The age of the 921 respondents in this survey was concentrated between 27 and 45 years old, and they were at the peak of sexual desire in young adults [30]. Their education level was mostly high school/vocational high school/technical school/technical secondary school and their family locations were mostly in rural areas, the highest education level of their parents was concentrated in junior high school, their workplaces were mostly high-class, their personal monthly income was mostly more than or equal 3800 RMB and the duration of their current occupation was mostly more than 12 months, considering that they chose to enter the society earlier due to their educational environment or family conditions, and they chose to engage in this profession because they could not find a high-paying job due to their personal knowledge level and the technical ability. It is suggested that the local government should pay more attention to rural young and middle-aged women, increase the opportunities for women to learn knowledge and skills, improve their education level and employability, obtain property through legal and compliant channels, and reduce the number of female sex workers in entertainment venues from the source, and fundamentally curb the occurrence and development of HPV and other diseases that cause disease mainly through sexual transmission. The majority of the respondents were unmarried and most of them said that they could accept premarital sex was acceptable, and the age of the first sexual intercourse of those who had sex was mostly less than 20 years old and the number of their sexual partners was more than or equal three. Only about one-third were free of tobacco and alcohol, which was consistent with the high-risk factors of HPV infection [31, 32], suggesting that women in this occupation are a high-risk group for HPV infection. It has been shown that single HPV infection increases the risk of cervical cancer by 19.9 times while multiple HPV infections increase this risk by 31.8 times[33], and the strongest predictors of multiple HPV types of infection are young and multiple sexual partners [34], and that HPV multiple infections may have a synergistic effect in cervical lesions, thus affecting the prognosis of cervical cancer [35, 36], suggesting that the risk of multiple HPV infections and cervical cancer in the respondents is much higher than that of ordinary women, and the development of the disease and poor prognosis may be more severe. Most female sex workers in entertainment venues use condoms as a contraceptive measure, and even though condoms may reduce the risk of HPV infection to some extent, they are not absolutely avoidable, so a multi-pronged approach such as HPV vaccination, condom wearing, and regular screening is still advocated to prevent HPV infection and cervical cancer development. Only 52.23% and 53.64% of the respondents have received sex education (sexual health training, male and female reproductive system learning) and training on infectious diseases, preventive medicine education or knowledge about sexually transmitted diseases such as AIDS, indicating that the level of knowledge about gender education and sexually transmitted diseases among this type of working women is not high and they cannot protect their personal health from infringement by themselves, and organizations such as communities and women's federations should pay attention to The community, women's federations and other organizations should pay attention to the management of such professional women, strengthen gender education and science popularization of knowledge about sexually transmitted diseases, call for and encourage them to have regular physical examination, pay attention to the screening of two cancers, and improve the level of health care knowledge and awareness.
China is currently in the initial stage of HPV vaccine promotion and research and development, female sex workers in entertainment venues, as a high-risk group of HPV infection, is a key group for HPV vaccination, and improving the awareness of HPV and HPV vaccination rate of women in this group is crucial to reducing the incidence of cervical cancer and protecting women's health in China. The results of this study showed that the willingness of female sex workers in an urban entertainment venue in Guangxi, China, to vaccinate against HPV was 77.31%, which was higher than the average in China (62.2%) [37], but lower than that of Peru (97.5%) [38] and Phnom Penh, Cambodia (100%) [39]. The approval of HPV vaccine on the market in China is short, the dissemination rate and popularity of HPV-related knowledge and HPV vaccination information are not high, and the public's understanding of it is even less optimistic [40]. In recent years, an urban area of Guangxi, China, has strengthened the detection and supervision of sexually transmitted diseases among female sex workers in entertainment venues, including a significant increase in the dissemination of HPV and HPV vaccine-related information, resulting in a relatively high willingness of female sex workers in entertainment venues to be vaccinated against HPV in this area.
It has been shown that the factors influencing HPV vaccination contain personal factors as well as social, family and interpersonal relationships [21]. Based on the IMB model theory, this survey analyzed the factors influencing female sex workers' willingness to receive HPV vaccination in an urban entertainment venue in Guangxi, China, in terms of three factors: information factors, motivational factors, and behavioral skill factors.
3.1 Information Factor
The survey found that female sex workers in entertainment venues with the higher level of awareness of cervical cancer, HPV and HPV vaccine-related information were more willing to receive HPV vaccine. Those who agreed that the vaccine could effectively prevent diseases were 2.144 times more willing to receive the HPV vaccine than those who did not, probably because they were more willing to receive the HPV vaccine to reduce HPV infection and develop HPV because they had a lower chance of developing the disease or reduced symptoms during their previous preventive vaccination, which was beneficial to their health and daily life, and they recognized the effectiveness of primary prevention measures such as vaccination. So they were more willing to reduce the probability of HPV infection and cervical cancer through HPV vaccination. Female sex workers in entertainment venues who have heard of the HPV vaccine were more willing to receive the HPV vaccine, 2.105 times more than those who have not heard of it, and after hearing about HPV vaccine could they know its preventive effects on HPV infection and cervical cancer and could they selectively receive the HPV vaccine in consideration of their own situation. It is recommended that communities, women's federations and disease prevention and control institutions should continue to strengthen the popularization of knowledge and information about the HPV vaccine when promoting science popularization, so that more age-appropriate and key groups have access to the HPV vaccine. At the same time, innovative publicity channels, such as information exchange through social media platforms or the development of peer education liaison, strengthen the level of awareness of cervical cancer, HPV and HPV vaccine-related information for professional women, and increase the willingness and vaccination rate of HPV vaccination.
3.2 Motivational factors
The stronger the motivation for HPV and HPV vaccination among the study participants, the higher the willingness to receive HPV vaccine. Among them, the perceived benefit is one of the main reasons affecting the willingness of female sex workers in entertainment venues to receive HPV vaccination, which is different from the findings of other populations in China such as female university students [21, 41]. The reason may be that female sex workers in entertainment venues can perceive the serious impact of HPV infection and cervical cancer on themselves and their occupation due to their occupational particularities, and to some extent understand their occupational susceptibility to HPV infection, and can overcome the obstacles to HPV vaccination such as vaccine safety, effectiveness, side effects, etc., and have a certain economic foundation and self-determination ability compared to students, but they have doubts about the beneficial degree of HPV vaccination to themselves. The results showed that those who could perceive the benefits of HPV vaccination were more willing to receive HPV vaccination than those who could not perceive the benefits of HPV vaccination, which was 1.134 times more than those who could not perceive the benefits of HPV vaccination, which was consistent with the fact that those who favored the vaccine could effectively prevent diseases were more willing to receive it, suggesting that vaccine production and development institutions should pay attention to effectiveness of the vaccine itself in the process of vaccine testing and marketing, guarantee the role of the vaccine in preventing diseases, and make the respondents feel beneficial in the behavior of vaccination. At the same time, in the publicity and education of female sex workers in entertainment venues, more attention should be paid to objectively explaining the beneficial effects of HPV vaccination to reduce the incidence of HPV infection and cervical cancer, strengthen the concept that primary prevention measures such as vaccination are beneficial to individuals in controlling the occurrence and development of disease, so that the public can establish the awareness that prevention is better than treatment and gradually eliminate the occurrence of high-risk sexual behavior.
3.3 Behavioral skill factors
The IMB model believes that even if individuals have a high willingness and cognition to change behavior, they need to master certain behavioral skills before they can achieve individual behavior change [21]. This survey found that female sex workers in entertainment venues with higher behavioral skill scores were more willing to receive HPV vaccine because they had good self-decision-making and self-efficacy so that they were able to communicate with relatives, friends or medical staff about HPV vaccine and use it to obtain HPV vaccination institutions and processes, and those who mastered more behavioral skills for HPV vaccination, that is, self-decision-making and self-efficacy, were 1.130 times and 1.135 times more willing to receive HPV vaccine was higher than those who were unable to do so, respectively. It is suggested that the future direction of popularization should appropriately add contents on the behavioral skills of HPV vaccination, such as vaccination locations, appointment methods, and vaccination processes, so as to enhance the willingness of female sex workers in entertainment venues to receive HPV vaccination.
3.4 Multifactorial analysis of HPV vaccination willingness
The results of the analysis showed that the willingness of female sex workers in entertainment venues to receive HPV vaccination was related to the rank of the venue, smoking and drinking habits, whether they agreed that the vaccine could effectively prevent diseases, whether they had heard of HPV vaccine, perceived the benefits of HPV vaccination, and mastering more behavioral skills of HPV vaccination, that is, self-decision-making and self-efficacy. Among them, the lower the grade of the venue, the less willing to be vaccinated against HPV among female sex workers in entertainment venues. Every time the grade of the place drops, the willingness to be vaccinated is 0.693 times that of the previous grade, which may due to the fact that female sex workers in upscale entertainment venues need to undergo some conventional standard selection and pre-service training before taking up their jobs, and their understanding of HPV and other sex-related transmission diseases and prevention methods has increased, making them have a certain awareness of sexual safety and can make more profit in the sex trade; while female sex workers in low-grade entertainment venues lack training and management, compared with the high-grade ones who are scattered and hidden, lack of self-health protection awareness, especially in sex-related education and training, the acceptance rate is not high, prompting local regulatory authorities to deal with the registration of female sex workers in entertainment venues, especially those in the low-end and middle-end. Conducting regular health education and training so that they can protect their own health while reducing the spread of sex-related diseases at the root.
Combined with the actual situation of the outreach interventions of female sex workers in entertainment venues by the Center for Disease Control and Prevention in an urban of Guangxi, China, it shows that there are still certain difficulties in face-to-face and in-depth communication with female sex service workers for example, some publicity and education are only allowed in the lobby, and in some venues only the foreman receives them. Due to the risk of being cracked down on by public security and other organizations, female sex workers in entertainment venues, especially those with low-grade places, are very wary of communication with investigators and are evasive of survey questions, which undoubtedly makes the work of popularizing HPV and HPV vaccine education and promoting vaccination more difficult. Secondly, due to the specificity of the survey site and insufficient investment for intervention funds, it is difficult to motivate grassroots staff and some departments are understaffed, making it difficult to carry out relevant work and making outreach intervention work inevitably a formality. It is suggested that the intervention model of institutions such as disease control and community health service centers need to be changed in the future, national government departments should increase funding, and at the same time, introduce relevant policies and regulations to standardize the management of entertainment venues with commercial sex transactions, provide practical assistance for female sex workers in entertainment venues for disease detection and mental health regulation, strengthen the intervention of sexually transmitted diseases, and increase the HPV vaccination rate.
In summary, female sex workers in an urban entertainment venue in Guangxi, China, had higher willingness to receive HPV vaccination, and their willingness to receive vaccination was associated with venue class and smoking and drinking habits in the basic situation of the respondents. In terms of information, motivation,and behavioral skills based on the IMB model, whether one agrees that the vaccine can effectively prevent diseases, whether one has heard of HPV vaccine, perceived the benefits of HPV vaccination, and master more behavioral skills of HPV vaccination, that is, self-decision-making and self-efficacy, are the influencing factors affecting the respondents' willingness to receive HPV vaccination. Local governments and preventive health care institutions should strengthen the management of female sex workers in entertainment venues, avoid the occurrence of high-risk sexual behaviors and effectively protect the physical and mental health of women in this profession. At the same time, they should widely carry out publicity and education on HPV and other sexually transmitted diseases, and innovate the methods and forms of science popularization, focusing on introducing the benefits of primary prevention measures such as HPV vaccine for individuals and behavioral skills of HPV vaccination, so as to improve the willingness and vaccination rate of HPV vaccination, promote the process of national immunization planning, and advance the construction of a healthy China.
