ABSTRACT
In 2020, the domestic (Chinese native) 2v human papillomavirus (HPV) vaccine was approved for use in females. At present, there are obvious differences in demand for different HPV vaccines. We aimed to investigate knowledge level of cervical cancer and HPV vaccine and its influencing factors among the eligible female recipients in Shenzhen, China, and to analyze the factors influencing choice of 2vHPV vaccine (domestic or imported) would be selected. A self-administered questionnaire was carried out on this investigation, and respondents were selected by random sampling method conducted by vaccination doctors. A total of 1197 valid questionnaires were collected, of which 729 (60.9%) were vaccinated with domestic vaccines and 468 (39.1%) were vaccinated with imported. Four hundred and fifty (61.7%) and 306 (65.4%) got a passing grade, respectively (χ2 = 1.637, P = .201). Logistic regression analysis showed that age (P = .002), ethnicity (P < .001), duration of residence in Shenzhen (P < .001), educational level (P < .001) and occupation (P < .001) were significant. It also showed that the manufacturers (P < .001), efficacy (P < .001), safety (P < .001), cognitive approach (P < .001), public opinion (P < .001), convenient acquisition (P < .001) and knowledge reserve (P = .035) were statistically significant. While price (P = .371) and doctor’s suggestion (P = .114) were not. In conclusion, eligible female recipients had a high degree of knowledge regarding cervical cancer and HPV vaccine, education level and occupation were the most important factors for scores. Domestic 2vHPV vaccine was more widely utilized than imported, manufacturer, efficacy, safety, cognitive approach, public opinion, convenient acquisition, and knowledge reserve had an impact on selection for recipients, while price and doctor’s suggestion did not.
Introduction
Cervical cancer is the most common malignant tumor for female reproductive tract, it affects women’s health seriously. A reportCitation1 showed that there are nearly 570,000 new cervical cancer cases and over 310,000 deaths from cervical cancer each year, which is the fourth most common cancer among women worldwide. Human papillomavirus (HPV) is the most common reproductive tract virus. At present, more than 200 HPV subtypes have been identified, of which more than 85 types have been identified in the human body.Citation2 HPV is divided into broad high-risk (hr-HPV) and low-risk types (lr-HPV) according to carcinogenicity. Infection with hr-HPV can cause head and neck cancer and oropharyngeal cancer in addition to anogenital cancer. In contrast, benign skin lesions, such as genital warts, are generally attributed to lr-HPV.Citation3 Although most HPV infections and their related precancerous lesions can resolve spontaneously, HPV infection and its sequelae is still an important cause of cancers of the cervix, vulva, vagina, penis, prostate, and anus.Citation4 For instance, a studyCitation5 has shown that persistent infection with hr-HPV (types 16 and 18) is a risk factor for cervical cancer, which causes 70% of cervical cancer worldwide. In 2020, there were nearly 110,000 new cases and 60,000 deaths in China, ranking second only to India, becoming the second largest country for burden of cervical cancer in the world.Citation6 Primary prevention is the most important measure for preventing cervical cancer, including HPV vaccination and routine screening, etc. Given that nearly all cervix carcinomas are caused by HPV, HPV vaccination programs have been progressively introduced in many countries, mainly in girls between 9 and 14 years old.Citation7–9 There is presently sparse literature and few clinical compasses that recommend prevention, screening, and treatment for HPV infections in men. However, the HPV vaccine utilized in men has been shown to be effective in preventing diseases such as anal cancer,Citation10 the Advisory Committee on Immunization Practices (ACIP) also recommends vaccination for males aged 13 through 21 years not vaccinated previously.Citation11
Since 2017, Chinese mainland has been using imported bivalent (2v, contains genotypes 16/18), quadrivalent (4v, contains genotypes 6/11/16/18) and nonavalent (9v, contains genotypes 6/11/16/18/31/33/45/52/58) HPV vaccines for several years, but only allows females to be vaccinated.Citation12 In 2020, the domestic (Chinese native) 2vHPV vaccine was also produced and administered to females. Currently, there are significant disparities in demand for different HPV vaccine options. The 9vHPV vaccine provides the most comprehensive preventive coverage, but has only one manufacturer in the world. Despite being the most expensive, it still faces high demand and limited supply. In comparison, the 4vHPV vaccine, has less protective coverage, costs less but the supply is still relatively tight. Compared to the 9v and 4vHPV vaccine, the 2vHPV vaccine is the most widely available and the least costly, while demand is the weakest. In China, HPV vaccine has not been included in the national immunization program, it is still classified as a non-immunization program vaccine (self-paid vaccines). Recipients should be vaccinated according to the package insert of vaccine, informed consent, voluntary and self-paying. Although HPV vaccine is a non-immunization vaccine, since the emergence of domestic 2vHPV vaccine, because of its relatively low price, some developed provinces or cities have included it in respective immunization program, so as to vaccinate students with certain age for free. In Shenzhen, for instance, only junior 1 students can enjoy domestic 2vHPV vaccine for free, but only two doses are given to be vaccinated, because research data showed that two doses vaccination can obtain the same immune effect as three doses for girls aged 9–14 years.Citation13 Even so, the usage quantity of domestic 2vHPV is also unsatisfactory in the self-paying groups, the reason for underutilization may be because most recipients would like to be vaccinated with 9vHPV if they met the conditions. According to a study by Abouelella,Citation14 HPV vaccine choice was influenced by a variety of factors, including income, age, local economic status, and ease of acquisition. However, being the first approved HPV vaccine, 2vHPV vaccine efficacy has been verified and should not be ignored. For instance,Citation15 data from 392 unvaccinated and 353 vaccinated women were compared. HPV 16/18 prevalence was 9.2% and 0.8%, respectively, and HPV 31/33/45 prevalence was 8.4% and 1.1%, respectively. Direct, indirect and total efficacy of the HPV vaccine were (%, 95% CI): 94 (72 − 99), 30 (−11 − 56) and 95 (79 − 99), respectively, for HPV 16/18 and 83 (46 − 94), −10 (−88 − 33) and 84 (54 − 94), respectively, for HPV 31/33/45. At present, whether domestic 2vHPV vaccine is more popular than imported 2vHPV vaccine is unknown, and there has been no relevant comparative researches. This project aims to study the knowledge level and differences on the two groups of people (vaccinated with domestic or imported 2vHPV vaccine) and analyze the factors influencing 2vHPV vaccine choices (domestic vs imported) will be selected. We hope the finding will help inform vaccine utilization promotional effort and rational resource utilization by health policy manager and policy makers.
Materials and methods
Survey subjects
In February 2023, females who had received or were scheduled to get the 2vHPV vaccine were chosen as the study’s participants. Inclusion criteria: (1) women vaccinated with 2vHPV vaccine in Shenzhen (including those who have or have not completed the vaccination procedure and those who will be vaccinated within one month); (2) Older than or equivalent to 18 years of age. (3) Preparing vaccination or the initial immunization take place within 1 year. (4) Got informed consent.
Sample size calculation
According to formula N=μ2α/2π(1-π)÷δ,2 α = 0.05, μ0.05/2 = 1.96, and δ = 0.03, it is estimated that the awareness rate about HPV vaccine was approximate 50% in Shenzhen women, namely π = 0.5, and n = 1067, however, the planned sample size was expanded by 20% to account for questionnaires not meeting quality criteria to 1280. The final sample size, i.e. number of valid questionnaires was 1197.
Survey methods
A cross-sectional investigation was conducted. Three districts from Shenzhen’s east, west, and middle districts (Yantian, Baoan, and Luohu) were chosen as representations, and three immunization clinics from each district were chosen for examination. We designed the questionnaire after reading numerous articles about the uptake of HPV vaccine, and we also took into account the respondents’ approximate average knowledge level. Prior to the official survey, a pre-survey was done, 90% of the respondents to the pre-survey expressed satisfaction with the questionnaire’s content and thought it accurately reflected the situation, indicating a good validity of questionnaire. Additionally, reliability was examined using test–retest method, with a reliability coefficient of r = 0.90, indicating high reliability. The final questionnaire was obtained after repeated revision. During the survey, all respondents received informed consent before enrolling in this study and were guaranteed voluntary participation, withdrawal, study risks, confidentiality, and secured data storage. Vaccination doctors who participated in this study received training on the study protocol and explanation of questionnaire items from the principal researcher. For this cross-sectional study, a link to the online questionnaire survey, administered in Chinese, was generated through the survey platform WJX.cn. The questionnaire was then published and a response URL and QR code were generated, they were sent subsequently by vaccination doctors to invite qualified survey subjects through “Wechat” and “QQ” chat groups or friends (Chinese native chat tools, made by Tencent). Respondents answered the questionnaire by logging in to the website through a browser or scanning the QR code on mobile phone, and they should fill out the questionnaire on their computer or mobile phone and submit it when all questions were completed. Subsequently, the results will be automatically saved and uploaded to our self-created URL (platform WJX.cn), and staffs can acquire all the answers from respondents on the website. In the end, from February 12th to 26th, a total of 1280 questionnaires were collected, while 83 unqualified questionnaires (including incomplete answers or serious logic errors) were removed, resulting in 1197 were valid questionnaires, i.e. with an effective rate 93.50%. The questionnaire included three dimensions: basic individual information, knowledge about cervical cancer and HPV vaccine, and factors influencing vaccine choices. (1) The basic respondent information had 7 questions, including age, marital status, ethnic group, duration of time lived in Shenzhen, education level, occupation and annual family income. (2) Ten questions about cervical cancer and HPV vaccine knowledge, include cervical cancer virus, whether all HPV may cause cervical cancer, major transmission route, whether vaccinated earlier better in prescribed age, how many HPV vaccines were applied in China, meaning of “x-valent”, whether cervical cancer may occur after vaccination, which HPV genotype contributed to cervical cancer, whether infected HPV could be removed after vaccination, whether HPV could cause other diseases (multiple-choice). This part scored as follows: one point for each correct answer and 0 point for each incorrect or no answer (multiple-choice questions: multiple selection, missed selection and wrong selection were also 0 points). The overall score ranged from 0 to 10 points. We regarded ≧6 points as an eligible respondent, while <6 points were ineligible. (3) 11 questions about influencing factors were displayed, including which 2vHPV vaccine to choose, manufacturer, price, efficacy, safety, cognitive approach, public opinion, convenient acquisition, HPV knowledge reserve and doctor’s suggestion. Additionally, a hypothetical scenario was presented, inquiring which type of HPV vaccine individuals would choose if they met the eligibility requirements.
Statistical analysis
The data derived from the questionnaire were processed and imported into SPSS 19.0 software for statistical analysis. The basic situation was analyzed by descriptive analysis. Continuous variables in accordance with normal distribution were described by mean ± standard deviation (μ±σ). Categorical variables were described by frequency (percentage). Chi-square test was used for statistical inference. Binary logistic was used for influencing factors analysis, with level of significance determined at a .05 p value.
Results
Basic information
A total of 1197 subjects were effectively surveyed, and 729 (60.9%) of them had received the domestic 2vHPV vaccine while 468 (39.1%) had received the imported ones. In terms of demographic information: the age distribution was 35.23 ± 6.736 years old. Nine hundred and twenty-seven(77.4%) subjects were married. One thousand one hundred and fifty-two (96.2%) were ethnic Han. Nine hundred and forty-five people (43.0%) have lived in Shenzhen for more than 5 years. In terms of education level, 513 (42.9%) subjects had a bachelor’s degree or above. In terms of occupations, 279 people were health care staffs, accounting for 23.3%. There were 531 people with annual household income less than or equal to 100,000 yuan, accounting for 44.4% ().
Table 1. Basic information of different types of 2vHPV vaccines recipients [n(%)].
Cervical cancer and HPV vaccine knowledge
The questionnaire qualification rate of cervical cancer and HPV vaccine knowledge was 61.7% in those vaccinated with domestic 2vHPV vaccine, while 65.4% in imported 2vHPV vaccine recipients, there were no significant differences (χ2 = 12.571, P = .002) between them (). The results of a logistic regression analysis revealed that younger, shorter residence time in Shenzhen, higher education, and occupation of white-colored workers, civil servants, health care staffs and teachers were protective factors for qualification scores, while occupation of workers and small business owners were risk factor. Marital status, occupation of housewife and students, and annual household income had no statistical significance ().
Table 2. Comparison of knowledge level among recipients of different 2vHPV vaccines [n(%)].
Table 3. Logistic regression analysis of influencing factors for different levels of scores.
Analysis of factors influencing 2vHPV vaccine choices
Logistic regression analysis was performed to assess factors influencing HPV vaccine choices (domestic vs imported). The results showed that factors such as manufacturer, efficacy, safety, cognitive approach, public opinion, ease of acquisition and knowledge reserve had significant impact on vaccine choices by the recipients. While vaccine cost and doctor’s suggestion were not significant factors. (1) In terms of manufacturer, 55.6% of domestic vaccine recipients selected “more trust in domestic manufacturer” (OR = 0.291, P = .017), while 42.3% of imported vaccine recipients selected “more trust in imported manufacturer” (OR = 473.349, P < .001), differences were statistically significant. (2) In terms of efficacy, 66.3% of domestic vaccine recipients selected “I think domestic products are better” (OR = 0.038, P < .001), while 71.2% of imported vaccine recipients selected “I think imported products are better” (OR = 212.859, P < .001). (3) In terms of safety, 65.4% of domestic vaccine recipients selected “I think domestic products are safer” (OR = 0.157, P < .001), while 61.5% of imported vaccine recipients selected “I think imported products are safer” (OR = 17.778, P < .001). (4) In terms of cognitive approach, domestic vaccine recipients were more likely to be affected by “popularization of science” (OR = 0.749, P = .043), while imported vaccine recipients were more likely to be affected by “expert recommendation” (OR = 1.920, P = .001). (5) In terms of public opinion, those who selected imported products were more likely to be affected by public opinion (OR = 12.918, P < .001). (6) In terms of ease of acquisition, domestic vaccine recipients were more affected by “convenient to acquire.” (7) In terms of knowledge reserve, domestic vaccine recipients were more likely to be affected by “knowledge reserve” and were more willing to read instructions or other related materials before inoculation (OR = 0.454, P = .035) (). In addition, for the final question, if the vaccination conditions were met and all types of vaccine could be freely selected again, 59.3% of domestic vaccine recipients would choose imported 9vHPV vaccine, versus 73.1% among imported vaccine recipients, suggesting a statistical difference (χ2 = 140.082, P < .001) among selection options, it can be considered that both groups would prefer imported 9vHPV vaccine if they were free to choose again.
Table 4. Logistic regression analysis of influencing factors for choosing different types of 2vHPV vaccines.
Discussion
HPV vaccine has been favored by the majority of female recipients and has also provided protection against cervical cancer for thousands of them. Although multiple, imported HPV vaccines have been introduced in Mainland China since 2017, domestic 2vHPV vaccine was not available until 2020. Since then, a number of studies on cervical cancer and HPV vaccine knowledge have emerged, with the majority concentrating on the student population.Citation16–18 Few comparative studies have been done on domestic and imported 2vHPV vaccine. This survey research showed that domestic and imported 2vHPV vaccine recipients had relatively high knowledge of cervical cancer and HPV vaccine, and successfully completed 61.7% and 65.4% of questionnaires, respectively, indicating that women with appropriate age were concerned with cervical cancer and its prevention. The qualification rate in our study was significantly higher than the research findings (46.7%) conducted by Zhang Fengzhi.Citation19 But the difference needed to be cautiously interpreted because the latter was mainly focused on the cervical cancer prevention and control, and the research subjects were students. In a way, cervical cancer and vaccine knowledge need to be improved in developing countries, such as in other Asian countries or regions, awareness of HPV was generally low. In Pakistan, only 57% of college students reported that they had already heard of HPV.Citation20 Similarly, 36.5% of Lebanon college students had never heard of the vaccine, and their knowledge was poor to moderate, with a median knowledge score of 52.7.Citation21 Also, in Jakarta, Indonesian, citizens were found to have poor knowledge in individual aspects of the inquiry but moderate knowledge overall, approximately 49.3% of people were still poor in understanding HPV, cervical cancer, and corresponding vaccines. Although the participants recruited in the study were from the urban community, the knowledge level was unsatisfactory.Citation22 It is worth noting that the subjects of this report include men, which is obviously different from our research. In contrast, in developed countries such as United States, the accuracy rate of adolescents’ knowledge about cervical cancer prevention and treatment reached 63.6%.Citation23 Significantly, in our questionnaire, a question that “what are the two main serotypes of HPV (human papillomavirus) that cause cervical cancer?”, 54.1% of recipients answered correctly, but 42.9% still gave “unclear” responses. Another multiple-choice question that “besides cervical cancer, what following diseases may HPV cause?”. Only 30.8% of the respondents had the correct answer. However, knowledge about both questions may affect their choice of different type of vaccine.
Cervical cancer is the 2nd most common female cancer in the women aged 15–44 years in the world,Citation13 although this study demonstrated a high knowledge awareness rate, more knowledge should be increased as high as possible, promoting greater public awareness of the disease, increasing health literacy and vaccination rates. In addition, Shenzhen, the survey region, the youngest developed city in China, is a first-tier city, where has higher percentage of residents with a bachelor’s degree or above (42.9%), and, more and more young people are likely to work and live in this city. It is possible that in our study, survey participants, with an average age of 35.23, had more obvious advantages than those living in second- or third-tier cities in China due to higher education level and better ability to understand public health education.
We analyzed the difference between qualified and unqualified questionnaires. Results showed that the younger age, ethnic Han, shorter duration of residence in Shenzhen, higher education level, occupations of white-collar workers, civil servants, medical and health staffs, and teachers were all the protective factors for qualified scores. It is possible that their higher overall education levels help them to become more receptive to new knowledge and more health conscious. In this study, the majority of individuals in these occupations held a bachelor’s degree or higher, with medical and health staff having the highest percentage at 90.3%. Occupation of workers and individual businessmen were the risk factors for qualified performance, among which their educational background played a negative role, mainly in middle schools and technical secondary schools. In this study, marital status did not have an effect, it was inconsistent with other studies,Citation24 but their questions asked was “prior sexual experience” instead, and coincidentally, those who answered “having had sex” had higher knowledge level. To avoid sensitive questions leading to a blank answer, “marital status” was utilized instead, however, it may still cause bias. Annual household income also had no statistical significance on knowledge level, maybe in the developed city like Shenzhen, even in low-income residents, as long as they were willing to learn, the popular science knowledge was easily acquired. Of course, the prevalence of mobile phones also played a vital role, enabling them to learn at any moment by browsing the Internet.
Since 2020, the domestic 2vHPV vaccine has been utilized, solving the problem of HPV vaccine shortage. In 2022, there had a big difference in number of doses administered between domestic and imported 2vHPV vaccine in Shenzhen, at 288,987 and 36,640 doses, respectively. In this study, we explored the factors that may explain the difference in inoculation from several aspects. We found that factors of manufacturer, efficacy, safety, cognitive approach, public opinion, convenient acquisition and knowledge reserve have a significant influence on selection for recipients. GlaxoSmithKline, known for its wide range of products that appeal to Chinese consumers, is a senior vaccine manufacturer. However, in our study, more recipients trusted domestic manufacturer than foreign manufacturer (36% vs. 17%). This may be related to another factor called “cognitive approach”. We can note that among the “cognitive approach” factors, domestic vaccine recipients were more likely to be affected by “public science”, which indicated that domestic companies may be more inclined to indirectly promote their brands and products in the name of “public science”. And that’s exactly what happened, as a lot of domestic media reported live when domestic 2vHPV vaccines started to be utilized, and relevant publicity posters were also posted on the popular science columns in many vaccination clinics. With the development of “self-media”, domestic companies may not only work hard on traditional TV ads, but also on various social media platforms such as “WeChat”, “Official Account”, by sharing pictures or videos. In “WeChat” tweets, they aim to promote their products while often using the approach of health education, disguised as promoting knowledge dissemination. Gradually, they permeate their products information into consumers’impressions. In addition, domestic 2vHPV vaccines being given in some middle school students for free may have played a vital role in improving publicity of domestic company brands and product marketing.
Efficacy and safety are two important indicators for evaluating vaccines. In this study, they were also the two most important indicators that recipients concerned about, accounting for 69.9% of the respective options, second only to the “knowledge reserve” factor (71.4%). Since the introduction of imported HPV vaccine, there is no doubt that the efficacy and safety have been repeatedly demonstrated.Citation25 As domestic 2vHPV vaccine has been used for a short time, studies on efficacy and safety were primarily based on data from the first three clinical trials, while long-term monitoring data in the real world was scarce. According to the Yue-Mei Hu’s study,Citation13 a randomized, immunogenicity noninferiority study of domestic vaccine was conducted in December 2015 in China, the immunogenicity of the HPV vaccine in girls receiving 3 or 2 doses was noninferior compared with that in young adult women. You-Lin Qiao’s study also demonstrated that the E. coli-produced HPV−16/18 vaccine was well tolerated and highly efficacious against HPV−16/18 associated high-grade genital lesions and persistent infection in women.Citation26 Although the amount of surveillance data for domestic HPV vaccines was less than imported HPV vaccines, it won trust of most recipients due to its multiple means of publicity. For instance, on question of “efficacy,” domestic and imported vaccine recipients accounted for 39.8% and 30.1%, and on question of “safety,” they were 43.6% and 26.3%.
In terms of cognitive approach, domestic vaccine recipients were more likely to be affected by “popularization of science”, while imported vaccine recipients were affected by “expert recommendation”. Since imported HPV vaccine was approved by the US FDA in 2006 and has more than ten years of clinical use experience, inoculation physicians or industry experts in China had sufficient awareness with this product. In addition, other widely used vaccines from GlaxoSmithKline, like hepatitis B vaccine, were given more often to recipients than those from domestic manufacturers, therefore the physicians/experts had more reasons to trust imported products. If recipients need recommendation, real-world data showed the physicians and experts prefer to recommend imported products to recipients if commercial factors weren’t taken into account. Selection of domestic products would be influenced by “popularization of science” as mentioned above. Those who chose to receive imported HPV vaccine were more likely to be influenced by public opinion of “relatives and friends vaccinated imported more”. Explanation for this phenomenon may be that recipients will find out the vaccination status of friends and relatives before choosing, when most people chose imported vaccine, out of trust in the familiar group, or peer pressure, it would produce a herd mentality result in a decision consistent within the group. Furthermore, it is well known that in China, people still have a prejudice against domestic products and preference for imported products, not only in vaccines, but also in other products. Customers will attempt to make a decision that is as consistent as feasible when they are aware of the preferences of well-known individuals in order to uphold their dignity. This is similar to the Liangru Zhou's study,Citation27 which said that compared to domestic vaccine, participants preferred imported vaccines.
In Shenzhen, only vaccination clinics are permitted to employ non-immunized program vaccine (self-funded vaccine), they determine the variety and quantity based on their daily dosage. Each month, vaccination clinic submits purchasing plan to the Center for Disease Control and Prevention (CDC), in event of sufficient supply, CDC will purchase vaccines from manufacturers on demand and distribute them to the clinic on schedule, which have influence on “convenient acquisition factor.” For instance, on the sales terminal of non-immunization program vaccines, apart from the unbeatable advantages that cannot be compared (such as 9vHPV vaccine, only imported), domestic vaccines may also be more competitive than imported ones, because in Mainland China, where the regulatory system may be imperfect, drug and vaccine rebates are available more frequently with domestic products. If better financial incentives are provided by the domestic companies, doctors will prefer domestic products when submitting the purchasing plan. Over time, the selection that immunization clinics can offer becomes increasingly constrained, and recipients occasionally have to settle for domestic products. Since domestic 2vHPV has only been used for a short time, the lack of validation of efficacy and safety by real-world experience, may bring slight uneasiness for recipients, and cause them to consider reading the instructions or other relevant materials before making a decision in “knowledge reserve factor.”
In this study, we found that “cost” and “doctor’s suggestion” were not factors influencing recipient choice. In Shenzhen, the price of imported 2vHPV is 590 ¥/dose vs 339 ¥/dose for the domestic vaccine, with a difference of 251 ¥/dose. Shenzhen is a first-tier city with income and consumption levels ranking among the top in China. According to the latest data report from “Hurun”, in 2022, there are 63,757,021 households with an annual income of more than 300,000 yuan in top 50 cities, among which Shenzhen has 2,075,400 households, accounting for 3.3%, ranking fourth in the country, after Beijing, Shanghai and Hong Kong. In this survey, most of the recipients chose an annual income below 100,000 ¥, accounting for 44.4%, while 15.1% chose an income higher than 300,000¥. We suspect, although have no way to verify, that out of concern for protecting sensitive income information most recipients may have opted to choose a lower income level than their actual income actual situation. “Doctor’s suggestion” did not play a significant role in the vaccine choices (χ2 = 3.515, P = .061). This finding contrasts from that of Noelia Lopez’s research,Citation28 which showed that sources of healthcare information (pediatricians, gynecologists, family physicians, etc.) played an important role in providing precise and accurate information about HPV and its vaccine. Recipients had higher acceptability if they consulted healthcare source. In Spain, pediatricians played a very relevant role in providing advice and recommendations about vaccine for children. On the other hand, gynecologists have traditionally been involved in managing HPV-related diseases, and relevant scientific societies in this field recommend individual-based HPV vaccine recommendation. The lack of influence by the factor of “doctor’s suggestion” could be that Shenzhen doctors’ suggestion on self-paid vaccine may have been silently biased by manufacturer financial incentive which we would not be able to verify.
At the end of the questionnaire, we posed a hypothetical question asking recipients which type of vaccine they would choose if given the opportunity again, the majority of respondents indicated that they would choose the 9vHPV vaccine. Even though the supply of 2v and 4vHPV vaccine is relatively sufficient, shortage of the 9vHPV vaccine remains. In Shenzhen, 9vHPV vaccine supply was traditionally allocated via a lottery system which runs only once every month, recipients need to pay attention to whether they have got it, if they miss the appointment time, they would not be able to participate again until half a year later. Recently, this model was changed and people can make appointments by themselves on the “Official Account,” but the outcome was often be disappointment due to the serious shortage of vaccines. The popularity of the 9vHPV vaccine may be due to both efficacy and Chinese consumer belief that goods that are in high demand and short supply must be good. There clearly is urgent need to accelerate research and development of 9vHPV vaccine to meet the needs of Chinese people and improve primary prevention of cervical cancer.
In this study, the knowledge of cervical cancer and vaccine among eligible women in Shenzhen was investigated in detail, and the influencing factors were analyzed. But as previously stated, the HPV，being the most prevalent reproductive tract virus, not only causes cervical cancer but also other severe ailments such as vaginal cancer. Moreover, it is not limited to women but also affects men. Consequently, future research will concentrate on the knowledge of HPV virus causing male cancer, and explore the attitudes and factors that influence HPV vaccination in men. If deemed necessary, we will plan to conduct a comparative study between men and women, so as to provide valuable information for policymakers to consider including the vaccine in the male vaccination program for China.
Limitations
Electronic questionnaire was used in this survey, naturally, problems encountered could not be solved timely when recipients were filling in the questionnaire. As a result, answers may not be objective and accurate enough. Moreover, questions in this questionnaire were designed by ourselves, which were not completely consistent with the content of other researchers. This lack of consistency made comparison between them less rigorous and may have caused bias on results interpretation. In addition, this study failed to provide health education about HPV after the survey. Therefore, in future electronic questionnaire research, we could provide a URL link of relevant knowledge for further study.
Conclusion
Eligible 2vHPV vaccine female recipients in Shenzhen had a high level of knowledge about cervical cancer and vaccines. Educational background and occupational category were the most important factors affecting knowledge score. Health care staffs should strengthen health education effort among people with low education level and those whose occupations with low score. They should consider to adopt other more accessible health education methods, so as to raise awareness of cervical cancer and vaccine and self-protection measures to reduce incidence. Domestic 2vHPV vaccine was more widely used than imported ones. Factors of manufacturers, efficacy, safety, cognitive approach, public opinion, convenient acquisition and knowledge reserve had significant influence on vaccine choice. Health care providers should focus on objective and unbiased comparison between domestic and imported vaccines in future health education to help recipients gain a correct understanding of the differences and similarities and make a decision to meet their own needs better.
Acknowledgments
Linxiang Chen and Xu Xie were involved in the questionnaire and study design, data acquisition and analysis, interpretation of the data, and manuscript writing. FangFang Lu and Ziqi Wang were involved in study design. Hanqing Chen, Mianling Chen, Chunmiao Peng, Kangming Chen, Cuili Chen and Huawei Xiong were involved in data acquisition. The first author, Linxiang Chen, wrote the first draft. All authors have approved the final version of the article. We thank vaccination clinics for their unfailing support with the questionnaire survey. We thank Mr Xiaojun Zhen for Data analysis guidance. We thank Mr Jun Wu, Senior Medical Director, AbbVie Inc, Illinois, USA, for his gracious editorial assistance.
Disclosure statement
No potential conflict of interest was reported by the author(s).
Additional information
Funding
References
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