https://orcid.org/0009-0006-2514-8441
Figures
Abstract
Human Papillomavirus (HPV) is a sexually transmitted infection associated with genital warts and multiple cancers. HPV awareness and vaccine coverage remain low in mainland China. With the rise of digital social media, young people increasingly acquire knowledge and information online, influencing their perceptions and decisions. Impact of social media on HPV knowledge and vaccine hesitancy remains unclear. The study aimed to assess the knowledge and awareness of HPV and its vaccines hesitancy among young adults in China using an online structured questionnaire with implied consent. Our findings showed that 94.4% of respondents had heard of HPV, with most aware of its sexual transmission and risks to both men and women. However, gaps in knowledge and misconceptions were identified, particularly concerning the asymptomatic nature of HPV infections and the lack of effective antiviral treatments for HPV. Misconceptions about HPV and vaccine safety were notable, contributing to vaccine hesitancy. Yet 78.4% of participants believed in the effectiveness of HPV vaccine, and 83.5% expressed their willingness to receive vaccination if recommended by a doctor. Although overall awareness of HPV and HPV vaccination was high, significant knowledge gaps and misconceptions remain. Thereby reshaping public perception and enhancing awareness, trust and motivation for HPV vaccination are under challenge. Addressing misinformation through strategic educational initiatives could enhance trust in HPV vaccination and improve coverage, ultimately reducing the burden of HPV-related diseases in China.
Citation: Li M, Liang L, Chen X, Zhu Z, Fang C, Zhou R (2025) Bridging knowledge gaps: An observational study on HPV awareness and misconceptions among young adults in China. PLoS One 20(12): e0337518. https://doi.org/10.1371/journal.pone.0337518
Editor: Morufu Olalekan Raimi, Federal University Otuoke, NIGERIA
Received: June 24, 2025; Accepted: November 10, 2025; Published: December 1, 2025
Copyright: © 2025 Li et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: All relevant data are within the manuscript and its Supporting Information files.
Funding: This pilot study is supported by the major project of the National Social Science Fund of China, “Research on the Innovative Development of Disabled Persons’ Social Organizations under the Background of Healthy China Strategy” (Number: 22&ZD185).
Competing interests: The authors have declared that no competing interests exist.
1 Introduction
Human Papillomaviruses (HPVs) are a diverse group of small DNA viruses, comprising approximately 450 different subtypes, that primarily infect the skin and mucosal surfaces [1]. The incidence of HPV is particularly high among young adults, peaking around 25–29 years of age before stabilizing or slightly declining [2]. HPV infection is the most common viral infection worldwide, with many cases being subclinical or asymptomatic infections [1]. Often the individual might not notice the infection unless an HPV genotyping test was done. While some HPV types, notably HPV6 and 11, cause benign lesions such as genital warts and papilloma [1,3], which are classified as sexually transmitted infected diseases, others are associated with more severe outcomes. Persistent infection with high-risk HPV types, particularly HPV 16 and 18, can lead to pre-malignant dysplasia that may progress into HPV-associated cancers of cervix, vagina, vulva, anus, penis, and oropharynx [3]. Indeed, hrHPVs are detected in over 90% of cervical cancer cases [4], underscoring their significant public health impact around the world [3].
The development of prophylactic vaccines targeting the most relevant HPV subtypes has proven highly effective in preventing HPV infections and their associated cancers [3]. These vaccines are available in bivalent (against HPV 16 and 18), quadrivalent (against HPV 6, 11, 16 and 18) and 9-valent (against HPV 6, 11, 16, 18, 31, 33, 45, 52 and 58) [5]. Since the first global launch of an HPV vaccine in 2006, Chinese authorities eventually approved Cervarix (GlaxoSmithKline Biologicals SA, Belgium) in 2016, Gardasil 4 (Merck & Co., USA) in 2017, and Gardasil 9 (Merck & Co., Inc) in 2018 for use in mainland China [6,7]. To alleviate the global burden of HPV-related diseases, the World Health Organization (WHO) has set an ambitious goal that 90% girls aged 9–14 years to be fully vaccinated against HPV by 2030 [8]. Despite the global initiative, China bears the second-highest absolute number of cervical cancer cases and deaths worldwide [5,9]. According to the WHO IARC GLOBOCAN 2022 estimates, the age-standardized incidence rate in China is approximately 13.8 per 100,000 women, and the mortality rate is 4.5 per 100,000. While the absolute numbers of cases and deaths are among the highest globally, the rates are relatively lower than in some other regions, largely due to its large population base [5,10,11]. The financial burden is substantial; a study by Chen et al. estimated the average cost of invasive cervical cancer in China ranging from US Dollar ($) 15,034.9 to $ 27,332.6 depending on disease stage [12], imposing a significant economic impact on families and the healthcare system. Similar economic impacts have been documented in other countries, highlighting the universal cost of HPV-related morbidity.
Recent data report relatively low HPV vaccination coverage across mainland China, with stark disparities among different age groups [9]. The highest first-dose HPV vaccine coverage (14.2%) was observed among women aged 20–24 years, while the lowest was in the 9–14 age group (4.0%) [9]. Full three-dose coverage was similarly uneven, with the highest rate in the 25–29 age group (9.39%) and the lowest in the 9–14 age group (0.31%) in 2022 [9]. These disparities are thought to result from a range of factors, including limited public knowledge, regional health care access, vaccine cost, and gender-specific policy limitations [6]. Financial issues might be a major consideration for vaccine-uptake in mainland China. Even if manufacturers adopt a low-price strategy, creating a more affordable and accessible vaccine environment, compared to imported vaccine (ranging from $ 299-$597 in Hong Kong, China), the price of domestic vaccine may cost less than $150, which is still the most expensive vaccine in mainland China [6]. Yet despite the expanded availability and reduced cost, vaccine uptake remains low. This evolving scenario suggests the importance of addressing persistent gaps in public awareness and combating vaccine hesitancy driven by misinformation.
Understanding the attitudes of younger Chinese adults-especially those Z-generation are individuals born around the turn of the 21st century-is key to identify new intervention opportunities. These demographic has been raised and grown up in a digital connected society, with broad access to education and online information, including health content disseminated through video-based and interactive social media platforms, representing a group with potentially high levels of HPV awareness [13]. However, HPV coverage among young girls is alarmingly low [9]. Existing studies have initially focused on public awareness or older generation, leaving a gap in understanding the specific attitudes and knowledge of the younger generation, especially those who belong to tech-savvy cohorts. In recent years, digital media and social networking platforms have emerged as powerful tools in public health education. Platforms like Zhihu, Weibo, TikTok, WeChat, and Xiaohongshu (RED) are widely used by younger Chinese populations and have shown protentional in disseminating HPV-related content. Studies have reported that social-media based interventions can improve health related knowledge, correct misinformation, and increase HPV -related awareness [14,15]. However, few have specifically focused on the Z-generation in China- an emerging demographic with high digital literacy but low vaccine coverage. Health Belief Model (HBM) is one of the most widely used conceptual frameworks under cognitive theory and developed to explain why many people fail to participate in programs preventing disease [16–18]. In this study we applied the HBM with adjustments to evaluate the health behaviour and to explain changes in HPV associated health behaviour.
The present study aims to explore the level of knowledge, awareness, and attitudes towards HPV and HPV vaccination among Chinese young adults, the Z-generation. By focusing on this cohort, we designed and conducted the current study to provide valuable insights into the current state of HPV awareness among young, educated Chinese adults and highlight critical areas where public health initiatives can be strengthened. Additionally, awareness levels still vary widely across different regions and populations, often reflecting disparities in economic and educational access. By examining the influence of social media on health information dissemination, this research also aims to inform the development of more effective, targeted communication strategies to improve HPV vaccination coverage in China.
2 Materials and methods
2.1 Study design, ethical approval and participants
The observational study received approval from the institutional review board (IRB) of Sun Yat-sen University (SJC-IRB-2024004) on April 25, 2024, and was conducted in the accordance with institutional, national and international ethical guidelines, including the principles of the 1964 Helsinki Declaration and its later amendments. Neither participants, the funders, nor the public were involved in the study design, conduct, data collection and analysis, decision to publish, or preparation of the manuscript.
Informed consent was implied through the voluntary completion of the anonymous online questionnaire, as approved by the IRB. Before accessing the survey, participants were provided with an online information sheet detailing the purpose of the study, its voluntary nature, the anonymity and confidentiality of their responses. They were informed of their right to withdraw at any time without explanation. Only those who agreed to participate proceeded with the survey.
All participants were 18 years or older. Between 26.04.2024 and 22.05.2024, a total of 250 male and female participants were recruited using convenience sampling from Sun Yat-sen University. Research team members approached eligible students on campus and via university-affiliated online channels, such as WeChat student groups. The number of students approached was not systematically recorded, and therefore, cannot calculate a precise response rate. Findings should be interpreted as representing the responses of this specific student group, rather than the broader university or general population. The sample size was calculated using the formular for estimating a single proportion. Assuming a conservative proportion (p) of 0.5 for maximum variability, a 95% confidence level, and a margin of error (d) of 0.07, a minimum samples size of 196 participants was required. Our final sample of 250 participants exceeded this requirement.
Data collection was conducted online using a professional online questionnaire survey platform, miniApp called Wenjuanxing (Zhongyan Technology Co., Ltd. Changsha, China), easily accessible via phone, tablet, or computer. No compensation or financial reward was provided for participation.
2.2 Questionnaire content
The questionnaire was available in both English and Chinese (S1 Appendix_EN and S2 Appendix_CN) and underwent content validation and piloting. Three medical doctors validated the content for relevance and accuracy. A piloted test with 50 conveniently selected participants was conducted to evaluate clarity and readability, resulting in a Cronbach’s alpha value of 0.816, indicating good internal consistency and reliability. Nevertheless, we acknowledge that some items-particularly those related to subjective concepts such as frequency or severity-may have been interpreted differently by respondents. The raw data from surveys is provided in S3 Dataset as Supporting Information.
The survey consists of four key perspectives: 1) demographic data; 2) basic knowledge of HPV and HPV infection; 3) health beliefs about HPV infection; and 4) concerns and attitudes about HPV vaccination. In the section assessing basic knowledge of HPV and HPV infection, participants responded to questions with ‘yes’, ‘no’, and ‘don’t know/not sure’. Correct answers were not indicated to participants, and the correct rate (%) was later analysed to assess general awareness rather than factual knowledge in all cases.
The HBM was selected as the conceptual framework for this study as it effectively captures the psychosocial factors influencing health behaviours like vaccination [16–18]. While other validated HPV knowledge and assess perceptions that directly predict behavioural intention, such as perceived susceptibility, benefits, and barriers. This approach aligns with recent studies investigating HPV vaccine hesitancy in similar young adult population [16,17]. This section comprised 18 items categorized into five domains: 1) perceived susceptibility to HPV infection (items 1–4); 2) perceived severity of potential HPV infection (items 5–8); 3) perceived benefits of preventing HPV infection (items 9–12); 4) potential barriers to HPV vaccination (items 13–15); and 5) self-efficacy related to receiving HPV vaccination (items 16–18). Participants rated their agreement with each statement using a 5-point Likert scale, ranging from ‘Strongly disagree’ to ‘Strongly agree’. Mean scale scores for each item were calculated and compared with corrected Likert-intervals as suggested by J. Pimentel [19], to predict the willingness of participants to receive HPV vaccine. Pimentel intervals are designed to produce more accurate confidence intervals for proportions by accounting for the ordinal nature of Likert scale data. Unlike standard methods, they avoid assuming equal distances between response options, helping to prevent overinterpretation of numerical values and providing more reliable estimates of variability [19,20]. The corrected Likert-intervals were applied to represent the five response categories: strongly disagree (interval 1.00–1.79), disagree (interval 1.80–2.56), neutral (interval 2.60–3.39), agree (interval 3.40–4.19), and strongly agree (interval 4.20–5.00).
3 Statistical analysis
All data were entered and analysed via SPSS software, Version 23. Descriptive statistics were used to analyse demographic data, and to assess overall awareness and misconceptions. Categorical variables were summarized as frequencies and percentages. Bivariate analyses were conducted to test specific hypotheses: 1) that there would be no significant differences in concerns about the HPV vaccine (side effects, cost, safety) between males and females (using χ² Test, as presented in Table 4); and 2) that there would be a significant association between gender and trust in social media as a source of HPV information (using χ² Test, as presented in Table 5). In the HBM section, a mean value was calculated for each item using the Likert scale. The distribution of mean scale scores across the corrected Likert-intervals was then used to assess participants’ perceptions and predict their willingness to receive the HPV vaccine. As the online questionnaire required responses to all fields before submission, there were no missing data, and thus no imputation methods were required.
4 Results
A total of 250 participants completed the study. The demographic characteristics of the attendees are summarized in Table 1. Among the respondents, 62.0% (n = 155/250) were female, and 85.2% were aged 18–26 years. The majority (94.0%) belonged to the Han ethnic group, and 89.6% were majoring in non-biomedical field, while 10.4% were in biomedical-related majors. No statistically significant difference in educational level was observed between females and males (p = 0.584, χ²-Test), indicating that the educational differences between genders did not influence the respondents’ awareness or concerns.
4.1 Basic knowledge and awareness of HPV and HPV vaccination
To assess the understanding of HPV and HPV vaccination, participants’ basic knowledge and awareness were weighed up using 18 statements (Table 2). Of the 236 participants aware of HPV, knowledge was high regarding its sexual transmission (63.6%, n = 150/236), its ability to infect both men and women (78.0%, n = 184/236), and its link to unsafe sex (83.1%, n = 196/236). Over 60% understood its link to cervical cancer and other cancers. Most believed in the vaccine’s efficacy (78.4%, n = 185/236) and worth (81.8%, n = 193/236). However, critical knowledge gaps were identified: only 28.8% (n = 68/236) knew HPV infections are often asymptomatic, and merely 12.7% (n = 30/236) were aware there is no antiviral treatment for the infection itself. Common misconceptions included beliefs that the vaccine affects the menstrual cycle (37.7% correct response rate) and that it is too late to vaccinate after infection (36.0% correct response rate).
4.2 Health belief about HPV and HPV vaccination
The HBM was further employed to predict participants’ willingness to receive HPV vaccine. Responses were measured on a 5-point (5’) Likert scale (1’ = strongly disagree, 5’ = strongly agree) and are presented in Table 3 and visualized in Fig 1. While Table 3 shows mean scale scores for each item, indicating the overall attitude and interpreted through five corrected Likert-intervals, the stacked bar charts in Fig 1 display the percentage of responses in each category, providing a detailed view of the response distribution.
Bars indicate the percentage of responses in each category, color-coded as: strongly agree (deep green), agree (light green), neutral (grey), disagree (yellow), and strongly disagree (brown). Number Q1 to Q18 in the X axis indicates the 18 different items in the health belief model.
Respondents perceived HPV as highly infectious to the general population (mean scale 3.52), especially among sexually active individuals (mean scale 3.85). However, they perceived their own susceptibility as lower (mean scale 2.56–3.20).
Higher mean scale (3.48–3.98) were noted in assessing the perceived severity of potential HPV infection, with the belief that ‘HPV infection can cause death’ scoring 3.16. Attendees expressed strong confidence in the benefits of HPV vaccination and motivation for vaccination in its effectiveness with mean scale ranging from 3.75 to 4.13. However, concerns about the vaccine’s safety and potential side effects remained (mean scale 3.25–3.42), as did worries about the time and effort required for HPV vaccination (mean scale 3.05). Overall, participants showed a positive attitude towards HPV vaccine uptake (mean scale 3.70–4.06). At last, most of the respondents (83.5%, n = 197/236) indicated that they would be willing to receive the HPV vaccine if recommended by a doctor, while only 4.7% (n = 11/236) stated they would decline such a recommendation.
4.3 Concerns about HPV vaccine
To further explore concerns and attitudes about HPV vaccine, additional questions were analyzed by sex and overall, as shown in Table 4. The most common concern was the potential side effects of HPV vaccine, cited by 79.2% (n = 187/236) of respondents. Cost of the HPV vaccine was also a significant concern, with 64.4% (n = 152/236) expressing their worry. In contrast, only 1.58% (n = 41/236) of respondents doubted the effectiveness and safety of the vaccine. Concerns about HPV vaccine side effects were similar between females (78.8%) and males (80.0%) (p = 0.828). No significant sex-based differences were observed for cost (p = 0.179), vaccine effectiveness/safety (p = 0.934), or other concerns (p = 0.080).
4.4 Sex differences in sourcing and trust of social media for HPV information
To investigate the role of social media as a source for HPV information dissemination, participants were asked about their usage and trust. Results were showed in Table 5. Of the participants who had heard of HPV or the HPV vaccines, most (77.5%, n = 183/236) reported obtaining related knowledge from social media with no statistical differences observed between female and male participants (p = 0.260), highlighting the powerful influence of social media on health information dissemination. A notable sex difference was observed in social media usage, with a higher proportion of female participants (51.3%, n = 121/236) reporting obtaining information through social media compared to males (26.3%, n = 62/236).
Regarding trust in the accuracy of HPV related information obtained on social media, opinions were mixed: 41.5% (n = 98/236) regarded it as trustworthy, while 49.2% (n = 116/236) were neutral. However, a statistically significant association was found between sex and trust (p = 0.034). This association was primarily driven by distrust; although only 9.3% (n = 23/236) of all participants found social media untrustworthy, male respondents were disproportionately represented in this group.
5 Discussion
This study assessed HPV knowledge, misconceptions, and health beliefs among young adults in China. Overall, a high awareness of HPV (94.4%) and strong belief in vaccine efficacy was found. However, substantial gaps in understanding the infection’s nature history and prevalent misconceptions about vaccine safety were identified. Although participants generally perceived HPV as a severe disease, many underestimated their personal susceptibility. Social media was the primary information source for most (77.5%), but trust in this information varies significantly by gender.
Our finding of a high overall awareness is consistent with recent studies among university students in China [21], confirming a positive trend in HPV knowledge among educated youth. Nevertheless, specific misconceptions remain, particularly regarding the asymptomatic nature of HPV and the misconception that vaccination is irrelevant after infection. These recurring patterns highlight a common and ongoing challenge that extends beyond our sample [21]. For example, our data reveal that a striking 31.8% of respondents incorrectly believed that vaccination is ineffective after HPV infection and another 32.2% expressed uncertainty. Despite these misconceptions and knowledge gaps, the majority held positive attitudes towards the vaccine: 78.4% trusted the effectiveness of HPV vaccine, and 81.8% believed that receiving HPV vaccine was worthwhile. Unique to our study is the detailed application of the HBM, which revealed a disconnect between the high perceived severity of HPV-related diseases (mean scale 3.16–3.98) and the neutral perception of personal susceptibility (mean scale 2.56–3.20). This nuance might be missed in knowledge-based surveys. The HBM assessment also showed a strong self-efficacy regarding vaccination (mean scale 3.70–4.06), consistent with prior reports [21–24], while perceived barriers to vaccination such as safety concerns were moderate (mean scale 3.05–3.42).
The financial burden of vaccination emerged as a major barrier in our study and is well-documented in the Chinese context [5,8], particularly among students without a regular income. This emphasizes the importance of recent policy developments, notably the Chinese government’s announcement to incorporate HPV vaccination into the national immunization program for females of eligible age (National Health Commission, September 11, 2025) [25], making a significant step towards improving vaccine accessibility. However, while such policy initiatives are crucial for removing cost barriers, our findings indicate that financial support alone is insufficient, consistent with previous studies [26–28]. Disparities in awareness persist across factors such as rural-urban residence, gender, race, ethnicity, and educational attainment [21–24]. These results highlight the need for targeted educational interventions addressing both structural and perceptual barriers to HPV and HPV vaccination. Furthermore, by examining the role of social media and the emerging gender disparity in trust levels, our study adds a novel dimension to understanding how information sources influence vaccine decision-making in the digital era.
Social media plays a dual role in spreading HPV-related information, functioning both as a major source of awareness and as a potential amplifier of misinformation. In our study, social media was identified as the primary source of HPV-related information for most respondents (77.5%), indicating its broad reach and influence. However, its role is complex. The same platform can increase exposure to health information, while it can also distribute misconceptions and unequal trust across different demographic groups [29,30]. Such dynamics may create substantial disparities in HPV knowledge, as biased or misleading content widens knowledge gaps and disparities, potentially reinforcing vaccine hesitancy. Myths and misinformation have been shown to discourage vaccination uptake among young people [30]. Previous studies in China have reported mixed levels of HPV awareness depending on region, age, and educational background [5,6].
A significant gender disparity in trust towards social media was identified in our study. Male respondents were disproportionately more likely to express distrust in the accuracy of information on these platforms (p = 0.034). This finding aligns with broader concerns about how algorithm-driven content distribution with sex disparities can reinforce biased or misleading health information. Social media’s influence is not neutral but is perceived differently across genders, specifically introducing a disparity in credibility. Strengthening scientific education and health communication is important in the digital age, where social media plays an irreplaceable role in shaping public perception [31,32] and attitudes towards HPV and HPV vaccination.
5.1 Implications for public health practice
In light of these challenges, the following strategies are recommended: (i) developing targeted awareness campaigns to address misconceptions among young people; (ii) partnering with digital platforms to develop content-moderation strategies that regulate and improve the quality of HPV-related information on social media; and (iii) advocating government-subsidized vaccination programs to reduce costs barriers.
These practical interventions could help bridge the gaps in HPV knowledge and vaccination intentions identified in our study. Our results suggest that future public health initiatives should move beyond simply raising general awareness and instead focus on correcting specific misconceptions through targeted educational campaigns. Such campaigns should: (i) clearly communicate that HPV is often asymptomatic and emphasize that the vaccine is the prophylactic rather than therapeutic; (ii) collaborate with social media platforms and key opinion leaders to disseminate accurate, evidence-based information and counteract misinformation, with content tailored to address the distrust observed particularly among male users; and (iii) advocate and promote government-subsidized vaccination programs, in line with the recently announced national immunization plan, to reduce the financial barrier, thereby ensuring broader vaccine accessibility for eligible young adults.
5.2 Limitations and strengths
The study has several limitations. The relatively small sample size and the use of online sampling method may introduce selection bias, limiting the generalization of the findings. As descriptive study in nature, we did not explore actual vaccination uptake rates or the specific reasons for non-vaccination. Another limitation is the role of digital and social media was not explored, which may influence on gender disparities through algorithm-driven content exposure. While the questionnaire was reviewed and pilot tested, certain dichotomous items may have oversimplified complex concepts, such as the overlapping nature of “safety” and “side effects”. Despite these limitations, the current study provides valuable insights for future HPV education and vaccine promotion efforts in China and beyond. Further larger-scale studies are to be built on these findings and to explore how social media platforms influence public health information dissemination and reshape narratives surrounding HPV and its vaccination.
6 Conclusion
The findings highlight misconceptions about HPV’s natural history and vaccine safety remain among even well-educated young adults in China. While overall awareness of HPV is high, and most participants expressed willingness to be vaccinated, knowledge gaps and inconsistent perceptions suggested a lack of fully informed decision-making. These findings show the importance of accessible, culturally tailored education strategies to address specific misunderstanding rather than general hesitancy. Improving the accuracy of HPV-related information-particularly through social media channels-could support public trust and foster more informed vaccine choices.
7 Patient and public involvement
Patients and/or the public were not involved in the design, conduct, reporting or dissemination plans of this research.
Supporting information
S1 Appendix. Implied consent and Questionnaire (English version).
The document includes the implied consent statement presented to all participants prior to data collection, followed by the complete English (EN) version of the questionnaire.
https://doi.org/10.1371/journal.pone.0337518.s001
(PDF)
S2 Appendix. Implied consent and Questionnaire (Chinese version).
This document provides the complete Chinese (CN) version of the survey instrument, including the implied consent statement and all survey items.
https://doi.org/10.1371/journal.pone.0337518.s002
(PDF)
S3 Dataset. Raw dataset of HPV knowledge and trust questionnaire responses.
This Excel spreadsheet contains the complete, anonymized raw data from the cross-sectional survey, including participant demographics (e.g., age, sex), coded responses to all knowledge and trust questions, and source of information preferences.
https://doi.org/10.1371/journal.pone.0337518.s003
(XLSX)
References
- 1. McBride AA. Human papillomaviruses: diversity, infection and host interactions. Nat Rev Microbiol. 2022;20(2):95–108. pmid:34522050
- 2. Bruni L, Albero G, Rowley J, Alemany L, Arbyn M, Giuliano AR, et al. Global and regional estimates of genital human papillomavirus prevalence among men: a systematic review and meta-analysis. Lancet Glob Health. 2023;11(9):e1345–62. pmid:37591583
- 3. Joura EA, Giuliano AR, Iversen O-E, Bouchard C, Mao C, Mehlsen J, et al. A 9-valent HPV vaccine against infection and intraepithelial neoplasia in women. N Engl J Med. 2015;372(8):711–23. pmid:25693011
- 4. Lee J-E, Chung Y, Rhee S, Kim T-H. Untold story of human cervical cancers: HPV-negative cervical cancer. BMB Rep. 2022;55(9):429–38. pmid:35725012
- 5. Wang H, Jiang Y, Wang Q, Lai Y, Holloway A. The status and challenges of HPV vaccine programme in China: an exploration of the related policy obstacles. BMJ Glob Health. 2023;8(8):e012554. pmid:37586782
- 6. Pan X-F, Li R, Pan A, Larson H. Human papillomavirus vaccine approval in China: a major step forward but challenges ahead. Lancet Infect Dis. 2016;16(12):1322–3. pmid:27998583
- 7. Zhao F, Qiao Y. Cervical cancer prevention in China: a key to cancer control. Lancet. 2019;393(10175):969–70. pmid:30860036
- 8. Prudden HJ, et al. Understanding the public health value and defining preferred product characteristics for therapeutic human papillomavirus (HPV) vaccines: World Health Organization consultations, October 2021-March 2022. Vaccine. 2022;40(41):5843–55.
- 9. Chen J, et al. Estimated human papillomavirus vaccine coverage among females 9-45 years of age - China, 2017-2022. China CDC Wkly. 2024;6(19):413–7.
- 10. Han B, et al. Cancer incidence and mortality in China, 2022. J Natl Cancer Cent. 2024;4(1):47–53.
- 11. Bray F, Laversanne M, Sung H, Ferlay J, Siegel RL, Soerjomataram I, et al. Global cancer statistics 2022: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin. 2024;74(3):229–63. pmid:38572751
- 12. Chen H, Zhao X, Hu S, You T, Xia C, Gao M, et al. Estimation of economic burden throughout course of cervical squamous intraepithelial lesion and cervical cancer in China: A nationwide multicenter cross-sectional study. Chin J Cancer Res. 2023;35(6):675–85. pmid:38204443
- 13. Garg A, Nyitray AG, Roberts JR, Shungu N, Ruggiero KJ, Chandler J, et al. Consumption of Health-Related Videos and Human Papillomavirus Awareness: Cross-Sectional Analyses of a US National Survey and YouTube From the Urban-Rural Context. J Med Internet Res. 2024;26:e49749. pmid:38224476
- 14. Li J, Zheng H. Coverage of HPV-Related Information on Chinese Social Media: a Content Analysis of Articles in Zhihu. Hum Vaccin Immunother. 2020;16(10):2548–54. pmid:32159420
- 15. Jiang S, Wang P, Liu PL, Ngien A, Wu X. Social Media Communication about HPV Vaccine in China: A Study Using Topic Modeling and Survey. Health Commun. 2023;38(5):935–46. pmid:34555993
- 16. Alsulami FT, Sanchez J, Rabionet SE, Popovici I, Baraka MA. Predictor of HPV Vaccination Uptake among Foreign-Born College Students in the U.S.: An Exploration of the Role of Acculturation and the Health Belief Model. Vaccines (Basel). 2023;11(2):422. pmid:36851299
- 17. Shao X, et al. HPV vaccination behavior, vaccine preference, and health beliefs in Chinese female health care workers: a nationwide cross-sectional study. Vaccines (Basel). 2023;11(8).
- 18. Oh KM, Alqahtani N, Chang S, Cox C. Knowledge, beliefs, and practice regarding human papillomavirus (HPV) vaccination among American college students: Application of the health belief model. J Am Coll Health. 2023;71(8):2329–38. pmid:34586013
- 19.
Pimentel J. A note on the usage of Likert Scaling for research data analysis. 2010;18:109–12.
- 20. Pimentel J. Some biases in Likert scaling usage and its correction. International Journal of Sciences: Basic and Applied Research (IJSBAR). 2019;45:183–91.
- 21. Dai Z, Si M, Su X, Wang W, Zhang X, Gu 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(6):2776–86. pmid:34825712
- 22. Mohammed KA, Subramaniam DS, Geneus CJ, Henderson ER, Dean CA, Subramaniam DP, et al. Rural-urban differences in human papillomavirus knowledge and awareness among US adults. Prev Med. 2018;109:39–43. pmid:29378268
- 23. Stephens ES, Dema E, McGee-Avila JK, Shiels MS, Kreimer AR, Shing JZ. Human Papillomavirus Awareness by Educational Level and by Race and Ethnicity. JAMA Netw Open. 2023;6(11):e2343325. pmid:37962885
- 24. Miraglia Del Giudice G, Sansone V, Della Polla G, Angelillo IF. Understanding the Reasons for Receiving HPV Vaccination among Eligible Adults in Italy. Vaccines (Basel). 2024;12(7):728. pmid:39066366
- 25.
National Health Commission. China plans to add HPV vaccine to national immunization program, expanding coverage for females. [Internet] 2025 September 11, 15:16 [cited 2025 October 19]; Available from: https://english.www.gov.cn/news/202509/11/content_WS68c27731c6d00fa19f7a25cf.html
- 26. Wemrell M, Gunnarsson L. Attitudes Toward HPV Vaccination in Sweden: A Survey Study. Front Public Health. 2022;10:729497. pmid:35619814
- 27. Gilkey MB, Reiter PL, Magnus BE, McRee A-L, Dempsey AF, Brewer NT. Validation of the Vaccination Confidence Scale: A Brief Measure to Identify Parents at Risk for Refusing Adolescent Vaccines. Acad Pediatr. 2016;16(1):42–9. pmid:26300368
- 28. McBride KR, Singh S. Predictors of Adults’ Knowledge and Awareness of HPV, HPV-Associated Cancers, and the HPV Vaccine: Implications for Health Education. Health Educ Behav. 2018;45(1):68–76. pmid:28595454
- 29. Kim L, et al. Relationships between social media use, exposure to vaccine misinformation and online health information seeking behaviour. Journal of Creative Communications. 2023;18(2):199–213.
- 30. Buller DB, Pagoto S, Henry K, Berteletti J, Walkosz BJ, Bibeau J, et al. Human Papillomavirus Vaccination and Social Media: Results in a Trial With Mothers of Daughters Aged 14-17. Front Digit Health. 2021;3:683034. pmid:34713152
- 31. eClinicalMedicine. Global strategy to eliminate cervical cancer as a public health problem: are we on track?. EClinicalMedicine. 2023;55:101842. pmid:36712891
- 32. Ginsburg O, Weiderpass E. What will it take to eliminate cervical cancer in the USA? Lancet Public Health. 2020;5(4):e182–3. pmid:32057316