Introduction

Human papillomavirus (HPV) infection poses a major global public health challenge. Despite the high preventability of HPV infection, the situation in China remains severe [1,2]. College students, who are in the early stage of sexual activity, are highly susceptible to HPV and constitute a key population for HPV prevention and control [3]. However, the current status of HPV vaccination among Chinese college students is not encouraging. Data have indicated that the peak first-dose HPV vaccination rate among Chinese youth aged 20–24 years is only 14.02% [4]; among female college students in northern China, despite a slightly higher vaccination rate of 18.11%, the willingness to receive the vaccine remains low, with a notable 41.71% explicitly stating their unwillingness to be vaccinated [5]. Additionally, vaccination behavior significantly differs across genders, geographical locations, and regions [5]. Consequently, it is imperative to conduct an ongoing, in-depth exploration of the psychological and cognitive mechanisms underlying the decision-making process regarding HPV vaccination among Chinese college students.

For a long time, the health belief model (HBM) has served as a classic theoretical framework for elucidating vaccination behavior. According to this model, individuals’ preventive health decisions are predominantly shaped by factors such as perceived benefits of preventive actions, perceived susceptibility to diseases, and perceived severity of disease [6]. However, the HBM, which is primarily grounded in a “rational choice” perspective, may fail to fully capture the complex social and psychological factors underlying contemporary vaccine hesitancy [7], which has been recognized as a major barrier to vaccination [8]. To obtain a more comprehensive understanding of this phenomenon, the World Health Organization’s Strategic Advisory Group of Experts on Immunization (SAGE) proposed the “3C” (complacency, convenience, and confidence) model as a metric for assessing vaccine hesitancy [9]. This model offers a complementary perspective for analyzing vaccination behaviors and demonstrates high applicability within the Chinese context. [10,11]. Within China’s unique policy context, college students are required to fully self-fund their HPV vaccinations, as these are not incorporated into the national immunization program [12]. The cost per dose varies from 360 CNY to 1331 CNY, depending on the vaccine type. This real-world situation introduces both structural and psychological barriers, which are frequently challenging to comprehensively elucidate within a singular theoretical construct.

Notably, although the aforementioned two theoretical frameworks play a pivotal role in predicting the willingness to receive vaccination, there remains a dearth of empirical evidence integrating them for application in studies on HPV vaccination among Chinese college students. Current studies predominantly concentrate on a singular dimension or isolated theoretical perspective, resulting in inconsistent findings and limited explanatory capacity. Such a fragmented tendency further complicates the elucidation of how health beliefs and vaccine hesitancy collectively influence vaccination decisions, thereby constraining the identification of precise intervention targets.

To address this issue, this study employs a cross-sectional design to investigate the associations among willingness to receive HPV vaccination, vaccine hesitancy, and health beliefs among students at a Chinese medical university. By simultaneously examining variables from both the HBM and the vaccine hesitancy framework. This study aims to delineate their independent associations with HPV vaccination intention in this population. While it does not formally test the structural integration of these two frameworks, the findings offer a preliminary empirical basis that may inform the development of more integrated theoretical models in future research. Furthermore, the study provides evidence to guide targeted campus-based immunization strategies within medical university settings.

Materials and methods

Sociodemographic characteristics

The following characteristics were assessed in this survey: gender, age, monthly consumption, household income, main economic source, parents’ occupations, sources/channels of information about HPV, and hearing negative news about the HPV vaccine and HPV vaccination intention. HPV vaccination intention was assessed using a single binary item: “If you had the opportunity to receive the HPV vaccine, would you be willing to be vaccinated?” Response options were “Yes” or “No” (Table 1).

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Table 1. Sociodemographic characteristics of the participants (n = 3584).

https://doi.org/10.1371/journal.pone.0354119.t001

Vaccine hesitancy

The vaccine hesitancy scale utilized in this study was developed by Wei et al. [11] (Table 2). This scale includes 12 items across 3 dimensions: necessity (consisting of 4 items), importance (consisting of 5 items), and safety (consisting of 3 items). Each item was scored on a 5-point Likert scale, where a score of 1 indicated “strongly disagree” and a score of 5 indicated “strongly agree”. Notably, the items assessing the necessity and safety dimensions were reverse-coded. The overall Cronbach’s α value for this scale was 0.732. And, the Cronbach’s α values for the necessity, importance, and safety dimensions of the scale were 0.922, 0.888, and 0.848, respectively.

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Table 2. Descriptive statistics of HPV vaccine hesitancy.

https://doi.org/10.1371/journal.pone.0354119.t002

Health beliefs

In this study, we employed the health belief model to measure students’ health beliefs regarding HPV vaccination. The HBM was validated by Chen et al. [13] (Table 3). This scale includes 13 items across 5 dimensions: perceived benefits of behavior (consisting of 3 items), trust in formal information (consisting of 4 items), perceived disease severity (consisting of 2 items), perceived disease susceptibility (consisting of 3 items), and perceived behavioral barriers (consisting of 1 item). Each item was also scored on a 5-point Likert scale. The overall Cronbach’s α value for the scale was 0.743, indicating acceptable internal consistency.

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Table 3. Descriptive statistics of HBM.

https://doi.org/10.1371/journal.pone.0354119.t003

The dimension-level Cronbach’s α values were 0.856 (perceived benefits) and 0.897 (trust in formal information). Lower α values were obtained for perceived disease severity (0.592, 2 items) and perceived susceptibility (0.657, 3 items). Notably, Cronbach’s α is sensitive to the number of items, and values derived from subscales with fewer than three items should be interpreted with caution [14]. The perceived behavioral barriers dimension consisted of a single item and therefore could not yield a Cronbach’s α. Thus, the overall scale Cronbach’s α of 0.743 provides a more robust estimate of reliability.

Results

Univariate analyses

Univariate analysis revealed significant associations between the intention to receive HPV vaccination and key variables, as detailed in Table 4.

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Table 4. Univariate associations with the HPV vaccination intention.

https://doi.org/10.1371/journal.pone.0354119.t004

Gender (p  <  0.001), age (p  =  0.001), monthly household income (p  =  0.03), main economic source (part-time job while studying, p  <  0.001), parents’ occupations (employees in enterprises, commercial, and service industries (including self-employed), p  <  0.001), parents’ occupations (teachers and medical professionals, p  =  0.007), sources/channels of information about HPV (schools/teachers/classmates, p  = 0.047; hospital/doctor, p  = 0.05; social media (WeChat, Weibo, QQ, etc.), p  <  0.001; TV/radio/newspapers/magazines, p  =  0.021) and hearing negative news about the HPV vaccine? (p  <  0.02) demonstrated particularly significant correlations.

Notably, the necessity and importance dimensions of HPV vaccine hesitancy were significantly correlated with HPV vaccination intention (all p < 0.001).

Furthermore, with the exception of the perceived behavioral barrier dimension (p  =  0.466), the perceived benefits of behavior, trust in formal information, perceived disease severity, and perceived disease susceptibility dimensions of the HBM were significantly correlated with HPV vaccination intention (all p < 0.001).

Factors associated with the intention to receive HPV vaccination

The variables that were significant in the univariate analysis were subsequently included in a binary logistic regression analysis. The results are presented in Table 5.

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Table 5. Binary Logistic Regression for the HPV Vaccination.

https://doi.org/10.1371/journal.pone.0354119.t005

The results indicated that gender was significantly associated with HPV vaccination intention (OR: 0.26; 95% CI: 0.22 ~ 0.31; p  <  0.001). Specifically, compared with female students, male students were more likely to report lower levels of intention.

In addition, having parents employed in enterprises, commercial, or service industries (including self-employment) was positively associated with higher HPV vaccination intention (OR: 1.43; 95% CI: 1.18 ~ 1.75; p  <  0.001).

Regarding information sources, obtaining HPV-related information from hospitals or doctors was also a significant positive correlate of vaccination intention (OR: 1.37; 95% CI: 1.15 ~ 1.64; p  =  0.001).

Moreover, for HPV vaccine hesitancy, lower perceived necessity (i.e., higher reverse-scored disagreement on vaccine necessity; OR: 0.91; 95% CI: 0.88 ~ 0.94; p  <  0.001) and higher perceived importance (OR: 1.07; 95% CI: 1.03 ~ 1.10; p  <  0.001) were significantly associated with greater HPV vaccination intention (Table 5).

Furthermore, for the HBM, the perceived benefits of behavior had a significant positive link to HPV vaccination (OR: 1.21; 95% CI: 1.12 ~ 1.32; p <  0.001). The other dimensions of the HBM were not significantly associated with the intention to receive the HPV vaccine.

Discussion

The findings of this study revealed that Chinese medical college students reported a 73.16% overall willingness to receive the HPV vaccine. However, willingness among males was significantly lower than that among females. This gender gap aligns with existing research [15–17]. Its persistence in a medical student sample underscores that professional knowledge does not automatically override sociocultural biases. The pronounced gender disparity primarily arises from the enduring gender-specific labeling of the HPV vaccine as a “cervical cancer vaccine”, which engenders cognitive bias among males, leading them to perceive the vaccine as “gender irrelevant”, even when they are aware of HPV-related male cancers. Consequently, their motivation remains largely altruistic, which may be insufficient to sustain personal vaccination behavior [18]. In reality, males are equally susceptible to health threats from HPV-related malignancies such as oropharyngeal cancer, penile cancer, and anal cancer. To narrow this gap, national immunization programs should transition to gender-neutral HPV vaccination [19], while medical universities could immediately integrate male-specific HPV education into mandatory curricula and offer male-inclusive campus vaccination services—strategies shown to improve vaccination intention [20,21]. While these recommendations are supported by the present findings, the evidence is derived from a medical university sample, and their applicability to the broader college population remains to be examined.

This study revealed that parental employment in enterprise, commerce, or service sectors (inclusive of self-employment) was significantly and positively associated with higher willingness to receive HPV vaccination. Beyond income stability and social security coverage, positions within these sectors are generally linked to more formalized employment than agricultural or informal work [22,23]. Such employment may also provide greater exposure to health information and preventive norms, which, in turn, shape family vaccination decisions. These findings imply that parental occupation, as a social structural variable, may significantly influence family vaccination decisions through combined economic and informational pathways [24]. Therefore, university-based vaccination programs should consider collecting data on parental occupation to identify students with potentially lower vaccination intention and offering them targeted subsidies [25] or parent-centred educational materials [26,27]. Analogous targeted strategies have been recommended in recent HPV vaccination research among parents [28]. From the vantage point of social occupational structure, this research underscores a notable association between parental occupation and medical college students’ willingness to receive HPV vaccination, highlighting the necessity of considering the impact of parental occupation on these students’ vaccine decision-making in efforts to promote HPV vaccine uptake in similar university settings.

Our findings also revealed that the acquisition of HPV-related information from hospitals and doctors was significantly associated with the higher willingness, consistent with prior studies and highlighting the critical role of professional health communication in vaccine decision-making processes [29,30]. Recommendations from hospitals and doctors not only enhance the accuracy of HPV knowledge, alleviate safety concerns, and heighten awareness of vaccination benefits but also foster trust and credibility, which are paramount for the development of positive attitudes and intentions toward vaccination among young people [31]. Research has demonstrated that doctors’ recommendations constitute a key determinant of vaccination uptake [32,33], even among vaccine-hesitant parents [34]. For medical students specifically, this finding suggests an actionable pathway: medical universities could integrate structured, in-person HPV vaccine counseling sessions delivered by clinicians from university-affiliated hospitals into existing preventive medicine clerkships, thereby embedding a trusted provider recommendation directly into the training curriculum [35–37]. Therefore, it is imperative to reinforce the role of doctors as pivotal advocates and to systematically mobilize the accessible hospital resources within medical universities in order to increase HPV vaccination rates among medical students.

Furthermore, in terms of vaccine hesitancy, this study revealed that college students’ perceptions of the necessity of the HPV vaccine significantly and positively correlate with their willingness to receive vaccination; this finding is in line with prior research findings [10,38]. Within the context of the vaccine hesitancy scale, perceived necessity embodies individuals’ subjective evaluation of the irreplaceability of preventive measures. According to the Necessity-Concerns Framework [39], individuals are more likely to accept a medical intervention when perceived necessity outweighs concerns about potential adverse effects. When students fully understand the prevalence of HPV infection and its causal relationship with cancer, the vaccine is perceived as an indispensable “necessity” for safeguarding their health. This psychological impetus effectively counterbalances minor apprehensions regarding side effects associated with the vaccine. In this study, individuals who declined vaccination because of their confidence in robust immunity, good health, or the absence of government mandates demonstrated an inadequate understanding of the necessity of the HPV vaccine. Studies have indicated that skepticism regarding the benefits and necessity of vaccines constitute the primary reason for nonvaccination [40]. Therefore, immunization program interventions in universities should move beyond generic safety reassurance and explicitly juxtapose the necessity of HPV vaccination against safety data—for instance, through structured classroom sessions where students quantitatively compare their personal lifetime risk of HPV infection with the low incidence of serious adverse events [10,41]—thereby enabling perceived necessity to outweigh safety concerns and reduce vaccine hesitancy in this population.

Our findings revealed that the perceived importance of the HPV vaccine was significantly and positively associated with vaccination intention, consistent with previous studies [42]. These findings indicate that when students understand the crucial role of the HPV vaccine in preventing HPV infection and related cancers while improving their own health and that of their families, their willingness to proactively get vaccinated significantly increases. Domestic studies confirm that students who perceive vaccination as less important are less inclined to be vaccinated [43], and international research links perceived importance to vaccination behavior [44,45]. Therefore, rather than solely raising general awareness, medical colleges should embed HPV vaccination importance messaging into existing clinical training (e.g., preventive medicine clerkships), using peer testimonials and case-based discussions to make the vaccine’s value tangible for future healthcare professionals, thereby more effectively enhancing their willingness to be vaccinated.

Finally, this study revealed that the perceived behavioral benefits related to health beliefs have a significant positive link to college students’ willingness to receive the HPV vaccine. Within the HBM framework, perceived benefits represent an individual’s evaluation of the efficacy of a recommended action [46]. When medical students clearly perceive the vaccine’s preventive value, this evaluation directly motivates their vaccination decisions. These findings suggest that individuals’ perceptions of the preventive efficacy and health benefits of the HPV vaccine constitute crucial psychological factors in promoting vaccination decisions, which align with related research on the health belief model [47,48]. Therefore, rather than merely emphasizing protective value in broad terms, future interventions should highlight the practical benefits most relevant to medical students’ dual role as both potential vaccine recipients and future recommenders—for example, personal protection during clinical rotations and their future credibility when counseling patients—thereby optimizing vaccination promotion strategies more effectively [40,49].

Limitations

This study has several limitations. First, as a cross-sectional survey, it cannot establish causal relationships between variables. HPV vaccination intention was assessed using a single binary (yes/no) item, which may oversimplify this nuanced construct and fails to capture the well-documented intention–behavior gap reported in the vaccination literature; therefore, the reported intention should not be equated with actual vaccine uptake. Second, although known confounding factors were controlled through multivariable analysis, unmeasured confounding variables may still exist. Additionally, the univariate pre-screening approach (p < 0.05) used for variable selection, while common, may risk omitting potential confounders or suppressor variables. Third, although the sample size in this study was large, the sample was obtained from a single medical university, and the generalizability of the findings to students in other settings may be limited. The sample was recruited via convenience sampling on WeChat. Medical students likely possess higher health literacy and greater familiarity with HPV than the general college student population, further restricting the external validity of the findings. Additionally, non-response bias cannot be ruled out: students with a greater interest in HPV vaccination may have been more inclined to participate, potentially overestimating the observed willingness. Moreover, the representativeness of the 5,384 respondents relative to the broader student body of the university (e.g., in terms of sex, grade, and major distribution) was not formally assessed, which limits the within-institution generalizability of the results. Fourth, the analytical strategy adopted in this study treated health beliefs and vaccine hesitancy variables as parallel predictors in regression models, consistent with examining their independent associations. No mediation, moderation, or structural equation modeling was performed to formally test the integrated structure of these two theoretical frameworks. Consequently, the findings cannot determine how the constructs from the HBM and vaccine hesitancy models causally relate to or interact with each other in shaping vaccination intention. Furthermore, two HBM dimensions—perceived disease severity and perceived disease susceptibility—showed relatively low internal consistency (Cronbach’s α = 0.592 and 0.657, respectively), which is partially attributable to their small number of items (2 and 3 items, respectively), consistent with the known sensitivity of Cronbach’s α to item count [14]. This level of reliability may have attenuated observed effect sizes and reduced statistical power to detect associations with HPV vaccination intention in the logistic regression models. Therefore, the non-significant findings for these two dimensions should be interpreted with caution, as they do not definitively rule out the potential theoretical and practical relevance of these constructs to HPV vaccination intention. Future studies could improve the measurement of these constructs by increasing the number of items in these subscales to enhance internal consistency and statistical power. Future research employing longitudinal or experimental designs and advanced path-analytic techniques is needed to directly test hypothesized integrative pathways. Moreover, such designs should be used not only to test hypothesized integrative pathways but also to evaluate interventions that can improve the current insufficient HPV vaccination coverage. Fifth, the final logistic regression model explained approximately 21% of the variance in HPV vaccination intention (Nagelkerke R² = 0.211), indicating modest explanatory power and that a substantial portion of variance remains unexplained. Additional constructs not captured by the current instruments—such as HPV-specific knowledge, peer norms, perceived access or cost barriers, and prior sexual health education,which are particularly relevant to student populations—may account for this remaining variance. Future studies aiming to build more comprehensive predictive models should consider incorporating these variables to improve model explanatory power and identify more robust determinants of HPV vaccine uptake.

Conclusions

In this study, the intentions to receive HPV vaccination among unvaccinated college students at Guangdong Medical University were assessed on the basis of vaccine hesitancy and the health belief theory. This study revealed that college students exhibit a high willingness to receive the HPV vaccine. Several positive factors associated with the willingness to receive vaccination were identified, including female gender, parents’ occupations (employees in enterprises, commercial, and service industries (including self-employed)), and information sources (hospitals or doctors). Furthermore, the study indicated that perceptions of the necessity, importance, and benefits of vaccination positively linked to the willingness to receive vaccination.

The study findings emphasize that, to increase Chinese medical college students’ willingness to receive HPV vaccination, targeted interventions are recommended: integrating structured clinician-delivered counseling into preventive medicine clerkships, collecting parental occupation data to guide targeted subsidies and education, and embedding classroom sessions that compare personal HPV infection risk with vaccine safety data. Furthermore, government evaluation of gender-neutral vaccination policies and the implementation of male-inclusive campus vaccination services are urged, although the generalizability of these findings to non-medical college populations requires further investigation.

Supporting information

Acknowledgments

Our heartfelt thanks go to all those who assisted with data collection, provided survey instruments, and participated in the survey. We thank AJE (www.aje.cn/) for their professional language editing services.