HPV vaccine hesitancy among medical students in China: A multicenter survey

doi:10.21203/rs.3.rs-889382/v1

Background: In order to examine HPV information sources, vaccine hesitancy, and the association between the two variables. An online survey of HPV information sources and vaccine hesitancy was conducted among Chinese medical students.

Methods: The World Health Organization (WHO) Vaccine Hesitancy 3C model was used to evaluate reasons for respondents' vaccine hesitancy. A probit model was used to investigate the association between vaccine information sources and vaccine hesitancy.

Results: The reported rate of vaccine hesitancy was 62.36%. Convenience was the primary factor for vaccine hesitancy in medical students, and 37.23% used a single source to obtain vaccine information. A multivariate analysis revealed that men were 9% more likely to be hesitant about the HPV vaccine than women. Respondents without partners were 15% less hesitant than those with a partner. Respondents receiving HPV information through the Internet were 12% less likely to report vaccine hesitancy than those receiving information from other information channels.

Conclusions: HPV vaccine hesitancy requires more attention. Future studies could examine whether increasing vaccination locations and dissemination of information about the safety and effectiveness of HPV vaccines as well as using Internet media would help reduce medical students’ vaccine hesitancy and expand HPV vaccine coverage.

Trial registration: The study was conducted according to the guidelines of the Declaration of Helsinki,and approved by the Harbin Medical University School of Health Management & nstitutional Research Board (reference No.HMUIRB20210006, approved on 30 June 2021).

Health Policy

Occupational Medicine

HPV vaccine

Vaccination Information

Hesitancy

3C Model

Human papillomavirus (HPV) is the most common genital tract infection virus. Most sexually active women and men will be infected with the virus at some point in their lives, some repeatedly[1]. HPV plays a role in the development of skin diseases such as head and neck cancer, cervical cancer, male genital cancer, and condyloma acuminatum. The HPV subtypes are classified into high-risk (HPVl6, 18, 31, 33, 35, 45, etc.) and low-risk types (HPV6, 11, 30, 39, 42, 43, etc.)[2–3]. Almost all cases of cervical cancer (99%) are associated with high-risk HPV infection[4].

According to the GLOBOCAN 2020 reported that there were 604,000 new cases of cervical cancer and 342,000 deaths worldwide in 2020; 110 thousand new cases of cervical cancer and 59,000 deaths were reported in China, making it the second-largest burden of cervical cancer in the world[5]. The prevalence of HPV-related head and neck cancer, especially throat cancer, is increasing rapidly. It is expected that the number of patients with HPV-positive throat cancer will exceed that of patients with cervical cancer in the next 15–20 years[6].

Prophylactic HPV vaccine is an effective way to prevent HPV-related diseases, including cervical cancer[7], and vaccination does not require any major lifestyle changes[8]. HPV vaccination has been implemented on a large scale and achieved remarkable results since the vaccine’s production and marketing in 2006[9]. Studies in several countries and regions have confirmed that HPV vaccination is cost-effective[10–13].

However, the emergence of vaccine hesitancy has dampened public enthusiasm for vaccination. In 2019, the WHO listed vaccine hesitancy as one of the top 10 threats to global health[14]. Vaccine hesitancy refers to either reluctance to accept or rejection of vaccination when it is available[15]. A decline in the HPV vaccination rate due to HPV vaccine hesitancy has been reported in many countries and regions. For example, in 2013, after the media reported that vaccination with untested vaccines would cause adverse events, HPV vaccine hesitancy spread widely in Japan, resulting in a significant decline in the Japanese vaccination rate[16]. A study of Brazilian medical students suggested that vaccine hesitancy is the fundamental determinant of the low HPV vaccination rate[17]. Although studies have been conducted on HPV infection awareness and knowledge in China[18–19], evidence concerning Chinese HPV vaccine hesitancy is lacking. According to the WHO, confidence is one of the three major determinants of vaccine hesitancy[20]. Undoubtedly, unproven negative news has undermined public trust in HPV vaccines. However, for the public, it is challenging to determine authentic and valid facts in the vast pool of available information. Transparent and accurate information is essential for rebuilding vaccine confidence[21]. In addition, it is necessary to understand the public’s sources of information and improve the efficiency of information transmission.

The HPV vaccine entered the Chinese market as a self-funded vaccine in 2016, with domestic approval of bivalent HPV vaccines for women aged 9–45; quadrivalent HPV vaccines for women aged 20–45; and 9-valent HPV vaccines for women aged 16–26[22]. In November 2020, mainland China reduced the minimum age for quadrivalent vaccines to 9 years. China’s HPV vaccine has been on the market for only a few years compared with other countries, and some people adopt the “wait-and-see” approach regarding vaccines, resulting in low vaccination rates. Many medical students are also target populations for the HPV vaccine. In addition, as the future generations of medical personnel, they bear the responsibility of promoting the health of the entire population and play an important role in the promotion and popularization of HPV vaccination. To investigate the factors related to HPV vaccine hesitancy among medical students and estimate the association between the source of information and vaccine hesitancy, the author developed an information source and hesitancy questionnaire and conducted a questionnaire survey with Chinese medical students.

Study Design and Implementation

At the beginning of November 2020, a preliminary survey was conducted at the author’s medical university. The purpose was to improve the preset items and test the practicality of the survey, such as whether the question expressions were easy to understand, and to improve the questionnaire through information from pre-survey feedback. The formal survey was conducted from mid-January to the end of March, and a cross-sectional multicenter survey on HPV information sources and hesitancy was conducted for medical students at the school. Participants were recruited online from the east, middle, and west regions of China; they were required to complete online questionnaire. The questionnaire takes 3–5 minutes to fill out. The study was open to people of any sex. To maintain survey quality, we implemented the following controls: 1) All questions were set as compulsory to avoid missing responses; 2) When a respondent chose the same option for all questions, they were prompted to repeat their answers, and the survey would not proceed until they had done so.

Data Collection and Questionnaire Measures

A questionnaire for medical students was compiled, and it included four parts. The first part of the questionnaire reported the purpose and objectives of the research, asked the participants whether they would voluntarily participate in the study, and indicated that they were free to withdraw from the research. The second part of the questionnaire surveyed participants’ demographic information, sex, age, type of family residence, partner status, economic level, health behavior, and whether they had internship experience in a medical institution.

The third part investigated participants’ vaccine hesitancy and their reasons. Hesitancy was scored as the percentage of participants endorsing each item. The WHO Vaccine Hesitancy 3C model classifies the reasons for vaccine hesitancy as complacency, convenience, and confidence. Complacency refers to the underestimation of the harm the disease can cause and doubts about the necessity of vaccine use. Confidence refers to the trust in the safety, effectiveness, health system, and administrators of vaccines. Convenience refers to vaccine supply capacity, vaccine price acceptance, and availability of vaccination services. Following this classification, and in accordance with China’s social and cultural environment, 13 possible reasons were included for participants to choose from, and open items were included for participants to add additional reasons.

The fourth part investigated HPV and vaccine information sources. Sources include online media, traditional media represented by television and radio, and person-to-person communication among doctors, family, and friends. The number of channels was collected from the results of the information sources and counted according to the reported information sources. The range of the number of channels was 0–5.

Statistical Analyses

Statistical analysis was performed using Stata 15.0. Categorical variables were analyzed using chi-squared tests, and continuous variables were analyzed using one-way analysis of variance. A probit model was used to identify whether the information source and number of information sources were the key factors for hesitancy, and the marginal utility of the regression coefficients of the probit model was calculated. In the analysis, we controlled for demographic characteristics of the respondents, including age, sex, place of residence (rural or urban), Monthly living expenses, and weekly exercise duration. A P-value < 0.05 was considered statistically significant throughout the study.

Ethical Approval and Consent to participate: The study was conducted according to the guidelines of the Declaration of Helsinki,and approved by the Harbin Medical University School of Health Management & nstitutional Research Board (reference No.HMUIRB20210006, approved on 30 June 2021).
Consent for publication:All authors have read and agreed to the published version of the manuscript.
Availability of data and materials:The data presented in this study are available on request from the corresponding author.
Competing interests: The authors declare no conflict of interest.
Funding: This research received no external funding.
Authors' contributions:Conceptualization, L.Z., J.W.,Y.L., P.C., X.Z. and G.L.; methodology, L.Z., J.W., Y.L. and P.C. ; validation, L.Z., X.Z. and G.L.; formal analysis, L.Z.,J.W. , P.C. and Y.L. ; investigation, Y.L., P.C.,J.W. and X.Z.; resources,X.Z. and G.L.;data curation, L.Z., J.W., P.C. and Y.L.; writing—original draft preparation, L.Z.; writing—review and editing, X.Z.; visualization, Y.L., P.C. and J.W.; supervision, X.Z. and G.L.; project administration, X.Z. and G.L. .
Acknowledgements:The author would like to thank the medical students who have participated in the study.
Authors' information:Liangru Zhou ¹, Jian Wang ¹, Pengxin Cheng ¹,Yue Li ¹, and Xin Zhang ¹,*, Guoxiang Liu ¹,*

1 School of Health Management, Harbin Medical University, Harbin,China

*Correspondence: [email protected] (X.Z.); [email protected] (G.L.); Tel.: +86-0451-8667-2745 (X.Z.); +86-0451-8750-2863 (G.L.)

Participants’ Characteristics

Table 1 shows participants’ baseline characteristics. Among the participants, 61.81% were women, and 38.19% were men. All were between 16 and 45 years old. A total of 77.61% of respondents lived in urban areas, and 86.40% did not have a partner. Overall, 85.30% of them had hospital internship experience, 41.35% had a monthly consumption level of less than 2,000 CNY (approximately $300), and 38.05% exercised less than 1 hour per week.

Table 1. Participants’ characteristics and vaccine hesitancy.

Characteristics	Sample	Hesitancy
Characteristics	N (%)	N (%)	P-value
Total	728 (-)	454 (-)	——
Sex			0.00
Female	450(61.81)	258(56.83)
Male	278(38.19)	196(43.17)
Age			0.07
16-26	538(73.90)	325(71.59)
27-45	190(26.10)	129(28.41)
Type of residence			0.80
urban	565(77.61)	351(77.31)
rural	163(22.39)	103(22.69)
Partner			0.00
No partner	629(86.40)	376(82.82)
Have a partner	99(13.60)	78(17.18)
Hospital Internship			0.42
Yes	621(85.30)	391(86.12)
No	107(14.70)	63(13.88)
Consumption level (monthly)			0.06
≤2000 CNY	427(41.35)	254(55.95)
>2000 CNY	301(58.65)	200(44.05)
Hours of exercise (weekly)			0.01
≤1 h	277(38.05)	159(35.02)
1≤3 h	341(46.84)	232(51.10)
> 3 h	110(15.11)	63(13.88)

Vaccine Hesitancy and Reasons for Vaccine Hesitancy

Among the respondents, 62.36% (454/728) reported having vaccine hesitancy. Participants of different sexes (P = 0.00), with or without partners (P = 0.00), and doing different amounts of exercise (P = 0.01) reported different levels of vaccine hesitancy (Table 1).

The reasons for respondents’ vaccine hesitancy are shown in Table 2. Overall, 41.85% of respondents believed that HPV vaccination was unnecessary. Among the convenience items, 63.22% of participants did not know where to obtain reliable information. Regarding the confidence items, most respondents worried about vaccine safety or side effects (61.67%), 51.32% reported negative reactions of others, and 50.66% reported that they had heard or read negative news.

Table 2. Reasons for respondents’ vaccine hesitancy.

Reasons	Yes, N (%)
Complacency
No vaccination was considered necessary	190 (41.85)
Convenience
Don't know where to get vaccinated	264 (58.15)
The vaccination site is far away and requires a long journey	270 (59.47 )
Repeated vaccination doses, feeling troublesome	274 (60.35 )
Don't know where to get good/reliable information	287 (63.22 )
Confidence
Hear or read negative news	230 (50.66)
Fear of needles	187 (41.19)
Someone told me they had a bad reaction	233 (51.32 )
Had a bad experience with previous vaccinations due to health clinics/vaccinators	185 (40.75 )
Worried about vaccine safety/side effects	280 (61.67 )
I've been told that vaccines aren't safe	188 (41.41)
Vaccination had bad physiological and psychological reactions before	190 (41.85)
Health care workers' attitudes towards the HPV vaccine	192 (42.29)

HPV Information Sources

Overall, 728 participants knew about the HPV vaccine. The main source of HPV knowledge was friends or family members and doctors, followed by the Internet and radio/television. Regarding the number of information channels, respondents with a single source (36.40%) and two sources (36.95%) accounted for the majority (Figure 2).

Multivariate Analysis

The results of the probit regression model showed that sex, the presence or absence of a partner, and Internet information sources were statistically significant at the 0.05 level. Among the demographic characteristics, men had higher levels of vaccine hesitancy. People without a partner had a reduced probability of vaccine hesitancy. People who obtained information from the Internet had a reduced probability of vaccine hesitancy compared to other sources (Table 3).

Table 3. Determinants of vaccine hesitancy using Probit model.

Hesitancy	Coef.	Std. Err.	95% CI
Years of age, 16-26	-0.03	0.12	-0.26,0.21
Male	0.25*	0.11	0.04,0.45
Urban	-0.13	0.12	-0.37,0.10
No partner	-0.42**	0.16	-0.74,-0.11
≤2000 CNY	-0.12	0.11	-0.33,0.09
Internship	0.04	0.14	-0.23,0.31
Hours of exercise (weekly)
1≤3 h	0.15	0.11	-0.06,0.37
>3 h	-0.07	0.15	-0.36,0.22
Radio/TV	0.05	0.11	-0.16,0.27
Internet	-0.33**	0.11	-0.54,-0.12
Family or friends	0.14	0.10	-0.05,0.33
Doctor	-0.14	0.10	-0.34,0.06
_cons	0.88	0.28	0.33,1.43

* indicates statistical significance (* p < 0.05, ** p < 0.01); CI: confidence interval.

The results of marginal utility showed that the average partial effect for males was 0.09, indicating that HPV vaccine hesitancy among male respondents was 9.00% higher than that among females. The average partial effect of not having a partner was -0.15, indicating that the probability of HPV vaccine hesitancy for those without a partner was 15% lower than for those with a partner. The average partial effect of online sources of information was -0.12, indicating that respondents receiving HPV information through the Internet were 12% less likely to report vaccine hesitancy than those receiving information from other information channels.

Table 4. Determinants of vaccine hesitancy using Probit model.

Characteristic	Marginal effect
Male	0.09
No partner	-0.15
Internet	-0.12

Our study targeted Chinese medical students and examined the incidence and reported reasons for HPV vaccine hesitancy among Chinese medical students. It also investigated the sources and number of sources of HPV vaccination information for medical students and explored the correlation between vaccination information and vaccine hesitancy.

The study found a high degree of HPV vaccine hesitancy among the people surveyed, with more than 60% of the respondents reporting hesitancy about the HPV vaccine. The findings showed that some people do not see the necessity of vaccination. This may reflect a cognitive bias, such as an optimistic bias, namely, that they themselves are unlikely to develop cervical cancer, or discounting the future, that is, lack of concern about their own middle or old age in the future. Beyond this, HPV infection might be stigmatized by some as related to life misconduct. Some respondents may believe that they could avoid contracting the virus by having the same sexual partner. However, global observations suggest that 75% of sexually active adults develop HPV at some point in their lifetime[23].

Convenience was reported as an important factor in the respondents’ hesitancy about the HPV vaccine. Participants reported issues with not knowing where to obtain reliable vaccination information (63.22%) and not knowing where to receive vaccination (58.15%). Medical students in Chongqing, China, have reported information as an important obstacle to receiving HPV vaccination[24].A total of 60.35% reported hesitancy on the grounds of repeated vaccination doses and inconvenient vaccination. The percentage of participants who reported having to travel long distances was 59.47%. This may be because HPV vaccination has clear time intervals and dosage requirements. This partly increases the cost of vaccination, such as transportation. To shorten the time cost and improve the accessibility of vaccination, vaccination sites could be added[25] by using mobile vaccination vehicles to provide vaccination services or by providing vaccination services in schools or pharmacies. Although this would improve the availability of vaccination, ensuring vaccine circulation and meeting storage standards should not be ignored; these require joint participation by the regulatory authorities. Opening online or telephone appointments is another way to make vaccination easier. SMS reminder services could also improve the rate of full vaccination.

The safety and effectiveness of vaccines was another key factor reported by medical students in vaccine hesitancy (61.67%). Research on the South East Asia and Western Pacific Regions has reported that safety concerns are related to vaccine hesitancy[26]. Safety concerns are also related to insufficient knowledge about HPV. In fact, the safety and effectiveness of the HPV vaccine have been widely demonstrated. The Global Advisory Committee on Vaccine Safety of the WHO evaluates HPV vaccine performance as “extremely safe”[2].

The US Centers for Disease Control and Prevention noted that many people who get the HPV vaccine experience no side effects. The most common side effects are usually mild, such as a sore arm from the shot. Severe allergic reactions following vaccination are rare[27]. Providing scientific information to the public is an indispensable way to reduce the impact of the vaccine controversy[28]. Fear of needles (41.19%) is also a factor in vaccine hesitancy. Taddio’s study confirmed that fear of pain is one of the major barriers to vaccination[29]. In future vaccine development, the vaccine dosage type could reduce the fear of needles.

The main source of HPV vaccine knowledge for medical students is friends/family and doctors, followed by the web and radio/television. A 2020 Italian study on HPV also noted that fewer people obtained information about vaccination via television, radio, or newspapers[30]. Traditional media may play a different role from that of the Internet in vaccine hesitancy. Respondents who derive their information from traditional media are more likely to report vaccine hesitancy, although this difference is not significant (P>0.05). Owing to the layout and time constraints of traditional media, respondents do not get enough information, which may lead to a “wait-and-see” attitude toward vaccination without a comprehensive understanding of the HPV vaccine. People who obtain information from Internet sources are less likely to report vaccine hesitancy (P = 0.00). Young students are used to finding solutions online when experiencing problems. The Internet plays an important role in disseminating information about vaccination[31]. Using the Internet as a key carrier of vaccine information may effectively increase respondents’ awareness of the HPV vaccine. However, few studies also suggest that social media platforms have become a common source of vaccine information and false information[32]. To reduce the spread of false information, it is necessary to increase the publication of accurate vaccine information and the supervision of online information.

Medical students who rely on family and friends for vaccine information were more likely to report vaccine hesitancy (P>0.05). As parents and friends are the main source of social communication among medical students, they can always obtain information from them. This experience also includes views and attitudes toward the HPV vaccine. This means that, in addition to providing more vaccine information for the respondents, the popularization of the HPV vaccine information among their parents or friends may also indirectly increase respondents’ knowledge of the HPV vaccine. Respondents obtaining information from their physician were less likely to report vaccine hesitancy, although this result was not significant (P > 0.05). As a professional source of information, doctors can provide authoritative HPV vaccine information to dispel people’s doubts about the vaccine. A study in Florida has noted that doctors’ advice on the HPV vaccine predicts vaccination status[33]. Therefore, training healthcare providers to address common vaccine problems[34] may be a feasible way to reduce vaccine hesitancy. On the one hand, public health providers can provide those considering vaccinations with any information they may need[35]. Information regarding the HPV vaccine is also available when other vaccines are administered to reduce parental hesitancy about the HPV vaccine[36]. On the other hand, clinicians can also publicize the correct information to the right-age vaccination population and their parents and encourage this population to undergo vaccination.

Limitations of this study include that there was no segmentation of vaccine hesitancy measurements and that we gathered information only on whether vaccine hesitancy occurred but not on the frequency and degree of vaccine hesitancy. The measurement of the degree is a very complicated issue. Even if there are HPV vaccine hesitancy scales developed in other countries, the applicability of the scales in China has yet to be verified. Using Likert scale and other tools to measure the degree of hesitancy will be our next research content. The study included 738 participants, and the study may have representative questions. However, the number of medical students in China is limited, and we have distributed the samples to different regions of China as much as possible. Another limitation was the cross-sectional design, which cannot provide causal relationships. Despite these limitations, the survey gained a high response rate, showing a strong interest in the HPV topic.

Vaccine hesitancy is prevalent among Chinese medical students. Medical students are potential beneficiaries of the HPV vaccine and a key force for future vaccination; thus, it is necessary to implement measures that address the reasons for their reported vaccine hesitancy. Making vaccination convenient by the use of mobile vaccination vehicles and increasing vaccination sites such as in schools or pharmacies could be an effective way to reduce HPV vaccine hesitancy. The role of medical workers in expanding respondents’ understanding of the safety and effectiveness of the vaccine may also help reduce vaccine hesitancy. Additionally, the role of online media in vaccine hesitancy should also be fully considered.

World Health Organization. Human papillomavirus (HPV) and cervical cancer; [accessed 2021 June 15]. https://www.who.int/zh/news-room/fact-sheets/detail/human-papillomavirus-(hpv)-and-cervical-cancer.
Human papillomavirus vaccines. WHO position paper. Wkly Epidemiol Rec. 2009 Apr 10;84(15):118 – 31. English, French. PMID: 19360985.
World Health Organization. Electronic address: [email protected]. Human papillomavirus vaccines: WHO position paper, May 2017-Recommendations. Vaccine. 2017 Oct 13;35(43):5753–5755. doi: 10.1016/j.vaccine.2017.05.069. Epub 2017 Jun 5. PMID: 28596091.
World Health Organization. Cervical cancer; [accessed 2021 June 15]. https://www.who.int/health-topics/cervical-cancer#tab=tab_1.
Sung H, Ferlay J, Siegel RL, Laversanne M, Soerjomataram I, Jemal A, Bray F. Global Cancer Statistics 2020: GLOBOCAN Estimates of Incidence and Mortality Worldwide for 36 Cancers in 185 Countries. CA Cancer J Clin. 2021 May;71(3):209–249. doi: 10.3322/caac.21660. Epub 2021 Feb 4. PMID: 33538338.
Mattoscio D, Medda A, Chiocca S. Human Papilloma Virus and Autophagy. Int J Mol Sci. 2018 Jun 15;19(6):1775. doi: 10.3390/ijms19061775. PMID: 29914057; PMCID: PMC6032050.
Drolet M, Bénard É, Pérez N, Brisson M. HPV Vaccination Impact Study Group. Population-level impact and herd effects following the introduction of human papillomavirus vaccination programmes: updated systematic review and meta-analysis. Lancet. 2019 Aug 10;394(10197):497–509. doi: 10.1016/S0140-6736(19)30298-3. Epub 2019 Jun 26. PMID: 31255301; PMCID: PMC7316527.
World Health Organization. immunization; [accessed 2021 June 15]. https://www.who.int/topics/immunization/zh/.
Thomas TL. Cancer Prevention: HPV Vaccination. Semin Oncol Nurs. 2016 Aug;32(3):273–80. doi: 10.1016/j.soncn.2016.05.007. Epub 2016 Jul 29. PMID: 27539281; PMCID: PMC4992181.
Jit M, Brisson M, Portnoy A, Hutubessy R. Cost-effectiveness of female human papillomavirus vaccination in 179 countries: a PRIME modelling study. Lancet Glob Health. 2014 Jul;2(7):e406-14. doi:10.1016/S2214-109X(14)70237-2. Epub 2014 Jun 9. PMID: 25103394.
Mo X, Gai Tobe R, Wang L, Liu X, Wu B, Luo H, Nagata C, Mori R, Nakayama T. Cost-effectiveness analysis of different types of human papillomavirus vaccination combined with a cervical cancer screening program in mainland China. BMC Infect Dis. 2017 Jul 18;17(1):502. doi: 10.1186/s12879-017-2592-5. PMID: 28720082; PMCID: PMC5516327.
Van Minh H, My NTT, Jit M. Cervical cancer treatment costs and cost-effectiveness analysis of human papillomavirus vaccination in Vietnam: a PRIME modeling study. BMC Health Serv Res. 2017 May 15;17(1):353. doi: 10.1186/s12913-017-2297-x. PMID: 28506297; PMCID: PMC5433243.
Chesson HW, Meites E, Ekwueme DU, Saraiya M, Markowitz LE. Updated medical care cost estimates for HPV-associated cancers: implications for cost-effectiveness analyses of HPV vaccination in the United States. Hum Vaccin Immunother. 2019;15(7–8):1942–8. doi: 10.1080/21645515.2019.1603562. Epub 2019 May 20. PMID: 31107640; PMCID: PMC6746487.
World Health Organization. Ten threats to global health in 2019; [accessed 2021 June 19]. https: //www. who. int/ emergencies/ten-threats-to-global-health-in-2019.
MacDonald NE. SAGE Working Group on Vaccine Hesitancy. Vaccine hesitancy: Definition, scope and determinants. Vaccine. 2015 Aug 14;33(34):4161-4. doi: 10.1016/j.vaccine.2015.04.036. Epub 2015 Apr 17. PMID: 25896383.
Hanley SJ, Yoshioka E, Ito Y, Kishi R. HPV vaccination crisis in Japan. Lancet. 2015 Jun 27;385(9987):2571. doi: 10.1016/S0140-6736(15)61152-7. Erratum in: Lancet. 2015 Jul 18;386(9990):248. PMID: 26122153.
Costa AS, Gomes JM, Germani ACCG, da Silva MR, Santos EFS, Soares Júnior JM, Baracat EC, Sorpreso ICE. Knowledge gaps and acquisition about HPV and its vaccine among Brazilian medical students. PLoS One. 2020 Mar 19;15(3):e0230058. doi: 10.1371/journal.pone.0230058. PMID: 32191725; PMCID: PMC7082043.
Wang X, Du T, Shi X, et al. Awareness and Knowledge about Human Papilloma Virus Infection among Students at Secondary Occupational Health School in China[J]. International Journal of Environmental Research Public Health. 2021;18(12):6321.
Lee P, Kwan T, Tam KF, et al. Beliefs about cervical cancer and human papillomavirus (HPV) and acceptability of HPV vaccination among Chinese women in Hong Kong[J]. Prev Med. 2007;45(2):130–4.
World Health Organization. Appendices to the report of the sage working group on vaccine hesitancy; [accessed 2021 June 20]. https: //www.who.int/immunization/sage//meetings/2014/october/2_SAGE_Appendicies_Background_final.pdf?ua=1.
Du F, Chantler T, Francis MR, Sun FY, Zhang X, Han K, Rodewald L, Yu H, Tu S, Larson H, Hou Z. Access to Vaccination Information and Confidence/Hesitancy Towards Childhood Vaccination: A Cross-Sectional Survey in China. Vaccines (Basel). 2021 Feb 28;9(3):201. doi: 10.3390/vaccines9030201. PMID: 33670971; PMCID: PMC7997233.
China National Medical Products Administration. HPV vaccine and prevention of cervical cancer;2019 July [accessed 2021 June 21]. https://www.nmpa.gov.cn/yaopin/ypjgdt/20190722080001877.html.[in Chinese].
Matsuo K, Mabuchi S, Okazawa M, Kawano M, Kuroda H, Kamiura S, Kimura T. Clinical implication of surgically treated early-stage cervical cancer with multiple high-risk factors. J Gynecol Oncol. 2015 Jan;26(1):3–11. doi: 10.3802/jgo.2015.26.1.3. Epub 2014 Oct 13. PMID: 25310856; PMCID: PMC4302282.
Fu CJ, Pan XF, Zhao ZM, Saheb-Kashaf M, Chen F, Wen Y, Yang CX, Zhong XN. Knowledge, perceptions and acceptability of HPV vaccination among medical students in Chongqing, China. Asian Pac J Cancer Prev. 2014;15(15):6187-93. doi: 10.7314/apjcp.2014.15.15.6187. PMID: 25124596.
Schmitt HJ, Booy R, Aston R, Van Damme P, Schumacher RF, Campins M, Rodrigo C, Heikkinen T, Weil-Olivier C, Finn A, Olcén P, Fedson D, Peltola H. How to optimise the coverage rate of infant and adult immunisations in Europe. BMC Med. 2007 May;29:5:11. doi:10.1186/1741-7015-5-11. PMID: 17535430; PMCID: PMC1903356.
Santhanes D, Yong CP, Yap YY, Saw PS, Chaiyakunapruk N, Khan TM. Factors influencing intention to obtain the HPV vaccine in South East Asian and Western Pacific regions: A systematic review and meta-analysis. Sci Rep. 2018 Feb;26(1):3640. doi:10.1038/s41598-018-21912-x. PMID: 29483541; PMCID: PMC5832144. 8 ) .
US Centers for Disease Control and Prevention. Safety Information for HPV Vaccine; 2020 September [accessed 2021 June 23]. https://www.cdc.gov/vaccinesafety/vaccines/hpv-vaccine.html.
Karafillakis E, Dinca I, Apfel F, Cecconi S, Wűrz A, Takacs J, Suk J, Celentano LP, Kramarz P, Larson HJ. Vaccine hesitancy among healthcare workers in Europe: A qualitative study. Vaccine. 2016 Sep 22;34(41):5013–5020. doi: 10.1016/j.vaccine.2016.08.029. Epub 2016 Aug 26. PMID: 27576074.
Taddio A, Appleton M, Bortolussi R, Chambers C, Dubey V, Halperin S, Hanrahan A, Ipp M, Lockett D, MacDonald N, Midmer D, Mousmanis P, Palda V, Pielak K, Riddell RP, Rieder M, Scott J, Shah V. Reducing the pain of childhood vaccination: an evidence-based clinical practice guideline. CMAJ. 2010 Dec 14;182(18):E843-55. doi: 10.1503/cmaj.101720. Epub 2010 Nov 22. PMID: 21098062; PMCID: PMC3001531.
Icardi G, Costantino C, Guido M, Zizza A, Restivo V, Amicizia D, Tassinari F, Piazza MF, Paganino C, Casuccio A, Vitale F, Ansaldi F, Trucchi C. Burden and Prevention of HPV. Knowledge, Practices and Attitude Assessment Among Pre-Adolescents and their Parents in Italy. Curr Pharm Des. 2020;26(3):326–42. doi:10.2174/1381612826666200114100553. PMID: 31942852; PMCID: PMC7527545.
Stahl JP, Cohen R, Denis F, Gaudelus J, Martinot A, Lery T, Lepetit H. The impact of the web and social networks on vaccination. New challenges and opportunities offered to fight against vaccine hesitancy. Med Mal Infect. 2016 May;46(3):117–22. doi: 10.1016/j.medmal.2016.02.002. Epub 2016 Mar 14. PMID: 26987960.
Piedrahita-Valdés H, Piedrahita-Castillo D, Bermejo-Higuera J, Guillem-Saiz P, Bermejo-Higuera JR, Guillem-Saiz J, Sicilia-Montalvo JA, Machío-Regidor F. Vaccine Hesitancy on Social Media: Sentiment Analysis from June 2011 to April 2019. Vaccines (Basel). 2021 Jan 7;9(1):28. doi: 10.3390/vaccines9010028. PMID: 33430428; PMCID: PMC7827575.
Malo TL, Ali KN, Sutton SK, Perkins RB, Giuliano AR, Vadaparampil ST. The content and context of physicians' communication with males about human papillomavirus vaccination. Hum Vaccin Immunother. 2016 Jun 2;12(6):1511-8. doi: 10.1080/21645515.2015.1132963. Epub 2016 Feb 2. PMID: 26835599; PMCID: PMC4964649.
Newcomer SR, Caringi J, Jones B, Coyle E, Schehl T, Daley MF. A Mixed-Methods Analysis of Barriers to and Facilitators of Human Papillomavirus Vaccination Among Adolescents in Montana. Public Health Rep. 2020 Nov/Dec;135(6):842–50. doi: 10.1177/0033354920954512. Epub 2020 Sep 24. PMID: 32972304; PMCID: PMC7649981.
Fokoun C. Strategies implemented to address vaccine hesitancy in France: A review article. Hum Vaccin Immunother. 2018 Jul 3;14(7):1580–1590. doi: 10.1080/21645515.2018.1458807. Epub 2018 Jun 14. PMID: 29608390; PMCID: PMC6067858.
Bratic JS, Seyferth ER, Bocchini JA Jr Update on barriers to human papillomavirus vaccination and effective strategies to promote vaccine acceptance. Curr Opin Pediatr. 2016 Jun;28(3):407 – 12. doi: 10.1097/MOP.0000000000000353. PMID: 27093354.

HPV vaccine hesitancy among medical students in China: A multicenter survey

Status:

Journal Publication

Version 1

Abstract

Figures

Introduction

Materials And Methods

Study Design and Implementation

Data Collection and Questionnaire Measures

Statistical Analyses

Declarations

Results

Discussion

Conclusions

References

Status:

Journal Publication

Version 1