Knowledge, attitude, and behavior of human papillomavirus vaccination among undergraduate students in Shanghai, China

Cervical cancer is second to breast cancer in the overall cancer-related mortality among women all over the world. In China, cervical cancer mortality has steadily increased over the years and Chen et al.¹ reported that, in 2015, there were an estimated 98,900 new cervical cancer cases and 30,500 deaths. The discovery that persistent high-risk human papillomavirus (HPV) infection which is sexually transmitted, contributes to the development of cervical cancer^2–4 brings possibilities for preventing and controlling this disease. In June 2006, the first vaccine against HPV, bivalent, was licensed by the US Food and Drug Administration (FDA),⁵ followed by 4-valent in 2009⁶ and 9-valent in 2014.⁷ Although national immunization policies for HPV have been adopted in many countries since 2006,⁸ it was not until July 2016 that China Food and Drug Administration approved the bivalent vaccine in the mainland of China.⁹ The comprehensive prevention and control guidelines for cervical cancer in China stated that the target population for HPV vaccination was 13–15 years old middle school adolescents.⁹ On the other hand, as the HPV vaccine has only been recently introduced in China, the guidelines also suggested women under 45 years old to take the vaccine preventing HPV infection.⁹ However, the women’s perspectives on the HPV vaccine and whether they would take it or not have not been revealed. College students are active in their social life and their perception of the likelihood of HPV infection and perspective on HPV vaccination are to be understood. Therefore, this study is going to explore undergraduates’ behavior regarding such a new vaccine, as well as the essential influencing factors for vaccination decision-making. The study is based on the Health Belief Model to explore the health-seeking behavior for HPV infection prevention¹⁰ in Shanghai. The study result can provide advice for future HPV vaccine implementation programs in mainland China for young women.

In this study, we assessed awareness of cervical cancer, HPV prevention, and HPV vaccinations. The study identified that undergraduates had a high awareness (86.9%) of cervical cancer, with a significant difference between health science and non-health science majors. Malignant tumor is one of the life-threatening diseases. Undergraduates, especially those with health science backgrounds had more opportunities to study for it and would pay more attention to the disease compared with non-health science major students. However, the perception or understanding of the cause of cervical cancer (38.9%) and the way to prevent it (8.7%) remained low. The knowledge level of HPV prevention and HPV vaccination in study participants was lower than that of university students in other countries.^11–13 The reason could be that the HPV vaccine was introduced to China in 2016, later than many Western countries. On the other hand, the perception rates on HPV and HPV vaccines of undergraduates in this study were higher than the rates of a general group in mainland China.¹⁴ Chinese undergraduates had lower awareness of HPV and HPV vaccines compared to their peers in other countries whereas higher than the general citizens within their same circumstance. This implied that the university students could be the more sensible population to health new issues and developments. Although health science students demonstrated statistically higher awareness of HPV vaccine than non-health science students, they had not shown an equivalent higher HPV vaccination rate. The barriers and gaps between perception and action were needed to be explored.

The present study found a moderate level of knowledge (5.027 ± 1.680 of a maximum of 10) associated with cervical cancer, HPV infection, and HPV vaccination. This result was similar to the knowledge level of colleague women in Yoda’s study¹² and that of colleague students in Bertram and Niederhuaser’s study.¹¹ Students had a good understanding of the possible consequences of HPV infection (77%), the necessity of a Pap smear after HPV vaccination (72%), the symptom of cervical, etc. (58.9%); whereas comparatively less understanding on the chances of HPV infection through a lifetime (32.7%), cervical cancer high-risk population (30.2%), the appropriate time for HPV vaccination (24.2%), etc. Health science students stated a significantly deeper understanding of most (8 of 10) and overall HPV-related questions than non-health science students. With increased exposure to the pathophysiological knowledge of cancer, nursing students were supposed to have more comprehensive knowledge of cervical cancer. The professional classes, speeches, and materials that nursing students could attend and reach were incomparable for language students. Therefore, it was reasonable to see that non-health science students were less familiar with cervical cancer and HPV.

Perceived effectiveness, negative consequence, and barriers associated with HPV vaccine were generally assessed by the Likert scale questions. Overall, participants’ attitudes toward HPV vaccine were at a moderate level (14.722 ± 2.609 of range 5–25). Similar questions were asked to assess participants’ attitudes on the HPV vaccine in other papers, and descriptive rate, such as 66.7% of women concerned about the side effects,¹⁵ was used to analyze and present the results.^13,15–17 It seemed that like the findings from other studies, participants’ attitudes toward HPV attitude were neutral or in a dilemma. They were positive about the necessity and benefits of the HPV vaccine, however, concerned about the side effects, price, and accessibility of the vaccine. Demographic characters had limited influence on attitude, whereas awareness of cervical cancer and its pathogen contributed to a more positive attitude toward HPV vaccine. Participants seemed to be concerned about the risk of cervical cancer and expected the prevention measure, however, not confident enough about the current measure.

The potential future behavior on receiving and promoting the HPV vaccine was correlated to many factors. Coincident with other studies, awareness, and knowledge lead to more likely future behavior on receiving HPV vaccine.^16,18,19 However, the impact of knowledge weakened in the multiple linear regression which indicated that knowledge was not the directed leading factor to health behavior. Zhang et al.¹⁸ found that adolescents’ mothers who had more knowledge than fathers showed a less willingness to vaccinate their children. Health behavior could be complicatedly influenced by many factors. A deeper understanding may lead to a person’s belief of barriers overwhelming benefits and result in not taking health action.

The Health Belief Model¹⁰ reveals that modifying variables, perceived susceptibility, severity, benefits, barriers, and cues to action could explain and predict health-related behavior, particularly in regard to the uptake of health services, for instance, HPV vaccination. Modifying variables consist of age, gender, race, and so on. Perceived susceptibility and severity, in this study, stood for individual’s perceptions of the risk of contracting cervical cancer and the seriousness of leaving unprotected. Education by diverse approaches could be a meaningful intervention to increase awareness and knowledge of a health condition.²⁰ Nursing students possessed better knowledge than language students could also be evidence. Perceived benefits and barriers, in this study, are presented for individuals’ perceptions of the effectiveness and impediments of vaccination to prevent cervical cancer. Again education should be a useful way to reveal and explain related health issues.²⁰ This would furthermore form individual’s attitude and decide his/her final action of taking or not taking the action. Zhang et al.¹⁸ found a negative relationship between knowledge and potential action. This study did not find an evident positive relationship between knowledge and happened or future potential action. The possible reason could be that the effectiveness of the HPV vaccine has not been proved and accepted because of the short implementation period. Diverse and multiple information from various countries, especially where the HPV vaccine was earlier introduced and progressed, with no limitation on potential side effects should be provided to offer a comprehensive version. Furthermore, the public would need the time to observe, reflect, and make final actions.

It would take time for a new health product to be aware, understood, accepted, and received. Education providing and information sharing are expected to break the dawn and make the procedure processed. This large scale study selected undergraduate students who are the targeted age group for HPV vaccination as the participants. Their knowledge, attitude, and practice/behavior of HPV vaccination, as well as the essential influencing factors for vaccination decision-making, would innovate the future strategy on the promotion and application of the HPV vaccine. However, this study only recruited undergraduate students from one university, so the generalizability could be the limitation. In the future, students from diverse institutes could be researched to enrich the findings in this research field.