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. 2021 Dec 6;94(6):2776–2786. doi: 10.1002/jmv.27478

Willingness to human papillomavirus (HPV) vaccination and influencing factors among male and female university students in China

Zhenwei Dai 1, Mingyu Si 1, Xiaoyou Su 1,✉, Wenjun Wang 2, Xi Zhang 3, Xiaofen Gu 4, Li Ma 5, Jing Li 6, Shaokai Zhang 7, Zefang Ren 8, Youlin Qiao 1,9,✉
PMCID: PMC9299831  PMID: 34825712

Abstract

This study compared the willingness to receive human papillomavirus (HPV) vaccination and the influencing factors between male and female university students who had never been vaccinated against HPV in China. University students were recruited from seven universities in China. A self‐administered questionnaire was used to collect information about demographic characteristics, willingness to HPV vaccination, and possible influencing factors including demographics, knowledge, and attitude toward HPV vaccination. The χ 2 test was used to test the difference between males and females' knowledge and attitudes to HPV vaccination. Multivariate logistic regression was employed to detect the factors associated with willingness to HPV vaccination. A total of 7335 university students participated in the survey (3570 males and 3765 females). Over 70% of the participants had previously received sex education and knowledge. The average age of sexual debut was 17.5 years old. More male students reported acceptance of premarital sex than female students did (χ 2 = 708.458, p < 0.001). Female students had better knowledge and attitudes to HPV in general, while male students perceived a higher chance of being infected by HPV compared with female students (χ 2 = 6.047, p =  0.014). The level of knowledge (male: adjusted odds ratio [AOR] = 1.935, 95% confidence interval [CI]:1.516–2.470; female: AOR = 1.227, 95% CI: 1.055–1.428) and receiving sex education (male: AOR = 1.414, 95% CI: 1.109–1.804; female: AOR = 1.289, 95% CI: 1.064–1.562) were indicators of the HPV vaccination willingness for both genders. For male students, those who had ever inoculated optional self‐paid vaccines were more likely to receive the HPV vaccine than those who had not (AOR = 1.567, 95% CI: 1.242–1.977). Female students were more willing to be vaccinated against HPV, if they had higher living expenses (AOR = 1.395 and 3.717, 95% CI: 1.071–1.426 and 1.776–7.752), relatives or friends had certain cancer (AOR = 1.290, 95% CI: 1.095–1.518), ever had sexual experiences (AOR = 2.628, 95% CI: 1.788–3.863), and had ever consulted on HPV vaccination issues (AOR = 1.612, 95% CI: 1.367–1.901). In China, more active education should be provided to improve university students' knowledge and attitudes on HPV and HPV vaccination. Including HPV vaccine uptake for both males and females at recommended ages in National Immunization Program would be the most cost‐effective way to prevent HPV infection.

Keywords: China, human papillomavirus, university students, vaccination

Highlights

This is the first large sample cross‐sectional study with a good coverage of different geographical locations in China to investigate and compare the willingness to human papillomavirus vaccination and influencing factors among male and female university students in China.

Abbreviations

ACIP

Advisory Committee on Immunization Practices

HPV

human papillomavirus

1. INTRODUCTION

The human papillomavirus (HPV) is one of the most common sexually transmitted infections worldwide. 1 It is estimated that about 80% of sexually active women and men will be infected with certain HPV types during their lives. 2 While females have an overall high prevalence of HPV infection and some may develop into cervical cancer, 3 previous studies proved that HPV infection can also result in cancers in men (e.g., penile cancer and anal cancer). 4 , 5 The prevalence of HPV infection in males ranges from 5.3% to 42.2% worldwide and approximately 10.5% reported in China. 6 , 7 , 8

In the United States, the Advisory Committee on Immunization Practices (ACIP) recommended that HPV vaccination should be given to girls and boys at the age of 11 or 12 years old, and they urged catch‐up HPV vaccination for all people up to the age of 26 years old in June 2019. 9 , 10 However, although National Immunization Programs offering free or discounted mandatory HPV vaccination are available in over 110 countries as of October 2020, it is still yet to be covered by the Chinese government in a short period of time. 11 , 12 , 13 In China, the cost‐effective HPV vaccination has been suggested for males aged 9–15 years old and females aged 9–45 years old. 14 The three‐dose HPV vaccine series has been available for women with a total price of around $ 300 since it was approved by the China Food and Drug Administration in 2016. 15 Despite the emerging demand for HPV vaccination among males, it has not been approved for use in mainland China. 16 Compared with many other countries, China faces obstacles in effectively preventing HPV infection due to the accessibility and affordability issues of HPV vaccination. Furthermore, former studies indicated that awareness and knowledge of HPV vaccination among Chinese is still relatively low, especially among university students. 17

Individuals aged 18–26 years old, who are most often university students, have the highest rate of new HPV infection. 18 The average age of sexual debut varies in different countries and cultural contexts. In Europe, America, and China, it was 19, 16, and 17 years old, respectively. 19 , 20 , 21 , 22 With the declining age of sexual debut and compromised condom use, young Chinese students are susceptible to sexually transmitted infections including HPV. 23 , 24 A cross‐sectional study aimed at university students in Jinan, China showed that gender was a significant factor of knowledge, attitude, and willingness toward HPV vaccination, 25 which indicated that males and females might have different levels of knowledge and attitude to HPV vaccination, as well as dissimilar willingness to receive it. 26 Compared with previous studies that aimed at students from specific regions in China, this study is a multicenter and school‐based survey on knowledge, attitude, and willingness toward HPV vaccination among university students in China. It aims to explore and compare the willingness to HPV vaccination, as well as influencing factors such as knowledge and attitude between male and female university students in China who have not been vaccinated against HPV, and thus to provide evidence for the future intervention of HPV vaccination and relevant policy‐making in China.

2. MATERIAL AND METHODS

2.1. Measures

This cross‐sectional study used an online questionnaire containing 35 questions to measure the knowledge, attitude, and willingness to HPV vaccination. In the part of knowledge and attitude, we included two aspects of measures: (1) knowledge and attitude to health and sexual behavior (six items, e.g., “Vaccines can effectively prevent diseases,” “I accept premarital sex”), and (2) knowledge and attitude to HPV‐ related issues (nine items, e.g., “I have ever heard of HPV related diseases, such as genital warts and cervical cancer,” “HPV infection is very serious and will affect my life on campus”). 27 , 28 , 29 , 30 In the part of willingness, we chose a single item to measure whether one is willing to be vaccinated against HPV (“Yes” or “No”). For female students, the item was “Do you want to be vaccinated against HPV in the next 6 months?,” while for male students was “Are you willing to receive HPV vaccine when it is approved among men in mainland in the future?”. Additionally, we asked participants to provide their demographic information such as age, ethnicity, and living expenses (yuan/month).

2.2. Study settings and recruitment

To guarantee the representativeness of the research findings, we recruited participants from seven comprehensive universities located in seven geographical territories of China: Shandong University in East China, Zhongshan University in South China, Zhengzhou University in Central China, Capital Normal University in North China, Sichuan University in Southwest China, Dalian University of Technology in Northeast China, and Xinjiang University in Northwest China by convenience sampling. The purposive selection of these universities resulted in good coverage of different geographic locations of the country. This study follows the regulations of Measures for the Ethical Review of Biomedical Research Involving Humans (implemented on December 1, 2016) of the National Health Commission of the People's Republic of China. Before the survey, all participants signed an informed consent after they agreed to attend the study.

Participants were screened at each university for their eligibility to participate in the study by their teachers. The inclusion criteria were as follows: (1) university students over 18 years old; (2) first‐ and second‐year undergraduate students; (3) no vaccination contraindications; (4) had a mobile phone or computer access; and (5) had never been vaccinated against HPV before. The exclusion criteria were as follows: (1) under 18 years old; (2) nonundergraduate first‐ or second‐year students; (3) previous history of vaccination contraindications; (4) medical students; and (5) current pregnant or breast‐feeding women.

2.3. Data analysis

Descriptive analyses were performed to examine the participants' demographic characteristics, as well as their knowledge and attitude to health, sexual behavior, and HPV. χ 2 tests were used to test the differences between males and females based on these items. Univariate logistic regression analysis began with a full set of demographics, knowledge, and attitude toward health and sexual behavior, knowledge, and attitude toward HPV, and so on, to evaluate the associations of willingness to HPV vaccination. Significant variables (p ≤ 0.10) in the univariate analysis were further incorporated into the multivariate logistic regression analysis. Adjusted odds ratio (AOR) and the corresponding 95% confidence intervals (CIs) were calculated to assess the results of the regression model. All analyses were conducted using SPSS 26.0, with level of significance determined at a 0.05 p value.

3. RESULTS

3.1. Demographic characteristics

A total of 7440 university students participated in the survey. One hundred and five people were excluded from our analysis because they had previously been vaccinated against HPV. As a result, the analysis employed data of 7335 university students (3570 male and 3765 female).

Table 1 shows the sociodemographics of the participants. The average age of participants was 19.22 years old. Among the participants, 48.7% were males, 46.9% majored in Art, 89.2% were Han ethnicity, 1.2% had a religious belief, 64.4% lived in a city as their residence place, and 24.4% had parents with an undergraduate or above educational level. A total of 70.9% spent 1000–2000 yuan per month on their living expenses and 23.4% had relatives or friends with cancer. The age gap between male students and female students was statistically significant (χ 2 = 104.215, p < 0.001). Specifically, female students were younger than male students in this study. Significantly more male students majored in science than female students (χ 2 = 105.593, p < 0.001) and more male students were Han than female students (χ 2 = 16.513, p < 0.001).

Table 1.

Demographic characteristics of participants

Variable Gender Total (%) χ 2 p
Male (%) Female (%)
Age (year)
18 435 (12.2) 693 (18.4) 1128 (15.3) 104.215 <0.001
19 2016 (56.5) 2231 (59.3) 4247 (57.9)
≥20 1119 (31.3) 841 (22.3) 1960 (26.8)
Major
Art 1454 (40.7) 1984 (52.7) 3428 (46.9) 105.393 <0.001
Science 2116 (59.3) 1781 (47.3) 3897 (53.1)
Ethnicity
Han 3239 (90.7) 3305 (87.8) 6544 (89.2) 16.531 <0.001
Other 331 (9.3) 460 (12.2) 791 (10.8)
Religion
Yes 44 (1.4) 34 (1.1) 78 (1.2) 1.513 0.219
No 3068 (98.6) 3142 (98.9) 6210 (98.9)
Missing value 458 (12.8) 589 (15.6) 1047 (14.3)
Residence
City 2304 (64.5) 2419 (64.2) 4723 (64.4) 0.066 0.797
Village 1266 (35.5) 1346 (35.8) 2612 (35.6)
Residence of parents
City 2322 (65.0) 2399 (63.7) 4721 (64.4) 1.400 0.237
Village 1248 (35.0) 1366 (36.3) 2614 (35.6)
Education level of parents
Secondary school or below 1582 (44.3) 1694 (45.0) 3276 (44.7) 5.441 0.066
Senior and vocational high school 1147 (32.1) 1122 (29.8) 2269 (30.9)
Undergraduate or above 841 (23.6) 949 (25.2) 1790 (24.4)
Living expenses (Yuan/Month)
<1000 728 (20.4) 771 (20.5) 1499 (20.4) 1.819 0.611
1000–2000 2522 (70.6) 2679 (71.2) 5201 (70.9)
2001–3000 275 (7.7) 279 (7.4) 554 (7.6)
>3000 45 (1.3) 36 (1.0) 81 (1.1)
Relatives or friends have cancer
Yes 801 (22.4) 913 (24.2) 1714 (23.4) 3.362 0.067
No 2769 (77.6) 2852 (75.8) 5621 (76.6)
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3.2. Knowledge and attitude to HPV vaccine

Table 2 shows participants' knowledge and attitude to health and sexual behavior. The majority of male and female students equally believed that vaccines can effectively prevent diseases (χ 2 = 0.350, p = 0.554). There is no statistically significant difference between male and female students in having ever inoculated the optional self‐paid vaccines (χ 2 = 0.927, p = 0.336). Female students were more likely than male students to receive sexual education and knowledge (χ 2 = 29.387, p < 0.001). Female students reported the same age of sexual debut as male students (χ 2 = 0.358, p = 0.550). The mean age of the sexual debut of the participants was 17.5 years old, and less than 5% of the participants had previously had sexual intercourse. Compared with male students, female students were more likely to be single (without a boyfriend/girlfriend) (χ 2 = 11.953, p = 0.001). Male students were more likely to agree with and engage in premarital sex than female students (χ 2 = 708.458, p < 0.001).

Table 2.

Participants' knowledge and attitude to health and sexual behavior(n = 7335)

Item Gender Total (%) χ 2 p
Male (%) Female (%)
Vaccines can effectively prevent diseases
Yes 3305 (92.6) 3499 (92.9) 6804 (92.8) 0.350 0.554
No 265 (7.4) 266 (7.1) 531 (7.2)
Ever paid for optional self‐paid vaccines
Yes 2333 (65.4) 2420 (64.3) 4753 (64.8) 0.927 0.336
No 1237 (34.6) 1345 (35.7) 2582 (35.2)
Ever received sex education and knowledge
Yes 2631 (73.7) 2977 (79.1) 5608 (76.5) 29.387 <0.001
No 939 (26.3) 788 (20.9) 1727 (23.3)
Age of first sexual behavior
<18 100 (2.8) 45 (1.2) 145 (2.0) 0.358 0.550
≥18 151 (4.2) 59 (1.6) 210 (2.9)
None 3319 (93.0) 3661 (97.2) 6980 (95.2)
Mean ± SD 17.552 ± 1.5329 min:10 max:22
Single
Yes 2840 (79.6) 3114 (82.7) 5954 (81.2) 11.953 0.001
No 730 (20.4) 651 (17.3) 1381 (18.8)
Acceptance of premarital sex
Yes 2471 (69.2) 1438 (38.2) 3909 (53.3) 708.458 <0.001
No 1099 (30.8) 2327 (61.8) 3426 (46.7)
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Table 3 shows participants' knowledge and attitude to HPV. Female students were more likely than male students to have ever heard of HPV (χ 2 = 239.532, p < 0.001) and HPV‐related diseases (χ 2 = 81.839, p < 0.001). For questions regarding the HPV vaccine, female students were more likely to have ever heard of HPV vaccine (χ 2 = 231.593, p < 0.001) and to have ever actively consulted on HPV vaccination issues (χ 2 = 108.926, p < 0.001). However, male students were more concerned about the risk of HPV infection than female students (χ 2 = 6.047, p = 0.014). While female students were more likely than male students to believe in the protection of the HPV vaccine (χ 2 = 37.594, p < 0.001), they were less willing to be vaccinated against HPV (χ 2 = 2533.642, p < 0.001) and to encourage their friends to be vaccinated (χ 2 = 402.377, p < 0.001).

Table 3.

Participants' knowledge and attitude to HPV (n = 7335)

Item Gender Total (%) χ 2 p
Male (%) Female (%)
I have ever heard of HPV
Yes 1493 (41.8) 2255 (59.9) 3748 (51.1) 239.532 <0.001
No 2077 (58.2) 1510 (40.1) 3587 (48.9)
I have ever heard of HPV‐related diseases, such as genital warts and cervical cancer
Yes 1754 (49.1) 2246 (59.7) 4000 (54.4) 81.839 <0.001
No 1816 (50.9) 1519 (40.3) 3335 (45.5)
I have ever heard of HPV vaccine
Yes 1410 (39.5) 2156 (57.3) 3566 (48.6) 231.593 <0.001
No 2160 (60.5) 1609 (42.7) 3769 (51.4)
I have ever actively consulted on HPV vaccination
Yes 774 (21.7) 1225 (32.5) 1999 (27.3) 108.926 <0.001
No 2796 (78.3) 2540 (67.5) 5336 (72.7)
HPV infection is very serious and will affect my life in campus
Yes 1924 (53.9) 1962 (52.1) 3886 (53.0) 2.336 0.126
No/Uncertain 1646 (46.1) 1803 (47.9) 3449 (47.0)
I think I have risk of infecting HPV
Yes 404 (11.3) 360 (9.6) 764 (10.4) 6.047 0.014
No/Uncertain 3166 (88.7) 3405 (90.4) 6571 (89.6)
Vaccination against HPV helps protect me from HPV infection
Yes 2548 (71.4) 2922 (77.6) 5470 (74.6) 37.594 <0.001
No/Uncertain 1022 (28.6) 843 (22.4) 1865 (25.4)
I am willing to be vaccinated with HPV vaccine
Yes 3201 (89.7) 1208 (32.1) 4409 (60.1) 2533.642 <0.001
No 369 (10.3) 2557 (67.9) 2926 (39.9)
I am willing to encourage my friends to be vaccinated with HPV vaccine
Yes 3212 (90.0) 2689 (71.4) 5902 (80.5) 402.377 <0.001
No 357 (10.0) 1076 (28.6) 1433 (19.5)
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Abbreviation: HPV, human papillomavirus.

3.3. Variables associated with willingness to vaccination

Table 4 shows the results of the factors associated with willingness to be vaccinated with the HPV vaccine. In univariate logistic regression, it was indicated that for male students, the 16 predictor variables “Ethnicity,” “Residence,” “Residence of parents,” “Education level of parents,” “Living expenses,” “Relative or friends have cancer,” “Ever heard of HPV,” “Ever heard of HPV related diseases,” “Ever heard of HPV vaccine,” “Level of knowledge,” “Vaccines can effectively prevent diseases,” “Ever had optional self‐paid vaccinations,” “Ever received sex education and knowledge,” “ever actively consulted on HPV vaccination issues,” “Ever had sexual behavior,” “Acceptance of premarital sex” were statistically significant and were later employed in multivariate logistic regression to predict male students’ willingness to the HPV vaccine among male students. A similar procedure was also applied to female students.

Table 4.

Univariate and multivariate analysis on participants' willingness to vaccinate against HPV

Item Willing to vaccinate with HPV vaccine
Male Female
Yes OR p AOR 95% CI p Yes OR p AOR 95% CI p
Age (year)
18 390 (89.7%) 1 206 (29.7%) 1
19 1830 (90.7%) 0.881 0.469 719 (32.2%) 0.890 0.216
≥20 981 (87.7%) 1.219 0.276 283 (33.7%) 0.834 0.101
Ethnicity
Han 2919 (90.1%) 1 1 1050 (31.8%) 1
Other 282 (85.2%) 0.631 0.005 0.813 0.573–1.153 0.245 158 (34.3%) 1.124 0.267
Religion
No 2762 (90.0%) 1 952 (30.3%) 1
Yes 41 (93.2%) 1.514 0.490 11 (32.4%) 1.1 0.796
Residence
City 2108 (91.5%) 1 1 858 (35.5%) 1 1
Village 1093 (86.3%) 0.587 <0.001 0.710 0.409–1.235 0.225 350 (26.0%) 0.639 <0.001 0.961 0.629–1.466 0.851
Residence of parents
City 2120 (91.3%) 1 1 850 (35.4%) 1 1
Village 1081 (86.6%) 0.617 <0.001 0.929 0.536–1.611 0.793 358 (26.2%) 0.647 <0.001 0.900 0.591–1.370 0.622
Education level of parents
Secondary school or below 1386 (87.6%) 1 1 464 (27.4%) 1 1
Senior and vocational high school 1056 (92.1%) 0.609 <0.001 0.816 0.612–1.088 0.166 375 (33.4%) 0.751 0.001 0.946 0.788–1.137 0.554
Undergraduate or above 759 (90.2%) 0.764 0.053 1.373 0.980–1.925 0.066 369 (38.9%) 0.593 <0.001 0.953 0.775–1.173 0.651
Living expenses (Yuan/Month)
<1000 622 (85.4%) 1 <0.001 1 196 (25.4%) 1 1
1000–2000 2280 (90.4%) 0.623 <0.001 0.820 0.626–1.074 0.150 859 (32.1%) 1.385 <0.001 1.031 0.844–1.258 0.769
2001–3000 259 (94.2%) 0.362 <0.001 0.583 0.323–1.052 0.073 130 (46.6%) 2.558 <0.001 1.395 1.012–1.923 0.042
>3000 40 (88.9%) 0.733 0.524 1.525 0.560–4.150 0.409 23 (63.9%) 5.181 <0.001 3.717 1.776–7.752 <0.001
Relatives or friends have cancer
No 2463 (88.9%) 1 1 850 (29.8%) 1 1
Yes 738 (92.1%) 1.455 0.009 1.119 0.831–1.507 0.457 358 (39.2%) 1.519 <0.001 1.290 1.095–1.518 0.002
I have ever heard of HPV
No 1808 (87.0%) 1 1 349 (23.1%) 1 1
Yes 1393 (93.3%) 2.073 <0.001 1.335 0.931–1.914 0.117 859 (38.1%) 2.047 <0.001 1.192 0.951–1.495 0.128
I have ever heard of HPV‐related diseases, such as genital warts and cervical cancer
No 1567 (86.3%) 1 1 385 (25.3%) 1 1
Yes 1634 (93.2%) 2.164 <0.001 1.291 0.980–1.700 0.069 823 (36.6%) 1.704 <0.001 1.027 0.867–1.216 0.759
I have ever heard of HPV vaccine
No 1888 (87.4%) 1 1 370 (23.0%) 1 1
Yes 1313 (93.1%) 1.95 <0.001 0.973 0.670–1.411 0.884 838 (38.9%) 2.129 <0.001 1.251 0.997–1.569 0.053
Level of knowledge
Low 1276 (84.4%) 1 1 489 (26.3%) 1 1
High 1925 (93.5%) 2.677 <0.001 1.935 1.516–2.470 <0.001 719 (37.7%) 1.692 <0.001 1.227 1.055–1.428 0.008
Vaccines can effectively prevent diseases
No 196 (74.0%) 1 1 68 (25.6%) 1 1
Yes 3005 (90.9%) 3.526 <0.001 2.492 1.813–3.425 <0.001 1140 (32.6%) 1.407 0.019 1.058 0.787–1.421 0.710
Ever paid for optional self‐paid vaccines
No 1052 (85.0%) 1 1 393 (29.2%) 1 1
Yes 2149 (92.1%) 2.054 <0.001 1.567 1.242–1.977 <0.001 815 (33.7%) 1.23 0.005 1.08 0.928–1.258 0.321
Ever received sex education and knowledge
No 788 (83.9%) 1 1 184 (32.1%) 1 1
Yes 2413 (91.7%) 2.121 <0.001 1.414 1.109–1.804 <0.001 1024 (34.4%) 1.721 <0.001 1.289 1.064–1.562 0.009
Ever actively consulted on HPV vaccination
No 2483 (88.8%) 1 1 660 (26.0%) 1 1
Yes 718 (92.8%) 1.616 0.001 1.023 0.738–1.418 0.891 548 (44.7%) 2.306 <0.001 1.612 1.367–1.901 <0.001
Ever had sexual behavior
No 2959 (89.3%) 1 1 1149 (31.4%) 1 1
Yes 242 (94.5%) 2.074 0.009 1.558 0.878–2.763 0.129 59 (54.6%) 2.628 <0.001 1.646 1.088–2.490 0.018
Single
No 658 (90.1%) 1 252 (38.7%) 1 1
Yes 2543 (89.5%) 0.937 0.638 956 (30.7%) 0.701 <0.001 0.837 0.692–1.011 0.065
Acceptance of premarital sex
No 943 (85.8%) 1 1 662 (28.4%) 1 1
Yes 2258 (91.4%) 1.754 <0.001 1.429 1.131–1.805 0.003 546 (38.0%) 1.54 <0.001 1.12 0.960–1.306 0.149
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Abbreviations: AOR, adjusted odds ratio; CI, confidence interval; HPV, human papillomavirus; OR, odds ratio.

In the multivariate analysis, among the male students, students with higher HPV knowledge scores were almost twice more likely to take the HPV vaccine than those with lower knowledge levels (AOR = 1.935, 95% CI: 1.516–2.470). Students who believed vaccines can effectively prevent diseases were over twice more likely to take the vaccine than those who did not (AOR = 2.492, 95% CI: 1.813–3.425). Students who ever had optional self‐paid vaccinations were more likely to take the HPV vaccine than those who did not (AOR = 1.567, 95% CI: 1.242–1.977). Students who ever received sex education were more willing to vaccination (AOR = 1.414, 95% CI: 1.109–1.804). Students who accepted premarital sex were more willing to be vaccinated (AOR = 1.429, 95% CI: 1.131–1.805). Among female students, the probability of willingness to HPV vaccine significantly increased as the living expenses increased (AOR = 1.395, 95% CI: 1.071–1.426; and AOR = 3.717, 95% CI: 1.776–7.752). Students whose relatives or friends had certain types of cancer were more likely to receive the vaccine (AOR = 1.290, 95% CI: 1.095–1.518). Students who had high knowledge scores (AOR = 1.227, 95% CI: 1.055–1.428), ever received sex education (AOR = 1.289, 95% CI: 1.064–1.562), and ever actively consulted on HPV vaccination issues (AOR = 1.612, 95% CI: 1.367–1.901) were more willing to be vaccinated against HPV. Additionally, students who ever had sexual experience were almost three times more likely to take the vaccine than those who had not (AOR = 2.628, 95% CI: 1.788–3.863) (Table 4).

4. DISCUSSION

The average age of participants in this study was 19.22 years old, which is around the first peak age of HPV infection in China. 31 In this study, up to 89.7% of male students indicated that they would be willing to be vaccinated against HPV if it became available in mainland China, while only 32.1% of the female students, the target population of HPV vaccination, indicated that they would be willing to get vaccinated in the following 6 months. Therefore, it is very important to explore the willingness to HPV vaccination and its influencing factors among male and female university students in China.

In this study, over 70% of female and male students had ever received sex education and knowledge. However, a considerable proportion of male students had never heard about HPV (58.2%), HPV‐related diseases (50.9%), or HPV vaccine (60.5%). Despite the fact that sex education curriculum has been introduced to China for more than 30 years, it is still inadequate in terms of content and frequency of its delivery. This might result from the traditional Chinese cultural context, which fosters a conservative attitude toward sex issues. However, it is concerning that there also exists the trend of earlier sexual intercourse among youngsters than decades ago. 32 Under this circumstance, it is worthwhile to explore effective ways to help university students avoid sexually transmitted diseases. In some western countries like Britain, the average age of sexual debut is around 19 years old, while in America, the average age is around 16 years old. 19 , 21 While in our study, apart from 95.2% of the participants who still had no sexual debut yet, the average age of sexual debut was 17.5 years old for both male and female students, indicating that they normally began their active sexual life when they were freshmen in university. In China, 70% of people had premarital sex in 2012, up from 15% in 1989. 33 The increasing rate of premarital sex urged us to address the related health issues caused by sexual behaviors. Consistent with a previous study, 25 we found that more male university students had more love affairs than female students (20.4% vs. 17.3%), male students were more likely to accept premarital sexual behavior (69.2% vs. 38.2%), and the rates of male and female students who ever had sexual behavior were 7.2% and 2.9%, respectively. Additionally, though anal sexual behavior between men had been historically regarded as a taboo, it is an emerging concern of contracting and spreading sexually transmitted diseases including genital warts among university students in China. 33 Therefore, given that the HPV vaccine is not yet available for males in mainland China even for men who have sex with men (MSM), and research has shown that the improvement of sex education in China can finally enhance the intention of HPV vaccination in both sexes, 17 the needs for appropriate, comprehensive and timely sex education among male students are of great urgency to prevent and control sexually transmitted diseases. 16 , 34

In addition, the affordability and accessibility of HPV vaccination should be addressed in China. Currently, the supply of HPV vaccine is insufficient to cover all recommended‐age customers when they demand the vaccination, not to mention the relatively high price for university students to afford. 35 Sometimes, the HPV vaccination becomes a privilege for those with better social economic status. Since the HPV vaccine is accessible among female students in China, the government should ensure that as many female students as possible should be vaccinated against HPV, while also considering policies that would allow male students to be inoculated with the HPV vaccine. Otherwise, the transmission of HPV would be unavoidable through both heterosexual and same‐sex routes.

In our study, female students had better knowledge and attitude to HPV in general. While female students were more likely to consult on the HPV vaccine and believe its effectiveness, male students were more willing to be vaccinated with HPV vaccine than female students (89.7% vs. 32.1%). HPV infection is common in males in China, 36 while most studies concentrated on the topic of HPV infection in females because of the serious results of cervical cancer, and only a rare amount of the studies focused on an emerging epidemic of HPV‐related cancers in males. 36 , 37 Another research aimed at studying the knowledge of HPV among male university students in China also revealed that male university students lacked the knowledge about HPV and lacked sufficient information to decide whether or not to take HPV vaccination compared with their female counterparts. 16 Considering the attitudes to HPV and its vaccination, more male students were afraid of their exposure to HPV infection than female students. This can further interpret the reason that more male students were willing to be vaccinated and encourage their friends to be vaccinated with the HPV vaccine. These findings suggested that only providing sex education and enhancing students' understanding of HPV infection are insufficient to promote the protection of students. Based on the present situation and results of this study, future research should pay more attention to interventions aimed at improving university students' perceptions of threat and severity of HPV and HPA‐related diseases.

Among the variables affecting willingness to vaccination, the level of knowledge and having ever received sex education were both the indicators of the willingness of male and female students. According to the theory of planned behavior (TPB), one's behavior intention will be affected by his attitude, and further affects behavior. 38 This indicated that students who have a good knowledge or had ever received education in some aspects tend to pay more attention to potential sexually transmitted diseases and take measures to cope with these infections. This suggests that improving attitudes and knowledge of HPV, as well as relative education, is an effective way to enhance university students' willingness to be vaccinated with the HPV vaccine.

For male students, those who had ever inoculted optional self‐paid vaccines were more willing to be vaccinated. Willingness to pay for the vaccines uncovered by the National Immunization Program indicated that they valued their health and were ready for taking action to prevent disease, making them more willing to be vaccinated against HPV. 39 For female students, living expense is an important factor in their willingness to be vaccinated. Some research indicate that China failed to promote the HPV vaccine mainly because of its high price. 15 , 25 In China, the majority of the population who can get access to HPV vaccines are females, hence female students were more sensitive to the money it takes by evaluating their living expenses than males. 40 In America, 65% of university students were willing to take the vaccination only if it was free. 41 A pilot project among teenage girls in one of the counties in China on promoting free HPV vaccination also showed a high HPV vaccination rate and intention. 42 In this case, to encourage more students to be vaccinated, policies aimed at including the HPV vaccine in the Expanded Program on Immunization and providing financial subsidies on vaccination could be helpful. 43

5. LIMITATIONS

This study has certain limitations. First, the questionnaire was designed by our research team, its validity and reliability were not tested before the research. However, the questions used in this study were based on a thorough literature search which covered various issues in this area. Second, we should take caution when interpreting the findings of our study, because a drawback of the cross‐sectional study is that we can not make any statements regarding causality.

6. CONCLUSIONS

Sex education and awareness should be improved among both male and female university students in China. Including the HPV vaccine for both males and females of appropriate age in the Expanded Program on Immunization would be the most cost‐effective way to prevent HPV infection.

CONFLICT OF INTERESTS

The authors declare that there are no conflict of interests.

ETHICS STATEMENT

This study has been approved by the Institutional Review Board of Chinese Center for Disease Control and Prevention on October 24, 2019 (approval number: 201918‐01).

AUTHOR CONTRIBUTIONS

Xiaoyou Su, Zhenwei Dai prepared the first draft. Youlin Qiao provided overall guidance, managed the overall project. Mingyu Si, Wenjun Wang, Xi Zhang, Xiaofen Gu, Li Ma, Jing Li, Shaokai Zhang and Zefang Ren were responsible for the questionnaire survey in seven geographical regions of China. Xiaoyou Su, Zhenwei Dai and Mingyu Si analyzed data.

ACKNOWLEDGMENTS

Asian Regional Special Cooperation Fund of National Health Commission of the People's Republic of China (BLXM01) and Innovation Fund for Medical Sciences sponsored by Chinese Academy of Medical Sciences (2019‐I2M‐2‐005, 2017‐I2M‐B&R‐17).

Dai Z, Si M, Su X, et al. Willingness to human papillomavirus (HPV) vaccination and influencing factors among male and female university students in China. J Med Virol. 2022;94:2776‐2786. 10.1002/jmv.27478

Mingyu Si is a Joint first author.

Contributor Information

Xiaoyou Su, Email: suxiaoyou@hotmail.com.

Youlin Qiao, Email: qiaoy@cicams.ac.cn.

DATA AVAILABILITY STATEMENT

The data that support the findings of this study are available from the corresponding author, Xiaoyou Su, upon reasonable request.

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Associated Data

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

Data Availability Statement

The data that support the findings of this study are available from the corresponding author, Xiaoyou Su, upon reasonable request.

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