ABSTRACT
China approved human papillomavirus (HPV) vaccines for women and men in 2016 and 2025 respectively. We aimed to online survey the knowledge of HPV and HPV vaccines, as well as the vaccine uptake, among medical college students in Inner Mongolia, during April 1–21, 2026. Of 5,846 eligible students, 660 (11.3%) participated in the survey. Fourteen respondents were excluded because of their incomplete questionnaires. Of 646 respondents aged 20.5 (±1.5) years with 65.5% (423) females, 93.6% and 87.6% were aware of HPV and HPV vaccines respectively. However, only 74.8% of them knew HPV as the main cause of cervical cancer and 73.5% knew the preventive effect of HPV vaccines against cervical cancer. Fewer respondents knew the association of HPV with other cancers. The males had less knowledge than females. Only 115 (27.2%) females had received HPV vaccination, and none of the males did due to transient availability of the vaccine for males. Family income, paternal education, and HPV vaccine knowledge were the main factors associated with the vaccination. The vaccination barriers included vaccine cost, perceived lack of necessity, doubts about effectiveness, concerns about adverse events, and unawareness of where to get vaccinated. Among the unvaccinated respondents, 61.4% (137/223) of the males and 86.4% (266/308) of the females intended to get vaccinated. The survey revealed gaps in HPV and HPV vaccine knowledge, as well as low vaccination coverage among medical students. The results indicate that enhancing education about HPV and HPV vaccines appears valuable for increasing HPV vaccine uptake.
KEYWORDS: Medical college students, HPV, HPV vaccine, knowledge, attitude, vaccination
Introduction
Since the identification of human papillomavirus (HPV) type 16 (HPV16) as a specific infectious agent in cervical cancer biopsy specimens in the early 1980s,1 HPV has been demonstrated to be the etiological agent of cervical cancer.2 Infection of high-risk HPV has also been causally associated with a considerable proportion of anal, vaginal, vulvar, penile, and oropharyngeal cancers.3–5 The HPV vaccine (Gardasil) was first approved in the USA in 2006. The World Health Organization (WHO) and many countries have also recommended HPV vaccination. Currently, three types of HPV vaccines are available, including two-valent (HPV 16 and 18), four-valent (HPV 6, 11, 16, and 18), and 9-valent (HPV 6, 11, 16, 18, 31, 33, 45, 52, and 58) vaccines. The vaccines have shown to be effective not only in preventing cervical cancer, but also in preventing other HPV related cancers.6–12 However, as of 2024, the global HPV vaccination coverage is low, just 18% (0% to 68%) and 6% (0% to 33%) in females and males by 15 y of age respectively, based on the data reported by WHO,13 far from the 2030 WHO goal of 90% vaccination coverage in girls.14
In mainland China, approximately 10.4% of women aged 35–64 y are infected with high-risk HPV,15 and cervical cancer is one of the most common cancers in women.16 Thus, HPV vaccination in females is crucial to reduce the burden of cervical cancer. The two-valent HPV vaccine was first approved for females in China in July 2016, followed by the four-valent vaccine in May 2017 and the nine-valent vaccine in April 2018. Before 2020, all HPV vaccines used in China were imported. The two-, four-, and nine-valent vaccines produced in China were approved for females in 2020, 2024, and 2025 respectively. A four-valent vaccine (Gardasil 4) imported from USA has been approved for males in January 2025.17,18 Currently, the HPV vaccination coverage in China is significantly lower than the WHO requirement. As of 2022, the first-dose coverage was only 10.2% among females aged 9–45 y and 4.0% in 9–14-year-old girls in China.19 Thus, increasing HPV vaccine coverage in the target population is of great significance for reducing the burden of cervical cancer and other HPV-related cancers.
Several reasons may explain the low coverage of HPV vaccines, including incomplete awareness of HPV and/or HPV vaccines, the vaccination cost, concerns about vaccine effectiveness, and vaccination-related adverse events.20 Surveys of the knowledge about HPV and HPV vaccines conducted in China have been reported.21–25 However, as China has a vast territory with remarkable regional differences, the individuals in different regions may have different attitudes to the HPV vaccination. Inner Mongolia has the largest grassland and the largest pastoral region in China. The knowledge about HPV and HPV vaccines among college students in Inner Mongolia remains unknown. In addition, the knowledge of and attitude to HPV vaccines among Chinese male college students have been less studied.26,27 In the present work, we report the results of a survey on the knowledge about HPV and HPV vaccines among undergraduate male and female students at Inner Mongolia Medical University.
Subjects and methods
Study design
This was a cross-sectional survey about the knowledge of HPV and HPV vaccines in the prevention of cervical cancer and other HPV-related cancers among medical students in Inner Mongolia Medical University, which is located in the northern region of China. The survey was conducted through the online Jinshan Document Platform between April 1 and April 21, 2026. All 5,846 undergraduate students majoring in clinical medicine, Chinese medicine, medical imaging, laboratory medicine, stomatology, and pharmacology at Inner Mongolia Medical University were invited to participate in this survey. A notification with a link to the questionnaire was sent to each student’s mobile phone.
At the beginning of the questionnaire, a notice explained the purpose of this survey and stated that submission of the questionnaire would be deemed to constitute electronic informed consent. Thus, all participants provided electronic informed consent. This study was approved by the Ethics Committee of the Affiliated Hospital of Inner Mongolia Medical University (KY2026046), and was conducted in accordance with the ethical principles stated in the Declaration of Helsinki.
Sample size
Recent surveys in China showed that 69.0% to 86.4% of the college students were aware of HPV21,25,28 and 64.9% to 72.7% of the students had heard of HPV vaccines.21,25 Thus, we assumed a conservative rate (50%) of awareness of HPV and HPV vaccines among medical students in Inner Mongolia. With a maximum allowable error of 5%, the sample size required at least 384 participants.
Survey contents
Previously, surveys of the knowledge about HPV and HPV vaccines among various subpopulations in both developed and underdeveloped countries have been reported. The questionnaire in the present survey was prepared by referring to the documented literature that investigated the knowledge of HPV and HPV vaccines, as well as HPV vaccination intention among college students,21–25,29 and by internal discussion in the study group. We prepared 55 items in 4 sections, including 19 items in the demographic section, 3 in the sexual activity section, 12 in the HPV knowledge section, and 21 in the section of HPV vaccine knowledge and practice. The questionnaire was in Chinese. The detailed questions, in both Chinese and English, are presented in the Supplemental file 1.
Statistical analyses
Continuous variable parameters were presented as mean and standard deviation. Comparisons between two groups were performed using the Student’s t-test. Categorical variables were presented as number and percentage. The proportions or rates of different groups were compared by the chi-squared test or Fisher’s exact test, as appropriate. The Mann-Whitney U test was applied to compare the difference between two groups on an ordinal categorical variable. Scores of the knowledge about HPV and HPV vaccine were calculated by assigning one point to each correct response and zero point to each incorrect or “do-not-know” response. The reliability and internal consistency and factorability of the HPV and HPV vaccine knowledge scales were assessed using Cronbach’s alpha coefficient, the Kaiser–Meyer–Olkin (KMO) measure, and Bartlett’s test of sphericity. Univariate analysis was used to explore factors associated with HPV vaccine uptake among female respondents, and the variables with P < .05 in the univariable analysis were considered candidates for the multivariable logistic regression model. Collinearity was assessed using design-matrix variance inflation factors (VIF, >5) and tolerance (<0.20) as diagnostic flags, supplemented by generalized VIFs adjusted for degrees of freedom. Model discrimination was assessed using the apparent area under curve (AUC) with a DeLong 95% confidence interval; fit was examined with the Hosmer–Lemeshow test using groups based on predicted-risk quantiles. All candidate variables were selected using a stepwise procedure with entry and retention criteria of P < .10 and P < .05, respectively. Odds ratios and corresponding 95% confidence intervals were estimated. For multiple comparisons, P values were adjusted using the false discovery rate correction. A two-sided P < .05 was considered statistically significant. All analyses were conducted using R software, version 4.4.2.
Results
Participant characteristics
Of the 5,846 invited students, 1,181, 1,165, 1,179, 1,169, and 1,152 were from grades 1, 2, 3, 4, and 5, respectively. They comprised 2,289 males and 3,557 females. A total of 660 (11.3%) students participated in the survey, including 228 (10.0%) males and 432 (12.1%) females (χ2 = 6.64, P = .010). Of the 660 respondents, 14 (5 males and 9 females) were excluded because they submitted incomplete questionnaires. Thus, 646 students (mean age 20.5 ± 1.5 y; median 20.1, range 17.5–27.7), comprising 423 females (65.5%) and 223 males (34.5%) were included in this study. The demographic and socioeconomic characteristics of the participants are presented in Table 1. Overall, most of these characteristics had no statistical difference between the male and female respondents, but more mothers of the female respondents had higher education (P = .025), and more male respondents declined to answer the sexual activity (P = .002).
Table 1.
Sociodemographic characteristics of participants.
| Item | Overall (n = 646) (%) | Male (n = 223) (%) | Female (n = 423) (%) | Statistic | P |
|---|---|---|---|---|---|
| Age, years | 20.5 ± 1.5 | 20.4 ± 1.5 | 20.5 ± 1.5 | t = −0.63 | .529 |
| Major | χ2 = 0.70 | .706 | |||
| Clinical medicine | 601 (93.0) | 210 (94.2) | 391 (92.4) | ||
| Chinese medicine | 34 (5.3) | 10 (4.5) | 24 (5.7) | ||
| Others* | 11 (1.7) | 3 (1.3) | 8 (1.9) | ||
| University grade† | Z = −0.71 | .475 | |||
| Freshman | 235 (36.4) | 83 (37.2) | 152 (35.9) | ||
| Sophomore | 146 (22.6) | 52 (23.3) | 94 (22.2) | ||
| Junior | 104 (16.1) | 38 (17.1) | 66 (15.6) | ||
| Senior | 86 (13.3) | 27 (12.1) | 59 (14.0) | ||
| Fifth grade | 75 (11.6) | 23 (10.3) | 52 (12.3) | ||
| Ethnicity | |||||
| Han | 468 (72.4) | 162 (72.6) | 306 (72.3) | χ2 = 0.01 | .934 |
| Others | 178 (27.6) | 61 (27.4) | 117 (27.7) | ||
| Religion | Fisher’s | .241 | |||
| Yes | 3 (0.5) | 2 (0.9) | 1 (0.2) | ||
| None | 643 (99.5) | 221 (99.1) | 422 (99.8) | ||
| Family residence | χ2 = 0.66 | .416 | |||
| City | 330 (51.1) | 109 (48.9) | 221 (52.2) | ||
| Rural or pastoral area | 316 (48.9) | 114 (51.1) | 202 (47.8) | ||
| Childhood residence | χ2 = 0.96 | .618 | |||
| City | 388 (60.1) | 134 (60.1) | 254 (60.1) | ||
| Town | 121 (18.7) | 38 (17.0) | 83 (19.6) | ||
| Rural or pastoral area | 137 (21.2) | 51 (22.9) | 86 (20.3) | ||
| Adolescence residence | χ2 = 3.45 | .179 | |||
| City | 526 (81.4) | 179 (80.3) | 347 (82.0) | ||
| Town | 90 (13.9) | 37 (16.6) | 53 (12.5) | ||
| Rural or pastoral area | 30 (4.7) | 7 (3.1) | 23 (5.5) | ||
| Marital status | Fisher’s | 1.000 | |||
| No | 639 (98.9) | 220 (98.6) | 419 (99.1) | ||
| Yes | 5 (0.8) | 2 (0.9) | 3 (0.7) | ||
| Divorced | 2 (0.3) | 1 (0.5) | 1 (0.2) | ||
| Paternal education | Z = 1.43 | .154 | |||
| Primary School or below | 108 (16.7) | 32 (14.3) | 76 (17.9) | ||
| High school | 303 (46.9) | 103 (46.2) | 200 (47.3) | ||
| Vocational school | 138 (21.4) | 51 (22.9) | 87 (20.6) | ||
| University and above | 97 (15.0) | 37 (16.6) | 60 (14.2) | ||
| Paternal occupation§ | χ2 = 2.47 | .651 | |||
| White-collar | 151 (23.4) | 55 (24.8) | 96 (22.7) | ||
| Blue-collar | 127 (19.7) | 41 (18.5) | 86 (20.3) | ||
| Farmer or herdsman | 193 (29.9) | 61 (27.5) | 132 (31.2) | ||
| Small business owner | 98 (15.2) | 39 (17.5) | 59 (14.0) | ||
| Jobless | 76 (11.8) | 26 (11.7) | 50 (11.8) | ||
| Maternal education | Z = 2.25 | .025 | |||
| Primary School or below | 129 (20.0) | 39 (17.5) | 90 (21.3) | ||
| High school | 282 (43.7) | 91 (40.8) | 191 (45.2) | ||
| Vocational school | 134 (20.7) | 48 (21.5) | 86 (20.3) | ||
| University and above | 101 (15.6) | 45 (20.2) | 56 (13.2) | ||
| Maternal occupation | χ2 = 8.66 | .070 | |||
| White-collar | 136 (21.1) | 56 (25.1) | 80 (18.9) | ||
| Blue-collar | 108 (16.7) | 37 (16.6) | 71 (16.8) | ||
| Farmer or herdsman | 158 (24.5) | 53 (23.8) | 105 (24.8) | ||
| Small business owner | 77 (11.9) | 32 (14.3) | 45 (10.6) | ||
| Jobless | 167 (25.8) | 45 (20.2) | 122 (28.9) | ||
| Yearly family income (Chinese Yuan, Thousand) | Z = 2.19 | .069 | |||
| <20 | 93 (14.4) | 32 (14.3) | 61 (14.4) | ||
| 20–<50 | 158 (24.4) | 45 (20.2) | 113 (26.7) | ||
| 50–<100 | 191 (29.6) | 60 (26.9) | 131 (31.0) | ||
| 100–<200 | 124 (19.2) | 53 (23.8) | 71 (16.8) | ||
| ≥200 | 80 (12.4) | 33 (14.8) | 47 (11.1) | ||
| Cervical or vulvar tumor in female family members or relatives | χ2 = 1.32 | .518 | |||
| Yes | 16 (2.5) | 5 (2.3) | 11 (2.6) | ||
| No | 501 (77.5) | 168 (75.3) | 333 (78.7) | ||
| Unknown | 129 (20.0) | 50 (22.4) | 79 (18.7) | ||
| Penile cancer in male family members or relatives | χ2 = 0.24 | .626 | |||
| Yes | 0 (0) | 0 (0) | 0 (0) | ||
| No | 511 (79.1) | 174 (78.0) | 337 (79.7) | ||
| Unknown | 135 (20.9) | 49 (22.0) | 86 (20.3) | ||
| Oropharyngeal cancer in any family member or relative | Fisher’s | .842 | |||
| Yes | 4 (0.6) | 1 (0.5) | 3 (0.7) | ||
| No | 523 (81.0) | 178 (79.8) | 345 (81.6) | ||
| Unknown | 119 (18.4) | 44 (19.7) | 75 (17.7) | ||
| Sexual activity | χ2 = 12.66 | .002 | |||
| Yes | 14 (2.2) | 6 (2.7) | 8 (1.9) | ||
| No | 583 (90.2) | 189 (84.7) | 394 (93.1) | ||
| Declined to response | 49 (7.6) | 28 (12.6) | 21 (5.0) |
*Including medical imaging, laboratory medicine, stomatology, and pharmacology.
†The full course in medical university in China is 5 y.
§The father of a participant was dead.
The reliability and internal consistency and factorability of the HPV-related knowledge scale were evaluated. For the 10-item HPV knowledge scale, Cronbach’s alpha was 0.631, the KMO value was 0.624, and Bartlett’s test of sphericity was significant (P < .001). For the 6-item HPV vaccine knowledge scale, Cronbach’s alpha was 0.469, the KMO value was 0.498, and Bartlett’s test was significant (P < .001).
Knowledge about HPV
Table 2 presents the overall knowledge of the 646 respondents about HPV. While the vast majority (>90%) of the respondents were aware of HPV and knew that HPV may infect both men and women, and HPV may be transmitted by sexual contact or mother-to-child contact, 42.7% and 40.4% of the respondents mistakenly considered that HPV may be transmitted by the respiratory tract and by uptake of food and drink respectively. Notably, 25.2% (163/646) respondents did not know the etiology of HPV in cervical cancer, and as high as 50.5% (326/646) and 56.7% (366/646) did not know the association of HPV with penile cancer and oropharyngeal cancer respectively. Compared to female respondents, male respondents had less knowledge about HPV (Table 2). We further compared HPV knowledge among respondents across the five grades, from the freshmen to the fifth-year students. Figure 1 shows that while the awareness rates of HPV had no statistical difference, the awareness rates of association of HPV with cervical, penile, and oropharyngeal cancer had statistical differences.
Table 2.
Awareness of knowledge about HPV in respondents.
| Item | Overall (n = 646) | Male (n = 223) | Female (n = 423) | Statistic | P | P for FDR* |
|---|---|---|---|---|---|---|
| Had you heard of HPV before this survey? | χ2 = 13.56 | <.001 | 0.002 | |||
| Yes | 605 (93.6) | 198 (88.8) | 407 (96.2) | |||
| No | 41 (6.4) | 25 (11.2) | 16 (3.8) | |||
| Transmission route† | ||||||
| Is HPV transmitted by respiratory tract? | χ2 = 6.92 | .009 | 0.027 | |||
| Yes | 276 (42.7) | 111 (49.8) | 165 (39.0) | |||
| No | 370 (57.3) | 112 (50.2) | 258 (61.0) | |||
| Is HPV transmitted by food or drink? | χ2 = 9.12 | .003 | 0.013 | |||
| Yes | 261 (40.4) | 108 (48.4) | 153 (36.2) | |||
| No | 385 (59.6) | 115 (51.6) | 270 (63.8) | |||
| Is HPV transmitted by sexual contact? | Fisher’s | .071 | 0.141 | |||
| Yes | 637 (98.6) | 217 (97.3) | 420 (99.3) | |||
| No | 9 (1.4) | 6 (2.7) | 3 (0.7) | |||
| Is HPV transmitted by skin and/or mucosa contact? | χ2 = 1.50 | .221 | 0.354 | |||
| Yes | 525 (81.3) | 187 (83.9) | 338 (79.9) | |||
| No | 121 (18.7) | 36 (16.1) | 85 (20.1) | |||
| Is HPV transmitted by mother-to-child contact? | χ2 = 1.25 | .265 | 0.385 | |||
| Yes | 585 (90.6) | 198 (88.8) | 387 (91.5) | |||
| No | 61 (9.4) | 25 (11.2) | 36 (8.5) | |||
| May HPV infect both men and women? | Fisher’s | .015 | 0.039 | |||
| Yes | 633 (98.0) | 214 (96.0) | 419 (99.1) | |||
| No | 13 (2.0) | 9 (4.0) | 4 (0.9) | |||
| Is it true that HPV infection can be either symptomatic or asymptomatic? | χ2 = 2.94 | .086 | 0.154 | |||
| Yes | 554 (85.8) | 184 (82.5) | 370 (87.5) | |||
| No | 92 (14.2) | 39 (17.5) | 53 (12.5) | |||
| Are there many HPV types, with high-risk types causing tumors and low-risk types causing benign diseases? | χ2 = 19.14 | <.001 | 0.002 | |||
| Yes | 615 (95.2) | 201 (90.1) | 414 (97.9) | |||
| No | 31 (4.8) | 22 (9.9) | 9 (2.1) | |||
| Association of HPV with cervical cancer | χ2 = 3.44 | .064 | 0.141 | |||
| Known | 483 (74.8) | 157 (70.4) | 326 (77.1) | |||
| Unknown | 163 (25.2) | 66 (29.6) | 97 (22.9) | |||
| Association of HPV with penile cancer | χ2 = 0.01 | .929 | 0.929 | |||
| Known | 320 (49.5) | 111 (49.8) | 209 (49.4) | |||
| Unknown | 326 (50.5) | 112 (50.2) | 214 (50.6) | |||
| Association of HPV with oropharyngeal cancer | χ2 = 0.01 | .929 | 0.929 | |||
| Known | 280 (43.3) | 100 (44.8) | 180 (42.6) | |||
| Unknown | 366 (56.7) | 123 (55.2) | 243 (57.4) | |||
| Ever tested for HPV | χ2 = 0.49 | .484 | 0.596 | |||
| Yes | 25 (3.9) | 7 (3.1) | 18 (4.3) | |||
| No | 621 (96.1) | 216 (96.9) | 405 (95.7) |
*P values were adjusted using the Benjamini–Hochberg false discovery rate (FDR) procedure for the multiple comparisons across HPV knowledge items.
†HPV may be transmitted by sexual contact, skin and/or mucosa contact, and mother-to-child contact, but not by respiratory tract and not by food or drink.
Figure 1.
Knowledge about HPV and HPV vaccines among respondents in different grades. The full course in medical university in mainland China is 5 y. The number of respondents in grade 1 to 5 was 235, 146, 104, 86, and 75 respectively.
Knowledge about and attitude to HPV vaccines
Of the 646 respondents, 80 (12.4%) had not heard of HPV vaccines, 171 (26.5%) did not know that HPV vaccines may prevent cervical and other HPV-related cancers, and more than half of the respondents did not know the optimal age for HPV vaccination (Table 3). The male respondents had less knowledge about HPV vaccines than the female respondents, with statistically significant differences (Table 3). In addition, while HPV awareness rates were comparable across all five grades, the respondents in grades 1–2 were less aware than those in grades 3–5 about the association between HPV and cancers, as well as the preventive effect of HPV vaccines against HPV-related cancers (Figure 1).
Table 3.
Participants’ knowledge of and attitudes to HPV vaccines.
| Item | Overall (n = 646) | Male (n = 223) | Female (n = 423) | Statistic | P | P for FDR* |
|---|---|---|---|---|---|---|
| Awareness of HPV vaccine | χ2 = 26.19 | <.001 | <0.001 | |||
| Yes | 566 (87.6) | 175 (78.5) | 391 (92.4) | |||
| No | 80 (12.4) | 48 (21.5) | 32 (7.6) | |||
| Awareness of the effect of the vaccine in preventing cervical cancer and other related cancers | χ2 = 5.91 | .015 | 0.017 | |||
| Yes | 475 (73.5) | 151 (67.7) | 324 (76.6) | |||
| No | 171 (26.5) | 72 (32.3) | 99 (23.4) | |||
| Optimal age (years) of HPV vaccination in females | χ2 = 28.94 | <.001 | <0.001 | |||
| ≤8 | 41 (6.3) | 29 (13.0) | 12 (2.8) | |||
| 9–14 | 257 (39.8) | 81 (36.3) | 176 (41.6) | |||
| 15–45 | 339 (52.5) | 112 (50.2) | 227 (53.7) | |||
| >45 | 9 (1.4) | 1 (0.5) | 8 (1.9) | |||
| Good preventive effect of HPV vaccination before the first sexual activity | χ2 = 2.41 | .120 | 0.120 | |||
| Yes | 576 (89.2) | 193 (86.5) | 383 (90.5) | |||
| No | 70 (10.8) | 30 (13.5) | 40 (9.5) | |||
| Worry about the efficacy of HPV vaccine | χ2 = 17.28 | <.001 | <0.001 | |||
| Yes | 42 (6.5) | 20 (9.0) | 22 (5.2) | |||
| Somewhat | 338 (52.3) | 92 (41.2) | 246 (58.2) | |||
| No | 266 (41.2) | 111 (49.8) | 155 (36.6) | |||
| Concern on the adverse effect | χ2 = 16.47 | <.001 | <0.001 | |||
| Yes | 133 (20.6) | 43 (19.3) | 90 (21.3) | |||
| Somewhat | 394 (61.0) | 120 (53.8) | 274 (64.8) | |||
| No | 119 (18.4) | 60 (26.9) | 59 (13.9) | |||
| Worry about HPV infection or even related cancer if not HPV vaccination | χ2 = 38.80 | <.001 | <0.001 | |||
| Yes | 226 (35.0) | 64 (28.7) | 162 (38.3) | |||
| Somewhat | 330 (51.1) | 102 (45.7) | 228 (53.9) | |||
| No | 90 (13.9) | 57 (25.6) | 33 (7.8) | |||
| Completely free from HPV infection after HPV vaccination | χ2 = 19.41 | <.001 | <0.001 | |||
| Yes | 64 (9.9) | 38 (17.0) | 26 (6.2) | |||
| No | 582 (90.1) | 185 (83.0) | 397 (93.8) | |||
| No risk for cervical cancer after HPV vaccination | χ2 = 22.83 | <.001 | <0.001 | |||
| Yes | 59 (9.1) | 37 (16.6) | 22 (5.2) | |||
| No | 587 (90.9) | 186 (83.4) | 401 (94.8) |
*P values were adjusted using the Benjamini–Hochberg false discovery rate (FDR) procedure for the multiple comparisons across HPV vaccine knowledge items.
Table 3 also presents the respondents’ attitudes toward HPV vaccines. Most respondents (58.8%) were concerned about the efficacy of the vaccines, while only 41.2% fully believed in their effectiveness. Surprisingly, the respondents expressed worry (20.6%) or some worry (61.0%) about the adverse events of HPV vaccines, while only 18.4% were not concerned. Female respondents had more significant concerns on the efficacy and adverse effects than male respondents.
In addition, considerable proportions (9.9% and 9.1% in all respondents respectively) of respondents, particularly the male respondents (17.0% and 16.6% respectively), mistakenly considered that no HPV infection and no cervical cancer may occur after HPV vaccination (Table 3).
Uptake of HPV vaccines and associated factors in female respondents
Since none of the male respondents in the present survey was vaccinated with HPV vaccines, we just analyzed the uptake of HPV vaccines and associated factors in the female respondents. Of the 423 female respondents, 115 (27.2%) were vaccinated and 308 (72.8%) were not. Table 4 shows the factors associated with the vaccination. Family residence, childhood and adolescent residence, parents’ education and profession, family incomes, and HPV vaccine knowledge scores were associated with HPV vaccination. While the respondents in the third to fifth grades appeared to have better knowledge of HPV vaccines than those in the first and second grades (Figure 1), the coverage of HPV vaccines showed no statistically significant difference among the respondents in the different grades (Table 4). The multivariable logistic regression models included 423 female respondents, including 115 vaccinated women, with no missing data in the modeled variables. The stepwise model retained the paternal education, family income, and HPV vaccine knowledge scores (Table 5). The dimension-adjusted GVIF ranged from 1.03 to 1.40 in the full candidate model and from 1.01 to 1.04 in the final model (Table S1 in Supplemental file 2). The apparent AUC was 0.740 (95% CI 0.686–0.794), and the Hosmer–Lemeshow statistic was 6.11 (8 df, P = .635) (Figure S1 in Supplemental file 2). In the fixed sensitivity model, the income and knowledge remained to be associated with the vaccination at nominal significance levels, whereas the overall paternal education association was attenuated (P = .149) (Table S2 in Supplemental file 2).
Table 4.
Factors associated with uptake of HPV vaccines in female respondents.
| Item | Total (n = 423) | Vaccinated (n = 115) | Unvaccinated (n = 308) | Statistic | P |
|---|---|---|---|---|---|
| Age, years | 20.5 ± 1.5 | 20.5 ± 1.5 | 20.5 ± 1.5 | t = 0.41 | .685 |
| Family residence | |||||
| City | 221 (52.3) | 78 (67.8) | 143 (46.4) | χ2 = 15.37 | <.001 |
| Rural or pastoral area | 202 (47.7) | 37 (32.2) | 165 (53.6) | ||
| Ethnicity | |||||
| Han | 306 (72.3) | 88 (76.5) | 218 (70.8) | χ2 = 1.38 | .240 |
| Others | 117 (27.7) | 27 (23.5) | 90 (29.2) | ||
| Religion | |||||
| No | 422 (99.8) | 115 (100.0) | 307 (99.7) | Fisher’s | 1.000 |
| Yes | 1 (0.2) | 0 (0) | 1 (0.3) | ||
| Childhood residence | |||||
| City | 254 (60.1) | 78 (67.8) | 176 (57.2) | χ2 = 9.56 | .008 |
| Town | 83 (19.6) | 25 (21.8) | 58 (18.8) | ||
| Rural or pastoral area | 86 (20.3) | 12 (10.4) | 74 (24.0) | ||
| Adolescent residence | |||||
| City | 347 (82.0) | 102 (88.7) | 245 (79.6) | χ2 = 7.47 | .024 |
| Town | 53 (12.5) | 12 (10.4) | 41 (13.3) | ||
| Rural or pastoral area | 23 (5.5) | 1 (0.9) | 22 (7.1) | ||
| Marital status | |||||
| No | 419 (99.1) | 115 (100.0) | 304 (98.7) | Fisher’s | .684 |
| Yes | 3 (0.7) | 0 (0) | 3 (1.0) | ||
| Divorced | 1 (0.2) | 0 (0) | 1 (0.3) | ||
| University grade* | |||||
| Freshman | 152 (35.9) | 39 (33.9) | 113 (36.7) | χ2 = 3.76 | .440 |
| Sophomore | 94 (22.2) | 25 (21.7) | 69 (22.4) | ||
| Junior | 66 (15.6) | 21 (18.3) | 45 (14.6) | ||
| Senior | 59 (14.0) | 12 (10.4) | 47 (15.3) | ||
| Fifth grade | 52 (12.3) | 18 (15.7) | 34 (11.0) | ||
| Major | |||||
| Clinical Medicine | 391 (92.4) | 108 (93.9) | 283 (91.9) | χ2 = 1.81 | .405 |
| Chinese Medicine | 24 (5.7) | 4 (3.5) | 20 (6.5) | ||
| Others | 8 (1.9) | 3 (2.6) | 5 (1.6) | ||
| Paternal education | |||||
| Primary school or below | 76 (18.0) | 11 (9.6) | 65 (21.1) | χ2 = 38.72 | <.001 |
| High school | 200 (47.3) | 41 (35.6) | 159 (51.6) | ||
| Vocational school | 87 (20.5) | 29 (25.2) | 58 (18.8) | ||
| University or above | 60 (14.2) | 34 (29.6) | 26 (8.5) | ||
| Paternal occupation | |||||
| White-collar | 96 (22.7) | 45 (39.1) | 51 (16.6) | χ2 = 37.74 | <.001 |
| Small business owner | 59 (14.0) | 21 (18.3) | 38 (12.3) | ||
| Blue-collar | 86 (20.3) | 24 (20.9) | 62 (20.1) | ||
| Farmer or herdsman | 132 (31.2) | 17 (14.8) | 115 (37.3) | ||
| Unemployed | 50 (11.8) | 8 (6.9) | 42 (13.7) | ||
| Maternal education | |||||
| Primary school or below | 90 (21.3) | 16 (13.9) | 74 (24.0) | χ2 = 28.97 | <.001 |
| High school | 191 (45.2) | 39 (33.9) | 152 (49.4) | ||
| Vocational school | 86 (20.3) | 31 (27.0) | 55 (17.9) | ||
| University or above | 56 (13.2) | 29 (25.2) | 27 (8.7) | ||
| Maternal occupation | |||||
| White-collar | 80 (18.9) | 39 (33.9) | 41 (13.3) | χ2 = 33.00 | <.001 |
| Small business owner | 45 (10.6) | 18 (15.7) | 27 (8.8) | ||
| Blue-collar | 71 (16.8) | 16 (13.9) | 55 (17.8) | ||
| Farmer or herdsman | 105 (24.8) | 16 (13.9) | 89 (28.9) | ||
| Unemployed | 122 (28.9) | 26 (22.6) | 96 (31.2) | ||
| Yearly family income (Chinese Yuan, Thousand) | χ2 = 47.48 | <.001 | |||
| <20 | 61 (14.4) | 8 (7.0) | 53 (17.2) | ||
| 20–<50 | 113 (26.7) | 17 (14.8) | 96 (31.2) | ||
| 50–<100 | 131 (31.0) | 31 (27.0) | 100 (32.5) | ||
| 100–<200 | 71 (16.8) | 38 (33.0) | 33 (10.7) | ||
| ≥200 | 47 (11.1) | 21 (18.3) | 26 (8.4) | ||
| Cervical or vulvar tumor in female family members or relatives | χ2 = 6.41 | .041 | |||
| Yes | 11 (2.6) | 2 (1.7) | 9 (2.9) | ||
| No | 333 (78.7) | 100 (87.0) | 233 (75.7) | ||
| Unknown | 79 (18.7) | 13 (11.3) | 66 (21.4) | ||
| Penile cancer in male family members or relatives | χ2 = 2.14 | .144 | |||
| Yes | 0 | 0 | 0 | ||
| No | 337 (79.7) | 97 (84.4) | 240 (77.9) | ||
| Unknown | 86 (20.3) | 18 (15.6) | 68 (22.1) | ||
| Oropharyngeal cancer in any family member or relative | Fisher’s | .095 | |||
| Yes | 3 (0.7) | 0 (0.0) | 3 (1.0) | ||
| No | 345 (81.6) | 101 (87.8) | 244 (79.2) | ||
| Unknown | 75 (17.7) | 14 (12.2) | 61 (19.8) | ||
| History of sexual activity | |||||
| Yes | 8 (1.9) | 2 (1.7) | 6 (1.9) | χ2 = 0.44 | .804 |
| No | 394 (93.1) | 106 (92.2) | 288 (93.5) | ||
| Decline to response | 21 (5.0) | 7 (6.1) | 14 (4.6) | ||
| HPV knowledge score | |||||
| Mean ± Std† | 8.44 ± 1.36 | 8.07 ± 1.60 | 8.17 ± 1.55 | Wilcoxon Z = 1.93 | .054 |
| 95% CI¶ | 8.02–8.32 | 8.19–8.70 | 7.89–8.25 | ||
| Median (P25–P75) | 8.00 (7.00–10.00) | 9.00 (7.00–10.00) | 8.00 (7.00–9.00) | ||
| Min–Max§ | 2.00–10.00 | 5.00–10.00 | 2.00–10.00 | ||
| HPV vaccine knowledge score | |||||
| Mean ± Std† | 4.78 ± 1.14 | 5.03 ± 0.96 | 4.69 ± 1.19 | Wilcoxon Z = 2.41 | 0.0161 |
| 95% CI¶ | 4.56–4.83 | 4.68–4.89 | 4.85–5.20 | ||
| Median (P25–P75) | 5.00 (4.00–6.00) | 5.00 (5.00–6.00) | 5.00 (4.00–6.00) | ||
| Min–Max§ | 1.00–6.00 | 2.00–6.00 | 1.00–6.00 |
*The full course in medical university in China is 5 y. †SD, Standard Deviation. ¶CI, Confidence Interval. §Min–Max, minimum–maximum.
Table 5.
Multivariable logistic regression analysis of factors associated with HPV vaccine uptake among female respondents.
| Item | Adjusted OR (95% CI) | P |
|---|---|---|
| Paternal education | ||
| Primary school or below | Ref | |
| High school | 1.22 (0.57–2.60) | .613 |
| Vocational school | 1.89 (0.82–4.36) | .135 |
| University or above | 4.08 (1.65–10.09) | .002 |
| Yearly family income (Chinese Yuan, Thousand) | ||
| <20 | Ref | |
| 20–<50 | 1.08 (0.43–2.71) | .868 |
| 50–<100 | 1.70 (0.71–4.08) | .238 |
| 100–<200 | 4.89 (1.93–12.40) | <.001 |
| ≥200 | 2.85 (1.02–7.97) | .046 |
| HPV vaccine knowledge score | 1.32 (1.06–1.66) | .015 |
*Items with P < .05 in univariate analyses (Table 4) were included in multivariable logistic regression.
Bidirectional stepwise selection used effect-level score entry and joint Wald retention tests. Entry/retention thresholds of 0.10/0.05 were used in the final model. Apparent AUC 0.740 (95% CI 0.686–0.794); Hosmer–Lemeshow χ2 = 6.11, df = 8, P = .635.
Reasons for not being vaccinated against HPV
As an HPV vaccine (Gardasil 4) imported from USA has been approved for males since January 202517,18 and the vaccine has been discontinued since February 2025,30 and males were less likely to get vaccinated, we just analyzed the reasons for not being vaccinated among the unvaccinated females. Six reasons, vaccine cost, concerns about adverse events, doubts about efficacy, uncertainty about where to get vaccinated, lack of knowledge about the vaccine, and the belief of low risk for HPV infection and related cancers, accounted for 91.5% of the choice to not vaccinate (Figure 2).
Figure 2.
Detailed reasons for not being vaccinated against HPV in 308 female respondents. *others (16 respondents) included vaccination scheduled but not yet accept (6), no attachment of the importance to HPV vaccination (5), no time to take the vaccination (3), and misconception of not at the appropriate age for vaccination (2).
Additionally, the HPV vaccination willingness among the unvaccinated respondents was 75.9% (403/531), and the willingness was significantly higher in females than in males (86.4% vs. 61.4%, χ2 = 43.94, P < .001).
Discussion
This survey investigated the knowledge about HPV and HPV vaccines, as well as the attitude to and uptake of HPV vaccines, among the medical students in Inner Mongolia, China. Overall, 93.6% and 87.6% of the respondents were aware of HPV and HPV vaccines respectively. However, only 74.8% of the respondents knew HPV infection as the etiology of cervical cancer and only 73.5% of respondents knew the preventive effect of the HPV vaccines against the HPV-related cancers. The survey revealed the gaps in the knowledge about HPV and HPV vaccines among the medical students. Moreover, only 27.2% of the female respondents had been vaccinated with HPV vaccines and none of the male respondents had been vaccinated, indicating the gaps in reaching the WHO’s 2030 goal of 90% vaccination coverage in girls by the age of 15 y.14
Knowledge gaps about HPV and HPV vaccines in university students appear to be a global issue. The findings that 93.6% and 87.6% of the respondents were aware of HPV and HPV vaccines respectively in the present survey are similar to the findings of 91.7% and 83.7% reported in Switzerland.31 A meta-analysis showed that, of 184,351 university students in various majors across the world, 68.3% and 53.5% were aware of HPV and HPV vaccines respectively.32 The higher rate of awareness of HPV and HPV vaccines in the present study appears to be associated with the participants’ medical education background. Studies showed that, compared to non-medical students, medical students had significantly greater awareness about HPV (86.4% vs. 66.1%, p < .001) and HPV vaccines (86.6% vs. 73.7%, p < .001).22,28,33
In this survey, we found that male respondents had less knowledge about HPV and HPV vaccines than female respondents (Tables 2 and 3). This may be associated with the historical view that HPV infection causes severe outcomes only in females.34 Indeed, HPV vaccines were initially administered only in females. On the other hand, more than 50% of the respondents did not know the association of HPV with penile or oropharyngeal cancer, even among male respondents. These findings indicate inadequate education about HPV, which may influence community-level infection control and the prevention of penile and oropharyngeal cancers. Thus, the results highlight the importance of education, particularly in males.
The survey showed that most of the respondents who had not been vaccinated were willing to receive HPV vaccination. However, none of the male respondents was vaccinated, which may be due to the fact that HPV vaccination (the four valent vaccine, Gardasil 4) for males (aged 9–26 y) was not approved until January 2025,17,18,34,35 and Gardasil 4 was discontinued in February 2025.30 On the other hand, although HPV vaccines have been approved for females in China since 2016, only 27.2% (115/423) of the female respondents in this survey were vaccinated, indicating the barriers to the vaccination (Figure 2). The high cost of HPV vaccines ranked at the top, accounting for 35.7%. This is in agreement with the findings that the respondents with higher family income were more likely to be vaccinated (Table 5). The other reasons included concern about adverse events, doubts about vaccine efficacy, uncertainty about where to get vaccinated, unawareness of HPV vaccines, the belief of unnecessariness because of low risk for HPV-related cancers, and others (Figure 2). Fortunately, since November 10, 2025, China has incorporated HPV vaccines into the national immunization program for girls born after November 10, 2011,36 providing two doses of the bivalent vaccine free of charge, which may increase the vaccination coverage among girls. The other reasons for the unvaccination indicate that education on HPV and HPV vaccines is not sufficient. Studies have demonstrated the effectiveness of HPV vaccines in preventing HPV-related cancers and other diseases.6–12 In addition, HPV vaccines are highly safe, and the rate of serious adverse events following the use of 113,839,996 HPV vaccine doses was 0.04 per 1000 doses.37 Thus, enhanced education about the high effectiveness and rare side effects of HPV vaccines and easy access to the vaccines may increase the coverage of HPV vaccines. Indeed, implementation of a multi-level program to recommend “start at 9” strategy significantly increased the HPV vaccine uptake among 9–10-year-old girls from 8% to 41% at the urban practice and from 3% to 23% at the suburban practice in the USA.38 Enhancing education through social media can help increase the knowledge about HPV and HPV vaccines.39
In the present survey, 3.2% of the respondents who were not vaccinated provided no reason for unvaccination. While the proportion of these individuals is small, further exploring the reasons for the HPV vaccine hesitancy will help increase vaccination rates.
There are several limitations in the present study. First, the participants were from a medical university, which may restrict the generalizability of the findings to university students in other majors. Second, since this is a cross-sectional survey from a single region, the generalizability of the findings to other regions may be limited. Third, this survey was conducted online and the response rate was low, which may lead to potential selection bias and possible overestimation, because those who are concerned about the topic are more likely to respond. Fourth, the HPV vaccine knowledge scale had weak internal consistency (Cronbach’s alpha = 0.469) and marginal sampling adequacy (KMO = 0.498). The knowledge-scale findings should therefore be interpreted cautiously, and further validation of the questionnaire, including factor-structure assessment in an independent sample, is needed. Fifth, since the questionnaire consisted of multiple-choice questions, some answers were likely determined by speculation, but not by certainty. Sixth, the data about the HPV vaccination were self-reported, but not verified by vaccination cards, which may cause recall bias. Lastly, a higher proportion of female students participated in the survey, which may limit the representativeness of the results.
In conclusion, although Inner Mongolian medical students had high awareness of HPV and HPV vaccines, they lacked sufficient knowledge regarding the association between HPV and cancers as well as the safety and efficacy of HPV vaccines in preventing HPV-related cancers. While most of the participants expressed their intention to be vaccinated, less than one-third of the female students had been vaccinated. Enhancing education about HPV and HPV vaccines by integrating HPV education into the medical curriculum and implementing campus-based vaccination programs appears to be essential to increase the uptake of HPV vaccines in the target population.
Supplementary Material
Biographies
Yi-Hua Zhou, MD, PhD, is a professor of Departments of Laboratory Medicine and Infectious Diseases at Nanjing Drum Tower Hospital, Nanjing University Medical School. Dr. Zhou received his Doctor of Medicine from Nihon University, Tokyo, Japan, in 1999, and then performed postdoctoral research in Nihon University. Dr. Zhou was employed as a research fellow in Dr. Purcell’s Viral Hepatitis Section, NIAID, NIH, USA, from 2002 to 2006. He has joined in Nanjing Drum Tower Hospital as a chief of Department of Laboratory Medicine since December 2006. His research mainly focuses on viral diseases, particularly in the prevention of mother-to-child transmission of hepatitis B virus in cooperation with the Department of Obstetrics and Gynecology at Nanjing Drum Tower Hospital, and the emerging infectious diseases. Dr. Zhou is an author or co-author of more than 150 articles published in peer-reviewed international journals.
Haixia Meng, MD, is a professor and chief of the Department of Obstetrics at the Affiliated Hospital of Inner Mongolia Medical University. Her research interest focuses on obstetric complications, including mother-to-child transmission of infectious diseases. Dr. Meng is an author or co-author of more than 60 articles published in peer-reviewed Chinese and English journals.
Funding Statement
This work was supported by a grant for Special Project for Scientific and Technological Innovation Development in Inner Mongolia Autonomous Region [2026YFSH0167], China.
Disclosure statement
No potential conflict of interest was reported by the author(s).
Data availability statement
The data used in this study is available upon reasonable request.
Supplementary material
Supplemental data for this article can be accessed online at https://doi.org/10.1080/21645515.2026.2738975
References
- 1.Dürst M, Gissmann L, Ikenberg H, zur Hausen H.. A papillomavirus DNA from a cervical carcinoma and its prevalence in cancer biopsy samples from different geographic regions. Proc Natl Acad Sci USA. 1983;80(12):3812–14. doi: 10.1073/pnas.80.12.3812. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Walboomers JM, Jacobs MV, Manos MM, Bosch FX, Kummer JA, Shah KV, Snijders PJ, Peto J, Meijer CJ, Munoz N. Human papillomavirus is a necessary cause of invasive cervical cancer worldwide. J Pathol. 1999;189(1):12–19. doi: 10.1002/(SICI)1096-9896(199909)189:1<12:AID-PATH431>3.0.CO;2-F. [DOI] [PubMed] [Google Scholar]
- 3.Gillison ML, Koch WM, Capone RB, Spafford M, Westra WH, Wu L, Zahurak ML, Daniel RW, Viglione M, Symer DE, et al. Evidence for a causal association between human papillomavirus and a subset of head and neck cancers. J Natl Cancer Inst. 2000;92(9):709–720. doi: 10.1093/jnci/92.9.709. [DOI] [PubMed] [Google Scholar]
- 4.Orengo JC, Bierrenbach AL, Aranda Flores CE, Lopez ED, Oliveira JCB, Queijo RG, Parellada CI. Trends in the burden of HPV-associated cancers in Mexico: an analysis from 2011 to 2019. PLOS ONE. 2025;20(11):e0335307. doi: 10.1371/journal.pone.0335307. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Tian T, Fu L, Li Y, Yong L, Lu Z, He J, Yu W, Asilibek SL, Zhang Z, Zhen C, et al. Global trends in the incidence of cancer attributable to human papillomavirus infection: a population-based study. Int J Cancer. 2025;157(8):1590–1599. doi: 10.1002/ijc.35520. [DOI] [PubMed] [Google Scholar]
- 6.Brotherton JML, LaMontagne DS, Bloem PJN. Global status of HPV vaccination two decades in: effective, safe and preventing cancer. Expert Rev Vaccin. 2026;25(1):2609869. doi: 10.1080/14760584.2025.2609869. [DOI] [PubMed] [Google Scholar]
- 7.Zhang Y, Fakhry C, D’souza G. Projected association of human papillomavirus vaccination with oropharynx cancer incidence in the US, 2020–2045. JAMA Oncol. 2021;7(10):e212907. doi: 10.1001/jamaoncol.2021.2907. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Wang Z, Zhang H, Zhu Y, Jiang Y, Yang D, Zou X, Fang Y. Comprehensive evaluation of prophylactic HPV vaccines: a systematic review and meta-analysis of efficacy, safety, and immunogenicity in males and females. Front Immunol. 2026;16:1747082. doi: 10.3389/fimmu.2025.1747082. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Montero-Macías R, Adam M, Rouzier R, Bonneau C. HPV vaccination efficacy in primary and tertiary prevention of vulvar and vaginal HPV-related high grade dysplasia and cancers: a systematic review. Hum Vaccin Immunother. 2025;21(1):2567704. doi: 10.1080/21645515.2025.2567704. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10.Chodick G, Strassberg M. Association between human papillomavirus vaccination and the risk of cervical cancer and precancerous lesions in Israel: a retrospective cohort study. J Clin Med. 2026;15(3):995. doi: 10.3390/jcm15030995. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11.Kitano T, Yoshida S. Nine-valent human papillomavirus vaccination and related cancers in males. JAMA Oncol. 2026;12(6):e260496. doi: 10.1001/jamaoncol.2026.0496. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12.Tuli A, Jit M, Abbas K, Portnoy A. Projections of human papillomavirus (HPV) vaccination impact on non-cervical cancer outcomes among women in 117 low- and middle-income countries: a modelling study. BMJ Glob Health. 2026;11(8):e021127. doi: 10.1136/bmjgh-2025-021127. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13.World Health Organization . Human papillomavirus (HPV) vaccination coverage. 2024. [accessed 2026 May 4]. https://immunizationdata.who.int/global/wiise-detail-page/human-papillomavirus-(hpv)-vaccination-coverage.
- 14.World Health Organization . Global strategy to accelerate the elimination of cervical cancer as a public health problem. 2020. [accessed 2026 May 4]. https://www.who.int/publications/i/item/9789240014107.
- 15.Yan M, Yang Y, Zhao Y, Ma L, Yang Y, Zheng R. Prevalence and genotype distribution of high-risk human papillomavirus infection among Chinese women aged 35–64: a national screening population-based study. J Infect. 2026;92(3):106697. doi: 10.1016/j.jinf.2026.106697. [DOI] [PubMed] [Google Scholar]
- 16.Wu S, Jiao J, Yue X, Wang Y. Cervical cancer incidence, mortality, and burden in China: a time-trend analysis and comparison with England and India based on the global burden of disease study 2019. Front Public Health. 2024;12:1358433. doi: 10.3389/fpubh.2024.1358433. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 17.Xiaoyu W. HPV vaccine for males approved in China. chinadaily.com.cn. 2025. Jan 8 [accessed 2026 Sep 6]. https://www.chinadaily.com.cn/a/202501/08/WS677e4266a310f1265a1d9b66.html.
- 18.MERCK . Merck’s GARDASIL® receives expanded approval for males in China. 2025. Jan 8 [accessed 2026 Sep 6]. https://www.merck.com/news/mercks-gardasil-receives-expanded-approval-for-males-in-china/.
- 19.Chen J, Zhang Z, Pan W, Song Y, Zheng L, Li L, Ye J, Cao L, Yu W. Estimated human papillomavirus vaccine coverage among females 9–45 years of age — China, 2017–2022. China CDC Wkly. 2024;6(19):413–417. doi: 10.46234/ccdcw2024.080. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 20.Rajaie S, Emamgholipour S, Azari S, Karimi Z, Karimi F. Acceptance and the willingness to pay for human papillomavirus (HPV) vaccine: a systematic review. Hum Vaccin Immunother. 2026;22(1):2609345. doi: 10.1080/21645515.2025.2609345. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 21.Liu Y, Di N, Tao X. Knowledge, practice and attitude towards HPV vaccination among college students in Beijing, China. Hum Vaccin Immunother. 2020;16(1):116–123. doi: 10.1080/21645515.2019.1638727. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 22.Abudurexiti G, Muhetaer K, Yang J, Zhuo Q, Qi T, Saimi Z, Ouyang Y, Yu H, Yilamujiang P, Adili N, et al. HPV vaccine knowledge gaps and vaccination intent: a cross-sectional study of vocational students in Southern Xinjiang of China in 2023. BMC Public Health. 2025;26(1):102. doi: 10.1186/s12889-025-25209-3. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 23.Yang L, Xing C, Yu X, Xu Y, Wang W, Chang C, Lu Q. Coverage of HPV vaccination and influencing factors among female college students in Northern China. Vaccines (Basel). 2025;13(6):598. doi: 10.3390/vaccines13060598. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 24.Zhang R, Du J, Zhang Z. The intention and influencing factors of human papillomavirus vaccination among female students in the secondary vocational schools in East China: a cross-sectional study. Front Public Health. 2025;13:1467546. doi: 10.3389/fpubh.2025.1467546. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 25.Nie R, Ma Z, Rui X, Li T. HPV vaccination willingness and behavior among nursing female students in China based on the protection motivation theory: a cross-sectional study. Hum Vaccin Immunother. 2025;21(1):2569738. doi: 10.1080/21645515.2025.2569738. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 26.Xu Y, Wang W, Cheng C, Yang L, Xing C, Yang X, Chang C, Lu Q. Factors influencing HPV vaccination willingness among male college students in Jinan according to the health belief model. Sci Rep. 2025;15(1):30369. doi: 10.1038/s41598-025-16299-5. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 27.Su Y, Luo F, Fang J, Zheng S, Chen Y, Zhou N, Dai W, Zhang Y, He H, Liu G. Knowledge, attitudes, and willingness towards HPV vaccine among male college students in Zhejiang Province, China. Hum Vaccin Immunother. 2025;22(1):2585549. doi: 10.1080/21645515.2025.2585549.]. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 28.Hu Q, Rui Y, Jiang J, Yang J, Yao H, Yang X, Liu Z, Li C, Pan H, Xie Y. Awareness regarding human papillomavirus and willingness for vaccination among college students with or without medical background in Guizhou Province. Hum Vaccin Immunother. 2024;20(1):2295992. doi: 10.1080/21645515.2023.2295992. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 29.Taha H, Alhawamdeh T, Alkhaldi SM, Ali Albsoul R, Al-Ani A, Awamleh S, Al-Maayeh AY, Qaqish A, Mahmoud A, Abu-Surrah D, et al. Knowledge and attitudes of medical students regarding human papilloma virus infection and vaccine: cross-sectional study from Jordan. Front Cell Infect Microbiol. 2025;15:1657090. doi: 10.3389/fcimb.2025.1657090. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 30.MERCK . Merck announces fourth-quarter and full-year 2024 financial results. 2025. Feb 4 [accessed 2026 Sep 6]. https://www.merck.com/news/merck-announces-fourth-quarter-and-full-year-2024-financial-results/.
- 31.Zens K, Baer N, Nur S, Renner S, Lang P. Knowledge, attitudes, and behaviors toward human papillomavirus vaccination among adults in Switzerland. JAMA Netw Open. 2026;9(3):e262780. doi: 10.1001/jamanetworkopen.2026.2780. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 32.Li W, Jin Y, Li X, Jin M. Human papillomavirus and vaccine knowledge, willingness, and uptake among university students: a systematic review and meta-analysis. BMC Public Health. 2025;25(1):4268. doi: 10.1186/s12889-025-25626-4. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 33.Mikołajczyk A, Lemkowska E, Mikołajczyk M. Awareness of virus-cancer links and willingness to vaccinate against a cancer-associated virus by HPV vaccination status among polish students: a cross-sectional study. Vaccines (Basel). 2026;14(4):335. doi: 10.3390/vaccines14040335. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 34.Wong LP, Chen X, Huang Z, Zimet G, Zhao Q, Lin Y, Hu Z. Addressing male HPV vaccination in China: a narrative review of challenges and opportunities. Hum Vaccin Immunother. 2025;21(1):2552061. doi: 10.1080/21645515.2025.2552061. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 35.Xing Y, Shi R, Li Y, Cai R, Ma T, Yuan X, Li L, Jiang Z, Gao W. Human papillomavirus awareness and vaccination willingness among male community residents in Beijing based on the Health Belief Model. Hum Vaccin Immunother. 2026;22(1):2641328. doi: 10.1080/21645515.2026.2641328. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 36.China National Center for Disease Control and Prevention . Notice on incorporating human papillomavirus vaccine in the national immunization program. 2025. Oct 10 [accessed 2026 Sep 6]. https://www.ndcpa.gov.cn/jbkzzx/ZCWJ/common/content/content_2038860923709853696.html.
- 37.Brown H, Nasreen S. Serious adverse events following human papillomavirus vaccination: a systematic review and meta-analysis of post-marketing evidence. Hum Vaccin Immunother. 2026;22(1):2635247. doi: 10.1080/21645515.2026.2635247. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 38.Malik S, Gu S, Sisskind J, Blatt S, Suryadevara M. Increasing HPV vaccine uptake using a “start at 9“ strategy: a pilot program. Vaccine. 2026;78:128401. doi: 10.1016/j.vaccine.2026.128401. [DOI] [PubMed] [Google Scholar]
- 39.Zhang L, Zhang S, Liu S, Jian W. Human papillomavirus vaccination policies and discourse on social media. JAMA Health Forum. 2026;7(2):e256425. doi: 10.1001/jamahealthforum.2025.6425. [DOI] [PMC free article] [PubMed] [Google Scholar]
Associated Data
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Supplementary Materials
Data Availability Statement
The data used in this study is available upon reasonable request.