV vaccination, HPV vaccine should be administered as early as possible (Figure 2).

Among adolescents, 39.8% of boys and 48.0% of girls were aware of HPV vaccine. A similar pattern that males are less aware than females was observed among parents, with 54.6% of fathers and 78.0% of mothers reporting awareness of HPV vaccine. In regions with free HPV vaccination, more adolescents were aware of HPV (37.0%) and HPV vaccine (55.3%) compared to 31.5% and 32.9% in regions without free HPV vaccination. Besides, adolescents in regions with free HPV vaccination had higher mean knowledge scores of 2.5/5 (50.0%) for HPV and related diseases, and 3.2/6 (53.3%) for HPV vaccine, compared to 2.3/5 (46.0%) and 3.0/6 (50.0%) in regions without free HPV vaccination (Supplementary Tables S4, S5).

Attitude

Among adolescents aware of HPV vaccine, 77.0% agreed that HPV vaccination would benefit themselves. Similarly, 82.5% of parents aware of HPV vaccine believed it would benefit themselves, and 78.2% agreed that HPV vaccination would also benefit their adolescent children. For a full course of HPV vaccination, 37.5% of parents were willing to pay less than 500 CNY (approximately $70), followed by 24.6% willing to spend 500 ~ 999 CNY (approximately $70 ~ 140) (Supplementary Table S6).

The percentages of boys and girls who agreed that HPV vaccination would benefit themselves were 70.4% and 82.5%, respectively. Among parents, 83.7% of fathers and 81.9% of mothers believed that HPV vaccination would be beneficial to themselves, while 78.5% of fathers and 78.1% of mothers also acknowledged its benefit to their adolescent children (Supplementary Tables S4, S5).

Willingness and practice

As reported by their parents, 7.4% of adolescents had already received HPV vaccination. Supplementary Table S6 showed that most of the adolescents received 9-valent HPV vaccine (32.4%), followed by 2-valent (29.7%) and 4-valent (6.8%) HPV vaccine. Around a quarter of the adolescents were willing to receive HPV vaccination (25.3%). Whereas for adolescents who were still unwilling to be vaccinated, the main reasons included “No or few friends around me get vaccinated” (44.2%) and “I think HPV vaccine is not safe enough, such as I may feel sick because of it” (44.8%).

Among parents, 12.0% had received HPV vaccination, and the willingness rate toward HPV vaccination was 44.9%. Additionally, 41.7% of parents were willing to vaccinate their children with HPV vaccine. Nearly half of the parents (49.9%) were willing to vaccinate their children with imported 9-valent HPV vaccine. The primary concern preventing parents from vaccinating both themselves (41.6%) and their children (48.3%) was the belief that HPV vaccine is not safe enough (Supplementary Table S6 and Figure 3).

Figure 3.

Factors that prevent HPV vaccination for adolescents and parents from vaccinating their adolescent children.

a. Factors that prevent adolescents from receiving HPV vaccination.

b. Factors that prevent parents from vaccinating their adolescent children.

Supplementary Table S4 showed that 3.8% of boys and 11.0% of girls had received HPV vaccination. Among all adolescents, including both vaccinated and unvaccinated individuals, 11.6% from regions with free HPV vaccination had been vaccinated, compared to 3.3% from regions without free HPV vaccination. In this overall adolescent population, the willingness to receive HPV vaccination was 31.9% in regions with free HPV vaccination and 18.9% in regions without free HPV vaccination.

Factors associated with the knowledge, attitude and willingness of adolescents

Factors associated with the knowledge of HPV, HPV-related disease and HPV vaccine

As shown in the multivariable regression results (Table 3), adolescents living in eastern China (coefficient [Coef.] [95% CI]: −0.90 [−1.67, −0.14]) and southern and western China (Coef. [95% CI]: −0.70 [−1.37, −0.02]) had significantly lower knowledge scores compared with those living in central China. Those with better knowledge on reproductive health had significantly higher knowledge scores (Coef. [95% CI]: 1.25 [0.36, 2.14]). Additionally, adolescents whose parents had high school or secondary vocational school education had significantly higher knowledge scores (Coef. [95% CI]: 0.75 [0.00, 1.49]) than those whose parents had middle school or lower education.

Table 3.

Linear regression for the association between the knowledge construct of HPV, HPV-related disease and HPV vaccine and related factors for adolescents.

Variable	Knowledge Score	Univariable regression[a]		Multivariable regression[a]
	Mean (SD)	Coef. (95% CI)	P-value	Coef. (95% CI)	P-value
Administrative region
Central China	6.1 (2.14)	ref.	–	ref.	–
Eastern China	5.7 (1.86)	−0.42 (−1.01 − 0.17)	.160	−0.90 (−1.67 − −0.14)	.020*
Southern and Western China	5.6 (1.76)	−0.50 (−1.03 − 0.03)	.065	−0.70 (−1.37 − −0.02)	.043*
Type of residence
Urban	5.9 (1.92)	ref.	–	ref.	–
Rural	5.4 (1.81)	−0.54 (−1.04 − −0.05)	.032*	−0.22 (−0.96 − 0.52)	.563
In regions with free HPV vaccination
No	5.5 (1.83)	ref.	–	ref.	–
Yes	6.0 (1.93)	0.52 (0.08–0.95)	.020*	0.56 (0.00–1.12)	.050
Educational level of parents
Middle school or lower education	5.4 (1.81)	ref.	–	ref.	–
High school or secondary vocational school education	6.0 (1.86)	0.57 (0.01–1.13)	.048*	0.75 (0.00–1.49)	.048*
College or higher education	5.7 (1.98)	0.28 (−0.29 − 0.85)	.334	0.38 (−0.35 − 1.10)	.309
Knowledge construct of HPV and HPV-related disease of parents (points)	5.8 (1.90)	−0.04 (−0.18 − 0.10)	.562	−0.15 (−0.31 − 0.01)	.070
Knowledge construct of HPV vaccine of parents (points)	5.8 (1.90)	0.15 (0.02–0.28)	.021*	0.13 (−0.01 − 0.27)	.078
Communication on reproductive health with adolescent child
No	5.9 (1.98)	ref.	–	ref.	–
Yes	5.6 (1.81)	−0.31 (−0.74 − 0.13)	.166	−0.53 (−1.08 − 0.02)	.057
Knowledge on reproductive health
No	5.2 (1.69)	ref.	–	ref.	–
Yes	5.8 (1.91)	0.68 (0.04–1.31)	.037*	1.25 (0.36–2.14)	.006**
Receipt of HPV vaccination by parents
No	5.8 (1.92)	ref.	–	ref.	–
Yes	5.4 (2.04)	−0.36 (−1.00 − 0.29)	.279	−0.25 (−0.92 − 0.41)	.450
Frequency of taking physical examination of parents
Half a year	5.6 (1.59)	ref.	–	ref.	–
Every year	6.0 (2.07)	0.47 (−0.18 − 1.13)	.158	−0.15 (−1.11 − 0.81)	.765
Every 2 ~ 3 y	5.5 (1.76)	−0.10 (−0.83 − 0.64)	.801	−1.08 (−2.17 − 0.01)	.052
>3 y or never	5.5 (1.77)	−0.08 (−0.85 − 0.69)	.837	−0.38 (−1.74 − 0.99)	.587
Frequency of taking physical examination of adolescent children
Half a year	5.5 (1.66)	ref.	–	ref.	–
Every year	5.9 (2.02)	0.46 (−0.08 − 1.00)	.097	0.26 (−0.62 − 1.15)	.559
Every 2 ~ 3 y	5.7 (1.64)	0.25 (−0.56 − 1.06)	.550	0.79 (−0.34 − 1.93)	.171
>3 y or never	5.3 (1.90)	−0.11 (−1.06 − 0.84)	.818	0.08 (−1.35 − 1.51)	.915

HPV = human papillomavirus; SD = standard deviation; Coef. = coefficient; CI = confidence interval.

[a] The linear regression analysis was conducted among 292 adolescents with available data for the assessment of knowledge construct of HPV, HPV-related disease, and HPV vaccine. The univariable analysis was conducted among adolescents with non-missing data for each of the covariates, whereas the multivariable analysis was conducted among 213 adolescents with non-missing data for all the covariates included.

*indicates p-value < .05; **indicates p-value < .01; ***indicates p-value < .001.

Factors associated with the attitude level of HPV vaccine

In the multivariable regression results shown in Table 4, adolescent girls (odds ratio [OR] [95% CI]: 4.20 [1.60–12.03]), those with higher knowledge score of HPV vaccine (OR [95% CI]: 1.51 [1.06–2.21]), and those aware of the consequences of getting HPV infections (OR [95% CI]: 6.98 [1.89–36.42]) were significantly more likely to recognize the health benefits of HPV vaccine.

Table 4.

Logistic regression for the association between the attitude level of HPV vaccine and related factors for adolescents.

Variable	Participants who agree with “HPV vaccination will bring me health benefits”	Univariable regression[c]		Multivariable regression[c]
	n (%)[b]	OR. (95% CI)	P-value	OR. (95% CI)	P-value
Age of adolescents (years) – continuous	338 (77.0%)	0.87 (0.77–0.97)	.016*	0.83 (0.52–1.31)	.418
In regions with free HPV vaccination
No	136 (81.4%)	ref.	–	ref.	–
Yes	202 (74.3%)	0.66 (0.40–1.05)	.084	0.74 (0.25–2.09)	.570
Sex of adolescents
Male	140 (70.4%)	ref.	–	ref.	–
Female	198 (82.5%)	1.99 (1.27–3.13)	.003**	4.20 (1.60–12.03)	.005**
Educational level of adolescents
Primary school or lower education	49 (96.1%)	ref.	–	ref.	–
Middle school education	112 (73.7%)	0.11 (0.02–0.39)	.004**	0.32 (0.03–2.87)	.337
High school, secondary vocational school or higher education	177 (75.0%)	0.12 (0.02–0.41)	.004**	0.59 (0.02–11.75)	.741
Knowledge construct of HPV and HPV-related disease of adolescents (points)	237 (81.2%)	1.30 (0.96–1.80)	.098	1.15 (0.70–1.88)	.585
Knowledge construct of HPV vaccine of adolescents (points)	338 (77.0%)	1.54 (1.29–1.84)	<.001***	1.51 (1.06–2.21)	.028*
Agreement on the risk of getting HPV infections by adolescents
Disagree	190 (79.2%)	ref.	–	ref.	–
Agree	47 (90.4%)	2.47 (1.02–7.41)	.068	2.36 (0.34–48.27)	.455
Agreement on the consequences of getting HPV infections by adolescents
Disagree	162 (78.3%)	ref.	–	ref.	–
Agree	75 (88.2%)	2.08 (1.03–4.58)	.051	6.98 (1.89–36.42)	.009**
Knowledge construct of HPV and HPV-related disease of parents (points)	233 (79.5%)	0.89 (0.75–1.04)	.158	0.86 (0.64–1.13)	.280
Knowledge construct of HPV vaccine of parents (points)	272 (78.8%)	1.08 (0.94–1.23)	.277	1.09 (0.83–1.43)	.537
Agreement on the risk of getting HPV infections by parents
Disagree	192 (78.0%)	ref.	–	ref.	–
Agree	41 (87.2%)	1.92 (0.83–5.25)	.159	1.33 (0.29–6.96)	.721
Agreement on the risk of adolescent children getting HPV infections by parents
Disagree	188 (78.3%)	ref.	–	ref.	–
Agree	45 (84.9%)	1.56 (0.72–3.75)	.286	1.94 (0.37–11.88)	.447
Agreement on the consequences of adolescent children getting HPV infections by parents
Disagree	121 (79.1%)	ref.	–	ref.	–
Agree	112 (80.0%)	1.06 (0.60–1.88)	.846	0.44 (0.14–1.28)	.136
People seeking for help from when encountering questions about reproductive health
Classmates or friends	27 (73.0%)	ref.	–	ref.	–
Parents	232 (74.8%)	1.10 (0.49–2.31)	.805	0.50 (0.05–3.11)	.489
Teachers	22 (88.0%)	2.72 (0.73–13.23)	.164	2.54 (0.16–70.17)	.513
Other[a]	9 (90.0%)	3.33 (0.52–65.49)	.281	NA	NA
Do not know reproductive health	46 (83.6%)	1.89 (0.68–5.34)	.219	0.21 (0.01–2.28)	.219
Receipt of HPV vaccination by parents
No	223 (77.2%)	ref.	–	ref.	–
Yes	49 (87.5%)	2.07 (0.95–5.20)	.089	1.08 (0.31–4.15)	.909
Frequency of taking physical examination of parents
Half a year	52 (92.9%)	ref.	–	ref.	–
Every year	168 (75.0%)	0.23 (0.07–0.60)	.007**	0.20 (0.02–1.18)	.100
Every 2 ~ 3 y	72 (76.6%)	0.25 (0.07–0.71)	.016*	0.33 (0.03–2.43)	.297
>3 y or never	46 (70.8%)	0.19 (0.05–0.54)	.004**	0.11 (0.01–1.01)	.060
Frequency of taking physical examination of adolescent children
Half a year	85 (83.3%)	ref.	–	ref.	–
Every year	206 (75.2%)	0.61 (0.33–1.07)	.095	0.98 (0.25–3.63)	.981
Every 2 ~ 3 y	30 (75.0%)	0.60 (0.25–1.49)	.258	1.94 (0.30–14.14)	.494
>3 y or never	17 (73.9%)	0.57 (0.20–1.75)	.297	3.96 (0.30–72.34)	.317

HPV = human papillomavirus; OR = odds ratio; CI = confidence interval.

[a] Other includes grandparents, doctors, internet or books, and unsure.

[b] The number of adolescents with available data for the attitude level of HPV vaccine in each category was used as the denominator for calculating the percentage of each category under the variable.

[c] The logistic regression analysis was conducted among 439 adolescents with available data for the attitude level of HPV vaccine. The univariable analysis was conducted among adolescents with non-missing data for each of the covariates, whereas the multivariable analysis was conducted among 213 adolescents with non-missing data for all the covariates included.

*indicates p-value < .05; **indicates p-value < .01; ***indicates p-value < .001.

Factors associated with the willingness level of taking HPV vaccine among adolescents who had not received HPV vaccination

For the factors associated with the willingness level of receiving HPV vaccination, the multivariable regression model in Table 5 was conducted exclusively among adolescents who had not received HPV vaccination. The results showed that adolescent girls (OR [95% CI]: 2.84 [1.04–8.34]), those with better knowledge of HPV and HPV-related disease (OR [95% CI]: 2.02 [1.12–3.88]), those who were aware of the risk (OR [95% CI]: 39.40 [3.64–1092.03]) or consequences (OR [95% CI]: 7.66 [2.10–33.73]) of HPV infections, those with parents employed as manual and industrial workers (OR [95% CI]: 10.18 [1.12–103.20], reference: students and education), those with parents aware of the risk of HPV infection on themselves (OR [95% CI]: 8.20 [1.21–70.13]), and those whose parents communicated reproductive health with them (OR [95% CI]: 9.16 [2.57–39.53]) were significantly more likely to be willing to receive HPV vaccination. In contrast, adolescents living in regions with free HPV vaccination (OR [95% CI]: 0.16 [0.04–0.57]) and those with higher educational level (OR [95% CI]: 0.07 [0.01–0.51]) were less likely to report willingness to receive HPV vaccination, as vaccinated adolescents in these regions were excluded from this analysis.

Table 5.

Logistic regression for the association between the willingness level of taking HPV vaccine and related factors for unvaccinated adolescents.

Variable	Participants who are willing to receive HPV vaccination	Univariable regression[c]		Multivariable regression[c]
	n (%)[b]	OR. (95% CI)	P-value	OR. (95% CI)	P-value
Administrative region
Central China	44 (41.9%)	ref.	–	ref.	–
Eastern China	66 (47.5%)	1.25 (0.75–2.10)	.386	0.40 (0.07–2.11)	.289
Southern and Western China	69 (57.5%)	1.88 (1.11–3.20)	.020*	2.55 (0.68–9.92)	.167
Type of residence
Urban	142 (52.8%)	ref.	–	ref.	–
Rural	37 (38.9%)	0.57 (0.35–0.92)	.021*	0.67 (0.16–2.75)	.584
In regions with free HPV vaccination
No	79 (51.0%)	ref.	–	ref.	–
Yes	100 (47.8%)	0.88 (0.58–1.34)	.556	0.16 (0.04–0.57)	.008**
Sex of adolescents
Male	80 (44.2%)	ref.	–	ref.	–
Female	99 (54.1%)	1.49 (0.99–2.25)	.059	2.84 (1.04–8.34)	.047*
Educational level of adolescents
Primary school or lower education	25 (59.5%)	ref.	–	ref.	–
Middle school education	58 (49.2%)	0.66 (0.32–1.33)	.249	0.22 (0.03–1.28)	.109
High school, secondary vocational school or higher education	96 (47.1%)	0.60 (0.30–1.18)	.144	0.07 (0.01–0.51)	.013*
Knowledge construct of HPV and HPV-related disease of adolescents (points)	127 (55.2%)	1.62 (1.22–2.19)	.001**	2.02 (1.12–3.88)	.025*
Knowledge construct of HPV vaccine of adolescents (points)	179 (49.2%)	1.36 (1.17–1.60)	<.001***	1.31 (0.91–1.91)	.151
Agreement on the risk of getting HPV infections by adolescents
Disagree	95 (49.0%)	ref.	–	ref.	–
Agree	32 (88.9%)	8.34 (3.16–28.78)	<.001***	39.40 (3.64–1092.03)	.008**
Agreement on the consequences of getting HPV infections by adolescents
Disagree	76 (46.9%)	ref.	–	ref.	–
Agree	51 (75.0%)	3.39 (1.84–6.52)	<.001***	7.66 (2.10–33.73)	.004**
Employment status of parents
Students and Education	10 (43.5%)	ref.	–	ref.	–
Healthcare and Public Services	12 (75.0%)	3.90 (1.02–17.50)	.057	2.52 (0.19–36.83)	.483
Business and Services	84 (55.3%)	1.61 (0.67–3.98)	.294	4.31 (0.55–33.14)	.156
Manual and Industrial Workers	50 (43.1%)	0.98 (0.40–2.48)	.974	10.18 (1.12–103.20)	.041*
Homemaker and Unemployed	20 (40.0%)	0.87 (0.32–2.39)	.779	0.63 (0.06–5.96)	.696
Other[a]	3 (42.9%)	0.98 (0.16–5.44)	.977	NA	NA
Knowledge construct of HPV and HPV-related disease of parents (points)	117 (51.5%)	1.07 (0.92–1.24)	.373	0.97 (0.65–1.42)	.885
Knowledge construct of HPV vaccine of parents (points)	143 (52.0%)	1.18 (1.04–1.34)	.014*	1.04 (0.77–1.40)	.807
Agreement on the risk of getting HPV infections by parents
Disagree	95 (49.0%)	ref.	–	ref.	–
Agree	22 (66.7%)	2.08 (0.98–4.68)	.064	8.20 (1.21–70.13)	.038*
Agreement on the consequences of getting HPV infections by parents
Disagree	61 (45.9%)	ref.	–	ref.	–
Agree	56 (59.6%)	1.74 (1.02–2.98)	.042*	0.81 (0.16–4.11)	.795
Agreement on the risk of adolescent children getting HPV infections by parents
Disagree	95 (49.7%)	ref.	–	ref.	–
Agree	22 (61.1%)	1.59 (0.77–3.35)	.213	0.10 (0.01–0.77)	.038*
Agreement on the consequences of adolescent children getting HPV infections by parents
Disagree	59 (45.4%)	ref.	–	ref.	–
Agree	58 (59.8%)	1.79 (1.05–3.06)	.032*	3.02 (0.62–15.67)	.173
Communication on reproductive health with adolescent child
No	83 (45.4%)	ref.	–	ref.	–
Yes	96 (53.0%)	1.36 (0.90–2.06)	.143	9.16 (2.57–39.53)	.001**
Knowledge on reproductive health
No	18 (39.1%)	ref.	–	ref.	–
Yes	159 (50.3%)	1.58 (0.84–3.01)	.159	1.73 (0.21–14.04)	.604
Receipt of HPV vaccination by parents
No	126 (52.7%)	ref.	–	ref.	–
Yes	17 (47.2%)	0.80 (0.39–1.62)	.539	0.22 (0.03–1.23)	.096
Frequency of taking physical examination of parents
Half a year	27 (60.0%)	ref.	–	ref.	–
Every year	94 (53.4%)	0.76 (0.39–1.48)	.429	0.91 (0.20–4.09)	.897
Every 2 ~ 3 y	37 (43.0%)	0.50 (0.24–1.04)	.067	0.57 (0.08–3.86)	.558
>3 y or never	21 (36.8%)	0.39 (0.17–0.86)	.021*	0.14 (0.01–1.26)	.093

HPV = human papillomavirus; OR = odds ratio; CI = confidence interval.

[a] Other includes electronic information technology, military, infant care and freelancer.

[b] The number of adolescents with available data for the willingness level of taking HPV vaccine in each category was used as the denominator for calculating the percentage of each category under the variable.

[c] The logistic regression analysis was conducted among 364 adolescents with available data for the willingness level of taking HPV vaccine. The univariable analysis was conducted among adolescents with non-missing data for each of the covariates, whereas the multivariable analysis was conducted among 157 adolescents with non-missing data for all the covariates included.

*indicates p-value < .05; **indicates p-value < .01; ***indicates p-value < .001.

Factors associated with the knowledge, attitude and willingness of parents

Supplementary Table S7 showed that no significant factors were associated with the knowledge level among adolescent fathers. However, adolescent mothers in regions with free HPV vaccination (Coef. [95% CI]: 0.69 [0.06, 1.33]) and those with higher educational levels (Coef. [95% CI]: 1.15 [0.31, 1.99]) had significantly higher knowledge scores. Conversely, mothers living in rural areas (Coef. [95% CI]: −1.12 [−1.83, −0.40]) had significantly lower knowledge scores (Supplementary Table S8). Moreover, adolescent fathers with higher knowledge score of HPV vaccine (OR [95% CI]: 1.30 [1.07–1.60]) were significantly more willing to have their children vaccinated (Supplementary Table S9), whereas for adolescent mothers, better knowledge on both HPV and HPV-related disease (OR [95% CI]: 1.29 [1.05–1.61]), as well as HPV vaccine (OR [95% CI]: 1.25 [1.03–1.53]), was significantly associated with a higher willingness to vaccinate their children (Supplementary Table S10). No significant association was observed between the sex of adolescents and their parents’ willingness to vaccinate them with HPV vaccine (OR [95% CI]: 1.75 [0.83–3.76] for fathers; 1.19 [0.62–2.30] for mothers) (Supplementary Tables S11, S12).

Comparisons of knowledge, attitude and willingness between vaccinated and unvaccinated adolescents and their parents

We further compared the KAP and relevant factors between vaccinated and unvaccinated adolescents and their parents (Supplementary Tables S13-14). Compared to adolescents not vaccinated, adolescents vaccinated were more likely to aware HPV diseases and HPV vaccine and agreed that HPV vaccination would benefit them. Similarly, those parents with their adolescent children vaccinated showed better awareness on HPV diseases and vaccine, positive attitude toward HPV vaccine on their children, willingness to receive HPV vaccine than those parents with their adolescent children not vaccinated.

Discussion

This nationwide cross-sectional survey offered a comprehensive evaluation of the KAP toward HPV, HPV-related diseases, and HPV vaccine among adolescents aged 9–17 y and their parents in China. The awareness of HPV and HPV vaccine among adolescents was 34.2% and 43.9%, respectively, while the parents demonstrated higher awareness, with 61.0% aware of HPV, and 68.0% knowing about HPV vaccine. The knowledge toward HPV and related diseases, as well as HPV vaccine were still limited for both populations with several unignorable knowledge gaps. The majority of adolescents and their parents believed HPV vaccine could benefit themselves, as well as their children from parental perspective. However, the vaccination rate remained low among both adolescents (7.4%) and their parents (12.0%). Nonetheless, 25.3% of adolescents and 41.7% of their parents expressed willingness to receive the vaccine and vaccinate their children, respectively. Several significant parental factors were identified for the knowledge and willingness of adolescent children. The willingness toward HPV vaccination among unvaccinated adolescents was higher when their parents acknowledged the risk of HPV infection on themselves or communicated with their children about reproductive health. From parental perspective, the willingness to vaccinate their adolescent children was not significantly associated with the sex of their children.

Knowledge gaps about HPV and HPV vaccine persisted among adolescents and their parents. Only 33.9% knew that HPV cannot be transmitted through food or cough/sneezing, and merely 43.0% knew that boys can also be infected with HPV. Furthermore, only 33.0% of adolescents correctly grasped that HPV vaccine cannot treat HPV infections, only 34.4% understood the necessity for boys to receive HPV vaccine, 42.1% were unaware that minors also need to be vaccinated, and 43.1% did not know that early vaccination within the recommended age range is preferable. Similar knowledge gaps also existed among parents of adolescents. Only 31.6% of parents knew HPV’s transmissibility through contact, and only 23.8% were aware that early sexual activity is associated with elevated risks of HPV infection. Regarding the HPV vaccine, only 35.1% and 33.5% of parents understood that it cannot treat HPV infections and recognized the necessity for males to be vaccinated, respectively. Parents were also unclear about the appropriate age range for HPV vaccination, with 50.0% unaware that adolescents aged 9–15 y are also eligible for HPV vaccination, and 31.2% not knowing that early vaccination within the recommended age range is advantageous. Parents’ awareness of HPV-related non-cervical disease was also low (for example, only 17.7% and 24.6% were aware that head and neck cancers and genital tumors were associated with HPV infection).

Adolescents vaccinated and those patients with vaccinated children showed better awareness on HPV diseases and vaccine and understand better on the benefits of vaccination. The knowledge gaps of both parents and children can interactively hinder the vaccination of adolescents.^5,17–19 In addition, although not evaluated in the current study, adolescents and parents who use only local dialects might have difficult in understanding the HPV educational materials targeted to the general population in the nation. Future educational initiative should focus not only on adolescents, but also on enhancing parental education, in a language-appropriate approach. This can be achieved through family-oriented methods, such as designing parent–child classes, which will help correct knowledge misconceptions across both generations simultaneously. Additionally, future science outreach should pertinently address the identified knowledge gaps to deepen the understanding of HPV infection among adolescents and parents, as well as highlight the significance and necessity of HPV vaccination. With the advances in the information technology, HPV education should expand beyond the traditional classroom face-to-face teaching. Utilizing online platforms, social media, instant messages, and e-mails can facilitate easy and rapid access to educational materials to improve knowledge, positive attitude, and high acceptance for HPV vaccination.

As found in this study, the HPV vaccination rate among adolescents was only 7.4%, which was significantly lower than that of the developed countries, such as 65.5% in the United States.⁷ Despite the low vaccination rate, the awareness rate of HPV vaccine among adolescents was 43.9%, indicating a discrepancy between awareness and practice. Moreover, among adolescents, 25.3% expressed willingness to receive the vaccine, and 41.7% of their parents were supportive in vaccinating them, revealing an unmet need for HPV vaccination among adolescents. The barriers to adolescent vaccination may include financial constraints, limited medical resources, and inconvenience of vaccination.^20,21 Meanwhile, parents may underestimate the urgency of HPV vaccination for their children due to knowledge gaps regarding the risks of HPV infection and the optimal age for vaccination, as evidenced by the results that parents with their children unvaccinated had poorer awareness on HPV diseases and vaccine than parents with their children vaccinated. The same discrepancy between awareness and practice, along with unmet vaccination needs, were also evident among parents. Although 68.0% of parents were aware of HPV vaccine, the vaccination rate was only 12.0%, whereas 44.9% of the parents were willing to receive HPV vaccine. This also implied that, in addition to enhancing educational efforts for parents, improving their accessibility to HPV vaccine is also crucial. For instance, the approval of a wider variety of HPV vaccines could foster a competitive market environment, potentially resulting in more reasonable pricing, thereby achieving border vaccine coverage. Besides, results of the subgroup analyses reported a higher willingness level toward HPV vaccination among adolescents from regions with free HPV vaccination (31.9%) compared with those from regions without free HPV vaccination (18.9%), revealing the critical impact of cost-related policy interventions on vaccine uptake. Therefore, to improve the vaccination rate among adolescents, multifaceted strategies should be implemented, such as advocating for early vaccination by KOLs including but not limited to medical experts and parent representatives; in the context of HPV vaccine inclusion in the National Immunization Program, continuing to optimize eligible populations and coverage strategies and expanding free or insurance-covered access to a broader population; and providing convenient vaccination services like on-campus vaccination. Given that over half of parents would spend less than 1,000 CNY ($140) on vaccination, there is a clear financial barrier to vaccine uptake. Even though those not covered by the NIP still need to pay for vaccination, public health education should still highlight the significantly higher cost associated with treating HPV-related illness, such as cervical cancer ($2,600 per person).²² Emphasizing this contrast can help parent understand the long-term economic trade-off between the cost of vaccine and the financial risks of HPV infection. Additionally, among parents who had not yet vaccinated their children but showed willingness, 49.9% were willing to vaccinate their children with the 9-valent HPV vaccine, underscoring the high demand for multivalent vaccines, which should also be considered a focus in HPV vaccination.²³ Several adolescents and parents exhibited reluctance toward receiving or allowing their children to receive the HPV vaccine. The present study identified vaccine safety concerns as the predominant barrier to HPV vaccination from both adolescent and parental perspectives. Furthermore, the willingness toward HPV vaccination among unvaccinated adolescents was significantly influenced by their parents’ knowledge level and communication with them, including parental awareness of HPV infection risks and their communication about reproductive health with their children. These findings highlighted the importance of educating both adolescents and parents about HPV vaccine, particularly in terms of enhancing their understanding of its safety.

Since the introduction of HPV vaccine in China in 2016, the awareness of HPV and HPV vaccine have improved among both adolescents and their parents. However, the HPV vaccine uptake rates remained low. By 2019, only 3% of eligible females had been vaccinated.²⁴ Among adolescents, the awareness rates of HPV and HPV uptake vaccine were 15.5% and 18.9%, respectively, as reported by a study conducted in Shandong Province from 2015 to 2017,²⁵ which was substantially lower than the awareness rates (34.2% and 43.9%) found in the current study. According to a study in 2018, only 28.2% and 38.0% of the parents of middle school students had heard of HPV and HPV vaccine,²⁶ contrasting sharply with the current study’s finding of 61.0% and 68.0%. By 2022, the first-dose coverage among girls aged 9–14 y old was only 4%, with full-dose coverage of 0.3%.²⁷ Similarly, in countries without a national HPV vaccination program, the HPV vaccine uptake rate was low. Vietnam, similar to China without a national HPV vaccination program, showed a low vaccine uptake of 12% in women and girls aged 15–29 y old as of 2023.²⁷ India reported an HPV vaccine coverage below 1% in 2019.²⁸ In contrast, countries with a national HPV vaccination program commonly had a high HPV vaccine uptake rate. Norway had 78.2% initiation and 74.6% completion rates of HPV vaccination among girls born 1997–1999.²⁹ The United States had 79% girls and 75% boys receiving at least one dose of HPV vaccine by 2021.³⁰ In Australia, 81.5% 15-y-old females and 78.6% males had completed two or three doses of HPV vaccine by 2020.³¹ In south Asia, Malaysia implemented a national school-based HPV vaccination program in 2010 and has achieved 75.5% vaccine uptake in young women aged 18–24 y old by 2019–2020.³² All of these highlighted the important role of national vaccination program to promote the HPV uptake rate.

Following the inclusion of HPV vaccination in the NIP in China in 2025, free vaccination is now provided to girls born on or after November 10, 2011, and once they reach the age of 13 y old.³³ Overall, this approach is expected to improve vaccine accessibility. However, multiple types and price levels of HPV vaccines currently coexist in the market. Policies should ensure transparent information and guaranteed service accessibility to ensure that individuals across all socioeconomic groups can be fully informed and have equal opportunities when making decisions about HPV vaccination. Still, ongoing research should test whether public confidence in HPV vaccine safety can be improved. Additionally, the study emphasized the importance of promoting reproductive health communication between adolescents and their parents, which aligned with findings from previous studies.^34,35 In addition, HPV infection is associated not only with cervical cancer, but also with various malignancies including head and neck cancers, vaginal cancer, vulvar cancer, penile cancer, and anal cancer, as well as genital warts and recurrent respiratory papillomatosis.^36–41 However, despite the vaccine’s role in preventing HPV-related diseases, its officially approved indications in China remain narrow, covering only the prevention of HPV infections to minimize the risk of cervical cancer and precancerous lesions in females, and anal cancer precursors and genital warts in males. The current study revealed a generally low awareness of HPV-related non-cervical diseases, with only 17.7% and 24.6% of the parents knowing that head and neck cancer and carcinoma of the external genitalia were related to HPV, respectively. On the other hand, a gender-neutral HPV vaccination strategy, which accords equal importance to vaccinating boys, is also essential in accelerating the elimination of cervical cancer.⁴² Globally, 85 countries and regions have already incorporated HPV vaccination for boys into their NIP; however, China has yet to adopt this inclusive policy.⁴³ Currently, there is no standardized nationwide curriculum specifically designed to educate adolescents on sexually transmitted diseases in China. Comprehensive education on sexually transmitted diseases is a critical determinant of HPV-related health literacy and is strongly associated with vaccine awareness among adolescents. This is a critical area requiring urgent policy intervention. To address these shortfalls, it is essential to implement targeted educational strategies, develop age-appropriate sexual health education materials, and improve vaccine accessibility, thereby enhancing HPV vaccination uptake among Chinese girls. Furthermore, pediatrician and family physicians should play an active role in promoting the HPV vaccination by educating adolescents and parents about HPV-related illnesses, addressing questions on the benefits and risks of HPV vaccine, and administering the vaccine or guiding them to appropriate vaccination access. In addition, policies should ensure transparent information and guaranteed service accessibility so that all socioeconomic groups can be fully informed and have equitable choices about HPV vaccines.

There are some limitations in this study. Firstly, both fathers and mothers could influence the decision to vaccinate their children, but only one parent was included in this study, possibly missing important insights. Nevertheless, the study included a well-balanced proportion of fathers (42.7%) and mothers (57.3%), ensuring minimal loss of parental factors. Secondly, the limited sample size might not represent all adolescents in China and could not adequately account for all confounding variables and restrict the generalizability of our results, although major confounders were controlled via multi-stage sampling methods. In addition, the limited sample size also restricted our further subgroup analysis in adolescents in different age groups. For example, those adolescents >13 y old could know more about HPV and its vaccine compared with younger adolescents, and therefore, these two subgroups of adolescents might have different answers on the questionnaires. Similarly, subgroup analyses in unvaccinated adolescents classified in different categories might also have not adequate power to reach robust results. Thirdly, as participation in the survey study was entirely voluntary, it was challenging to avoid non-response bias. Individuals with a stronger interest in HPV vaccine or health-related topics were more likely to respond, potentially resulting in the overestimation of the KAP. In addition, information on vaccine uptake was self-reported, without confirmation from immunization records, which could bring information bias in the study. Fourthly, those adolescents and their parents living in rural areas or those speaking dialects might not have access to or understand the survey, leading to selection bias. Future survey using language-appropriate approach should be implemented to address this issue.

In conclusion, this study underscored critical gaps in KAP toward HPV and HPV vaccination among Chinese adolescents and their parents, despite increased awareness since the licensure of HPV vaccine in China. HPV vaccination rate among adolescents remained suboptimal. Addressing these challenges requires family-oriented, school-based and physician-led educational initiatives to enhance understanding of HPV and the importance and safety of HPV vaccination, as well as efforts to improve the accessibility and convenience of HPV vaccination. Furthermore, incorporating HPV vaccine into NIP and expanding its use to include male indications could help bridge the gaps between China and global practices. Fortunately, China has announced the inclusion of the HPV vaccine in its NIP in 2025. This study offers crucial evidence to guide the rollout of this landmark public-health initiative.

Biography

Fanghui Zhao, Director and Professor at the Department of Cancer Epidemiology, National Cancer Center & Cancer Hospital, CAMS & PUMC. 2025 National March 8th Red–Banner Holder; Chairman of Cancer Prevention and Control Committee, Chinese Preventive Medicine Association; Director of the Department of Academic Exchange and International Cooperation at the Cancer Foundation of China; member of the National Immunization Advisory Committee (NIAC). Expert of the WHO Working Group on the Global Strategy to Accelerate the Elimination of Cervical Cancer; President of the Asia Oceania Research Organisation on Genital Infections and Neoplasia (AOGIN); Chairman of the Education Committee of the Asian Pacific Organization for Cancer Prevention (APOCP); Member of APEC Cervical Cancer Prevention and Control Expert Group. Research focuses on major scientific issues in the prevention and control of malignant tumors, with emphasis on comprehensive prevention and control of cervical and breast cancers as key breakthroughs, including etiology and epidemiological trends, clinical and real-world studies of HPV vaccines, development and evaluation of screening and treatment technologies, and research on prevention and control strategies, aiming to enhance health equity and accessibility for low-resource and vulnerable populations and promote the implementation of China’s national cancer prevention and control initiatives.

Funding Statement

This work was supported by MSD China.

Disclosure statement

Yue Yan, Xingxing Zhang, Rui Bian and Lifang Jia are employees of MSD China. Other authors have none to declare.

Date availability statement

The datasets generated and analyzed during the current study are available from the corresponding author on reasonable request.

Supplemental material

Supplemental data for this article can be accessed online at https://doi.org/10.1080/21645515.2026.2681256

Abbreviations

HPV

human papillomavirus;

KAP

knowledge, attitude, and practice;

KOLs

Key Opinion Leaders;

SD

standard deviation,

CI

confidence intervals