HPV vaccination intention and its association with vaccine hesitancy and health beliefs among unvaccinated Chinese medical college students: A cross-sectional study
Plos.org·July 20, 2026
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A cross-sectional study examined HPV vaccination intentions among unvaccinated Chinese medical college students, analyzing the relationship between vaccine hesitancy and underlying health beliefs. The research highlights the need for targeted interventions to improve HPV vaccination uptake in this population despite their medical education background.
Human papillomavirus (HPV) infection poses a significant public health challenge, and HPV vaccination uptake among Chinese college students remains suboptimal. Therefore, it is essential to conduct ongoing, in-depth investigations into the psychological and cognitive mechanisms of HPV vaccination intention. This study aims to explore the associations among HPV vaccination intention, vaccine hesitancy, and health beliefs among Chinese medical college students.
A cross-sectional survey was conducted from June 16 to July 16, 2024, to assess sociodemographic characteristics, vaccine hesitancy, and health belief model (HBM) among college students at Guangdong Medical University. Descriptive statistics, univariate analysis, and binary logistic regression were performed to identify factors associated with HPV vaccination intentions among unvaccinated students.
Among 3,584 unvaccinated participants, 73.16% expressed willingness to receive the HPV vaccine. The key significant associations identified included gender (male) (OR: 0.26; 95% CI: 0.22 ~ 0.31; p < 0.001), parental occupation (employees in enterprises, commercial, and service industries (including self-employed)) (OR: 1.43; 95% CI: 1.18 ~ 1.75; p < 0.001), and information sources (hospitals or doctors) (OR: 1.37; 95% CI: 1.15 ~ 1.64; p = 0.001). Vaccination intention was also directly associated with the perceived necessity (OR: 0.91; 95% CI: 0.88 ~ 0.94; p < 0.001) and importance (OR: 1.07; 95% CI: 1.03 ~ 1.10; p < 0.001) of vaccine hesitancy, as well as the perceived benefits of behavior for the HBM (OR: 1.21; 95% CI: 1.12 ~ 1.32; p < 0.001).
In this sample, Chinese medical college students demonstrated a relatively high willingness to receive HPV vaccination. Willingness was positively associated with perceived necessity, importance, and benefits of vaccination. Integrating structured clinician-delivered counseling into curricula, using parental occupation data for targeted subsidies, and embedding classroom sessions comparing personal HPV risk with vaccine safety data may improve uptake. Government evaluation of gender-neutral vaccination policies and provision of male-inclusive campus services are also recommended.
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Citation: Cui Y-A, Li Y, Yang L, Cui Z-A (2026) HPV vaccination intention and its association with vaccine hesitancy and health beliefs among unvaccinated Chinese medical college students: A cross-sectional study. PLoS One 21(7): e0354119. https://doi.org/10.1371/journal.pone.0354119
Editor: Gulzhanat Aimagambetova, Nazarbayev University School of Medicine, KAZAKHSTAN
Received: March 10, 2026; Accepted: July 3, 2026; Published: July 20, 2026
Data Availability: All relevant data are within the paper and its Supporting information files.
Funding: This research was funded by the 2026 Dongguan Philosophy and Social Sciences Planning Youth Project (No. 2026QN12), the State Key Laboratory of Pathogenesis, Prevention, Treatment of Central Asian High Incidence Diseases Fund (No. SKL-HIDCA-2025-GD9), the Guangdong Provincial Undergraduate Teaching Quality and Teaching Reform Project (No. 4SG25104P), the Special Project for Clinical and Basic Sci & Tech Innovation of Guangdong Medical University (No. GDMULCJC2025202), the Guangdong Medical University Undergraduate Teaching Quality and Teaching Reform Project (2025) (No. 1JG25040) and the Guangdong Medical University Undergraduate Teaching Quality and Teaching Reform Project (2025) (No. 1JG25100). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Competing interests: The authors have declared that no competing interests exist.
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.
This cross-sectional study was carried out at Guangdong Medical University between June 16 and July 16, 2024. A convenience sampling approach was employed, and the data were collected through an online questionnaire hosted on the Chinese survey platform “Wenjuanxing” (www.wjx.cn). The survey link was shared with full-time students via WeChat.
A total of 5,384 individuals participated in the survey. To ensure data quality, 456 invalid responses were excluded based on three pre-defined criteria: (1) completion time < 180 seconds (n = 199), given that the 35-item survey (including single-choice, multiple-choice, and fill-in-the-blank questions) allowed an average of approximately 5 seconds per item—insufficient for attentive reading and responding, especially for text-entry items; (2) inconsistent or implausible responses (n = 45), operationalized as a self-reported age below 14 or above 30, which are extreme outliers relative to the typical full-time student age range (16–25 years) as verified by the university’s student affairs office; (3) unverifiable or inaccurate academic/professional information (n = 212). After exclusion, this yielded 4,928 valid questionnaires (validity rate: 91.53%). Among the participants with valid responses, 3,584 participants (unvaccinated rate: 72.73%) had not received the HPV vaccine or were in the process of scheduling an appointment for it. Therefore, the final analysis included 3,584 Chinese college students.
Ethical approval for this investigation was granted by the Clinical Research Ethics Committee of the Affiliated Hospital of Guangdong Medical University (approval NO. PJKT2023−126). An online informed consent document was reviewed and signed by each participant before enrollment. Furthermore, all prospective participants were assured of the voluntary nature of the study and their prerogative to withdraw their consent at any given moment.
The survey included sociodemographic characteristics, the vaccine hesitancy scale, and the health belief model.
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).
https://doi.org/10.1371/journal.pone.0354119.t001
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.
https://doi.org/10.1371/journal.pone.0354119.t002
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.
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.
Data analysis was performed by using IBM SPSS Statistics for Windows, version 29.0 (IBM Corporation, Armonk, NY, USA, 2022; official website: https://www.ibm.com/spss). Univariate analyses were conducted to assess the associations among the variables (Sociodemographics and various dimensions of vaccine hesitancy and the HBM) and HPV vaccination intentions among college students. Variables with p < 0.05 in the univariate analyses were entered into a binary logistic regression model to identify significant independent associations with HPV vaccination intentions. Adjusted odds ratios (ORs) with 95% confidence intervals (CIs) were computed, with statistical significance set at p < 0.05.
Among the study participants, 55.69% (n = 1,996) were female college students, and 44.31% (n = 1,588) were male, with a mean age of 20.63 ± 1.74 years. Regarding main economic source, the majority (95.98%) relied on parental support, while 32.31% reported income from part-time jobs while they were studying. Most participants (78.85%) reported monthly expenditures between 1,000 and 2,000 CNY, and 74.86% reported a monthly family income exceeding 4,000 CNY. The most prevalent parental occupations were employees in enterprises, commercial, and service industries (including self-employed individuals) (27.93%) or workers (27.04%), with 8.23% of the participants having at least one parent in education or medical professions.
Regarding sources of HPV-related information, the five most frequently reported channels were schools/teachers/classmates, social media (WeChat, Weibo, QQ, etc.), the internet (website, email, newsletter, etc.), and hospital/doctor and traditional media (TV/radio/newspapers/magazines).
Notably, nearly half of the respondents had encountered negative information regarding the HPV vaccine. Among the unvaccinated cohort, a substantial proportion (73.16%, n = 2,622) expressed a positive intention to receive the HPV vaccine (Table 1).
Vaccine hesitancy analysis revealed distinct characteristics across dimensions: the necessity dimension had a mean score of 7.56 ± 3.18, which was below the critical threshold of 12. The importance dimension had significantly higher scores (20.56 ± 3.28), exceeding the critical threshold of 15. Notably, the safety dimension had a mean score of 10.78 ± 2.44, which was higher than the critical threshold of 9 (Table 2).
The scores of the perceived benefits of behavior, trust in formal information, perceived disease severity, perceived disease susceptibility, and perceived behavioral barriers for the HBM dimensions were 12.28 ± 1.74, 16.13 ± 2.36, 8.15 ± 1.47, 7.19 ± 2.36, and 3.75 ± 0.84, respectively (Table 3).
Univariate analysis revealed significant associations between the intention to receive HPV vaccination and key variables, as detailed in Table 4.
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).
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.
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.
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.