Exploring mother-daughter communication and social media influence on HPV vaccine refusal for daughters aged 9-17 years in a cross-sectional survey of 11,728 mothers in China

Figures & data

Table 1. Background characteristics of the participants (n = 11,728).

	All participants (n=11,728)	Participants with daughters aged 9–12 (n=7,154)	Participants with daughters aged 13–17 (n=4,574)	P values
	N (%)	N (%)	N (%)
Age group, years
28–35	3175 (27.0)	2464 (34.4)	711 (15.5)	<.001
36–40	4863 (41.5)	2967 (41.5)	1896 (41.5)
41–61	3690 (31.5)	1723 (24.1)	1967 (43.0)
Education level
Junior high or below	3321 (28.3)	1756 (24.5)	1565 (34.2)	<.001
Senior high or equivalent	2753 (23.5)	1568 (22.0)	1185 (25.9)
College and above	5654 (48.2)	3830 (53.5)	1824 (39.9)
Relationship status
Married	11,236 (95.8)	6873 (96.1)	4363 (95.4)	.07
Currently single	492 (4.2)	281 (3.9)	211 (4.6)
Employment status
Full time	4881 (41.6)	3103 (43.4)	1778 (38.9)	<.001
Part-time	860 (7.3)	489 (6.8)	371 (8.1)
Self-employed	3559 (30.3)	2098 (29.3)	1461 (31.9)
Unemployed	250 (20.1)	147 (2.1)	103 (2.3)
Housewife	1756 (15.1)	1058 (14.8)	698 (15.2)
Others	422 (3.6)	259 (3.6)	163 (3.6)
Monthly household income, ¥ (US$)
<5000 (685)	1958 (16.7)	1033 (14.4)	925 (20.2)	<.001
5000–9999 (685–1369)	3562 (30.4)	2138 (29.9)	1424 (31.2)
10,000–15,000 (1369–2054)	1910 (16.3)	1188 (16.6)	722 (15.8)
>15,000 (2054)	3123 (26.6)	2083 (29.1)	1040 (22.7)
Refuse to disclose	1175 (10.0)	712 (10.0)	463 (10.1)
Self-reported history of HPV infection
No	11,247 (95.9)	6868 (96.0)	4379 (95.7)	.48
Yes	481 (4.1)	286 (4.0)	195 (4.3)
Self-reported history of HPV-related diseases (i.e., genital warts, cervical/anus/vagina cancers, and precancerous lesions)
No	11,467 (97.8)	7006 (97.9)	4461 (97.5)	.15
Yes	261 (2.2)	148 (2.1)	113 (2.5)
Age of the index daughter, years
9–12	7154 (61.0)	–	–	–
13–17	4574 (39.0)	–	–

Table 2. HPV vaccine uptake and refusal, mother-daughter communication, and influence of social media related to HPV vaccination.

	All participants (n = 11,728)	Participants with daughters aged 9–12 (n = 7,154)	Participants with daughters aged 13–17 (n = 4,574)	P value
	N (%)	N (%)	N (%)
HPV vaccine uptake and refusal
The index daughters have received HPV vaccines
No	9515 (81.1)	6748 (94.3)	2767 (60.5)	<.001
Yes	2213 (18.9)	406 (5.7)	1807 (39.5)
Likelihood of having the index daughter take up HPV vaccines (among mothers whose index daughters have never received any HPV vaccines, n=9515)
Very unlikely/unlikely/neutral	5071 (55.3)	3735 (55.3)	1336 (48.3)	<.001
Likely/very likely	4444 (46.7)	3013 (44.7)	1431 (51.7)
HPV vaccine refusal for their daughters
No	6657 (56.8)	3419 (47.8)	3238 (70.8)	<.001
Yes	5071 (43.2)	3735 (52.2)	1336 (29.2)
HPV vaccine refusal among mothers
No	7396 (63.1)	4726 (66.1)	2670 (58.4)	<.001
Yes	4332 (36.9)	2428 (33.9)	1904 (41.6)
Mother-daughter communication related to HPV vaccination
Who will decide whether to have the index daughter take up HPV vaccines?
Mainly decided by you (the mother)	6273 (53.5)	3841 (53.7)	2432 (53.2)	<.001
Mainly decided by your husband	649 (3.5)	396 (5.5)	253 (5.5)
Mainly decided by the index daughter	400 (3.4)	166 (2.3)	234 (5.1)
A shared decision among family members	4406 (37.6)	2751 (38.5)	1655 (36.2)
Perceived positive outcomes of discussing HPV vaccines with the index daughter
The index daughter will understand the purpose of taking up HPV vaccines	7235 (61.7)	4035 (56.4)	3200 (70.0)	<.001
The index daughter will feel that you care about her	9798 (83.5)	5894 (82.4)	3904 (85.4)	<.001
The index daughter will be more willing to take up HPV vaccines	8270 (70.5)	4749 (66.4)	3521 (77.0)	<.001
Positive Outcome Expectancy Scale ^a, mean (SD)	7.9 (1.6)	7.7 (1.6)	8.1 (1.4)	<.001
Perceived negative outcomes of discussing HPV vaccines with the index daughter
The index daughter will get confused	3829 (32.6)	2539 (35.6)	1280 (28.0)	<.001
The index daughter will ask you some questions that make your feel embarrassed	5071 (43.2)	3391 (47.4)	1680 (36.7)	<.001
The index daughter will argue with you	2728 (23.3)	1570 (21.9)	1158 (25.3)	<.001
Negative Outcome Expectancy Scale ^b, mean (SD)	5.6 (2.0)	5.7 (1.9)	5.3 (2.0)	<.001
The Openness Subscale ^c of the Parent-adolescent Communication Scale
Mean (SD)	37.4 (6.7)	37.5 (6.8)	37.3 (6.6)	.05
Influence of social media related to HPV vaccination
Frequency of exposure to the following information on social media platforms (i.e., WeChat moments, Weibo, Tiktok, Red) in the past month
Testimonials given by parents about daughters’ HPV vaccination
Almost none	3997 (34.1)	2474 (34.6)	1523 (33.3)	.29
Seldom	4314 (36.8)	2599 (36.3)	1715 (37.5)
Sometimes	2710 (23.1)	1637 (22.9)	1073 (23.5)
Always	707 (6.0)	444 (6.2)	263 (5.7)
Item score, mean (SD)	2.0 (0.9)	2.0 (0.9)	2.0 (0.9)	.26
Negative information about HPV vaccines (i.e., concerns about efficacies and supplies, side effects of the vaccines)
Almost none	3667 (31.3)	2241 (31.3)	1426 (31.2)	.34
Seldom	4803 (41.0)	2889 (40.4)	1914 (41.8)
Sometimes	2730 (23.2)	1693 (23.7)	1037 (22.7)
Always	528 (4.5)	331 (4.6)	197 (4.3)
Item score, mean (SD)	2.0 (0.9)	2.0 (0.9)	2.0 (0.8)	.02
Negative information about other vaccine incidents in China (i.e., selling problematic vaccines and severe side effects)
Almost none	3990 (34.0)	2419 (33.8)	1571 (34.3)	.60
Seldom	4719 (40.2)	2866 (40.1)	1853 (40.5)
Sometimes	2468 (21.1)	1535 (21.5)	933 (20.5)
Always	551 (4.7)	334 (4.7)	217 (4.7)
Item score, mean (SD)	2.0 (0.9)	2.0 (0.9)	2.0 (0.9)	.97
Information that encourages parents to vaccine their daughters against HPV
Almost none	2737 (23.3)	1724 (24.1)	1013 (22.1)	<.001
Seldom	3114 (26.6)	1993 (27.9)	1121 (24.5)
Sometimes	3688 (31.4)	2225 (31.1)	1463 (32.0)
Always	2189 (18.7)	1212 (16.9)	977 (21.4)
Item score, mean (SD)	2.5 (1.0)	2.4 (1.0)	2.5 (1.1)	.005
Thoughtful consideration about veracity of information specific to HPV vaccines in the past month
Almost none	2566 (21.9)	1599 (22.4)	967 (21.1)	.06
Seldom	3239 (27.6)	2006 (28.0)	1233 (27.0)
Sometimes	4025 (34.3)	2434 (34.0)	1591 (34.8)
Always	1898 (16.2)	1115 (15.6)	783 (17.1)
Item score, mean (SD)	2.5 (1.0)	2.4 (1.0)	2.5 (1.0)	.62

^aPositive Outcome Expectancy Scale, 3 items, Cronbach’s alpha: .69; one factor was identified by exploratory factor analysis, explaining for 63.2% of total variance.

^bNegative Outcome Expectancy Scale, 3 items, Cronbach’s alpha: .62; one factor was identified by exploratory factor analysis, explaining for 57.1% of total variance.

^cThe Openness Subscale of the Parent-adolescent Communication Scale, Cronbach’s alpha: .93.

Table 3. Associations between background characteristics and HPV vaccine refusal for the index daughters.

	All participants (n=11,728)		Participants with daughters aged 9–12 (n=7,154)		Participants with daughters aged 13–17 (n=4,574)
	OR (95%CI)	P values	OR (95%CI)	P values	OR (95%CI)	P values
Age group, years
28–35	Reference		Reference		Reference
36–40	0.85 (0.77, 0.93)	<.001	0.91 (0.82, 1.02)	.10	1.18 (0.97, 1.43)	.10
41–61	0.84 (0.76, 0.92)	<.001	1.00 (0.88, 1.13)	.96	1.36 (1.12, 1.66)	.002
Education level
Junior high or below	Reference		Reference		Reference
Senior high or equivalent	0.86 (0.78, 0.96)	.005	0.80 (0.70, 0.92)	.002	0.81 (0.68, 0.95)	.01
College and above	0.77 (0.71, 0.85)	<.001	0.64 (0.56, 0.72)	<.001	0.60 (0.51, 0.70)	<.001
Relationship status
Married	Reference		Reference		Reference
Currently single	0.72 (0.59, 0.86)	<.001	0.68 (0.54, 0.87)	.002	0.84 (0.61, 1.15)	.28
Employment status
Full time	Reference		Reference		Reference
Part-time	1.48 (1.28, 1.71)	<.001	1.79 (1.47, 2.19)	<.001	1.45 (1.13, 1.84)	.003
Self-employed	1.09 (0.99, 1.19)	.07	1.09 (0.97, 1.21)	.15	1.32 (1.13, 1.54)	<.001
Unemployed	1.41 (1.09, 1.83)	.008	1.62 (1.15, 2.28)	.005	1.45 (0.95, 2.22)	.09
Housewife	1.37 (1.22, 1.53)	<.001	1.47 (1.28, 1.69)	<.001	1.43 (1.18, 1.74)	<.001
Others	1.12 (0.92, 1.37)	.26	1.12 (0.87, 1.44)	.39	1.22 (0.86, 1.74)	.27
Monthly household income, ¥ (US$)
<5000 (685)	Reference		Reference		Reference
5000–9999 (685–1369)	0.84 (0.75, 0.94)	.002	0.78 (0.67, 0.91)	.002	0.74 (0.62, 0.88)	<.001
10,000–15,000 (1369–2054)	0.71 (0.62, 0.81)	<.001	0.59 (0.50, 0.70)	<.001	0.70 (0.57, 0.87)	.001
>15,000 (2054)	0.66 (0.59, 0.81)	<.001	0.58 (0.50, 0.68)	<.001	0.46 (0.37, 0.57)	<.001
Refuse to disclose	0.99 (0.86, 1.16)	.98	0.92 (0.75, 1.11)	.37	0.92 (0.73, 1.17)	.52
Self-reported history of HPV infection
No	Reference		Reference		Reference
Yes	0.81 (0.75, 0.88)	<.001	0.82 (0.65, 1.05)	.11	0.85 (0.61, 1.18)	.32
Self-reported history of HPV-related diseases (i.e., genital warts, cervical/anus/vagina cancers, and precancerous lesions)
No	Reference		Reference		Reference
Yes	0.84 (0.66, 1.09)	.19	0.84 (0.61, 1.17)	.31	0.93 (0.61, 1.41)	.72
Age of the index daughter, years
9–12	Reference		–		–
13–17	0.39 (0.36, 0.42)	<.001	–	–	–	–

Note. OR: crude odds ratios obtained from two-level logistic regression models (level 1: schools, level 2: individual participants).

CI: confidence interval.

Table 4. Associations of mother-daughter communication and social media influence with HPV vaccine refusal for the index daughters.

	All participants (n = 11,728)			Participants with daughters aged 9–12 (n = 7,154)			Participants with daughters aged 13–17 (n = 4,574)
	AOR (95%CI)	P values	Hosmer and Lemeshow test	AOR (95%CI)	P values	Hosmer and Lemeshow test	AOR (95%CI)	P values	Hosmer and Lemeshow test
HPV vaccine refusal among mothers
No	Reference		.38	Reference		.35	Reference		.31
Yes	2.81 (2.58, 3.06)	<.001		2.97 (2.67, 3.30)	<.001		2.47 (2.15, 2.82)	<.001
Mother-daughter communication related to HPV vaccination
Who will decide whether to have the index daughter take up HPV vaccines?
Mainly decided by you (the mother)	Reference		.26	Reference		.22	Reference		.06
Mainly decided by your husband	1.28 (1.08, 1.52)	.004		1.20 (0.97, 1.48)	.09		1.44 (1.08, 1.90)	.01
Mainly decided by the index daughter	1.43 (1.16, 1.77)	.001		1.85 (1.33, 2.56)	<.001		1.17 (0.87, 1.58)	.31
A shared decision among family members	1.46 (1.44, 1.70)	<.001		1.51 (1.36, 1.67)	<.001		1.67 (1.45, 1.92)	<.001
Positive Outcome Expectancy Scale	0.77 (0.75, 0.79)	<.001	.16	0.78 (0.76, 0.81)	<.001	.06	0.76 (0.72, 0.79)	<.001	.06
Negative Outcome Expectancy Scale	1.06 (1.04, 1.08)	<.001	.19	1.07 (1.04, 1.09)	<.001	.20	1.05 (1.01, 1.08)	.006	.06
The Openness Subscale of the Parent-adolescent Communication Scale	0.99 (0.98, 0.99)	<.001	.88	0.99 (0.98, 0.99)	<.001	.10	0.98 (0.98, 0.99)	.002	.92
Influence of social media related to HPV vaccination
Frequency of exposure to the following information on social media platforms (i.e., WeChat moments, Weibo, Tiktok, Red) in the past month
Testimonials given by parents about daughters’ HPV vaccination	0.81 (0.78, 0.85)	<.001	.41	0.81 (0.77, 0.85)	<.001	.78	0.83 (0.77, 0.89)	<.001	.07
Negative information about HPV vaccines (i.e., concerns about efficacies and supplies, side effects of the vaccines)	1.01 (0.96, 1.05)	.84	.12	0.97 (0.92, 1.03)	.35	.07	1.06 (0.98, 1.15)	.12	.07
Negative information about other vaccine incidents in China (i.e., selling problematic vaccines and severe side effects)	1.01 (0.96, 1.05)	.73	.06	0.97 (0.92, 1.03)	.28	.06	1.08 (0.99, 1.17)	.06	.06
Information that encourages parents to vaccine their daughters against HPV	0.76 (0.73, 0.79)	<.001	.50	0.76 (0.73, 0.80)	<.001	.34	0.75 (0.71, 0.80)	<.001	.16
Thoughtful consideration about veracity of information specific to HPV vaccines in the past month	0.80 (0.77, 0.83)	<.001	.20	0.82 (0.78, 0.86)	<.001	.69	0.78 (0.73, 0.83)	<.001	.06

AOR: adjusted odds ratios, odds ratios obtained from two-level logistic regression models (level 1: schools, level 2: individual participants) after adjusting for significant background characteristics listed in Table 3.

CI: confidence interval.

Table

	n	%
HPV vaccine uptake among the index daughters
Number dose of HPV vaccination uptake among the index daughters (Among 2213 participants whose index daughters had received at least one dose of HPV vaccine)
1 dose	380	17.2
2 doses	1495	67.6
3 doses	221	10.0
Uncertain	117	5.2
Type of HPV vaccination uptake among the index daughters (Among 2213 participants whose index daughters had received at least one dose of HPV vaccine)
Domestic bivalent vaccines	1120	50.6
Imported bivalent vaccines	83	3.8
Quadrivalent vaccine (Gardasil 4)	53	2.4
9-valent vaccine (Gardasil 9)	436	19.7
Uncertain	521	23.5
Venues of vaccination uptake among the index daughters (Among 2213 participants whose index daughters had received at least one dose of HPV vaccine)
Public hospitals or community health centers in Shenzhen	2032	91.8
Private hospitals in Shenzhen	166	7.5
Other provinces or cities	53	2.4
Hong Kong, Macao or other countries	51	2.3

Data availability statement

The datasets generated and/or analyzed during the current study are not publicly available as they contain sensitive personal behaviors but are available from the corresponding author on reasonable request.