Knowledge, awareness, and correlates of HPV vaccine acceptability among male junior high school students in Zhejiang Province, China

ABSTRACT

This study assessed the knowledge of 12- to 15-year-old male junior high school students of HPV and HPV vaccines and their willingness to be vaccinated against it. From March to May 2023, students from six junior high schools in Zhejiang Province were randomly selected to complete an online, anonymous, self-administered questionnaire. Of the 1786 students, 618 (34.6%) reported knowledge of HPV vaccine. In general, junior high school boys have low general knowledge about HPV, the consequences of HPV infection, and the effects of HPV vaccination. Multivariate analysis showed that the subgroup scoring 6–7 on the measure of the consequences of HPV infection(7 questions with 1 score for each correct answer) compared to the subgroup scoring 0, the subgroups scoring 2 and 3 on the measure of the preventive effect of HPV vaccine(3 questions with 1 score for each correct answer) compared to the subgroup scoring 0 were were more likely to be willing to be vaccinated against HPV. Hearing that someone close to them had cancer, believing that men also need to be vaccinated against HPV, knowing that someone close to them had been vaccinated against HPV, and being concerned about cervical cancer in their female sexual partners were all more likely to generate positive responses. HPV vaccine education for this group of students should emphasize the possibility and consequences of HPV infection in males, along with the importance and benefits of HPV vaccination; actual cases of vaccination in students around them can be used to achieve this goal.

KEYWORDS:

• Junior high school
• males
• HPV
• HPV vaccine
• willingness to be vaccinated
• correlates

Introduction

Human papillomavirus (HPV) infection is one of the most common sexually transmitted infections (STIs)¹ and can lead to many serious diseases; almost all cases of cervical cancer are associated with HPV infection.² Worldwide, there were an estimated 604,127 new cases of cervical cancer and 341,831 deaths in 2020,³ and in the same year there were an estimated 109,741 new cases of cervical cancer and 59,060 associated deaths in China.⁴ Diseases caused by HPV infection can occur in men and women. In addition to cervical cancer, HPV infection can cause vulvar, anal, vaginal, penile, head and neck, and oropharyngeal diseases, as well as genital warts, resulting in a significant health impact.⁵

Numerous studies have confirmed that HPV vaccines play an important role in preventing HPV-related disease. Three vaccine types are available internationally: bivalent (targeting types 16 and 18), quadrivalent (targeting types 6, 11, 16, and 18), and nonovalent (targeting types 6, 11, 16, 18, 31, 33, 45, 52, and 58) vaccines. HPV types 6 and 11 cause 90% of genital warts; types 16 and 18 cause about 70% of cervical cancers and even higher percentages of other HPV-caused cancers; types 31, 33, 45, 52, and 58 are high-risk HPVs that cause an additional 10–20% of cervical cancers. HPV vaccination can prevent or significantly reduce infection with the corresponding HPV strains and associated diseases.⁶

By the end of 2022, the national immunization programs of 130 World Health Organization (WHO) Member States included HPV vaccine.⁷ Bivalent, quadrivalent, and nonovalent HPV vaccines were approved for use in China by the State Food and Drug Administration in July 2016, May 2017, and April 2018, respectively.⁸ Currently, individuals in China can access the vaccines through local public health departments. In China, HPV vaccine is currently available only to women, but there is growing discussion that men should also be vaccinated against HPV to protect not only themselves but also their sexual partners.^9,10

HPV vaccine is most effective when given before sexual activity (prophylactic vaccination).¹¹ Vaccination at a younger age produces higher antibody levels and is more effective at preventing cancer.^5,12 International guidelines have consistently called for prioritizing vaccination before sexual activity commences.¹³ Worldwide, 47 countries have already included HPV vaccination for boys in their national immunization programs.¹⁴ The American Cancer Society recommends that teenagers/adolescents and young adults aged 13 to 26 years who have not been vaccinated or have not received all of their shots should be vaccinated as soon as possible.¹⁵ The 2017 Guidelines for Comprehensive Prevention and Control of Cervical Cancer in China state that the primary target group for HPV vaccination is 13- to 15-year-olds who are typically junior high school students.¹⁶ Chinese studies have found that the average age of sexual debut among Chinese college students is 18.39¹⁷ and 17.5¹⁸ years, suggesting that Chinese junior high school students, who are generally not yet sexually active, are the best population for HPV vaccination.

Although many studies in China have examined students’ HPV and vaccine awareness and vaccination intentions, they have focused mainly on college students^19,20 and the parents of school students.^21,22 These studies show that college students and parents of adolescents have little knowledge of HPV and HPV vaccines, and that awareness of both, as well as concern about HPV infection and related diseases, are important factors influencing the decision to receive the vaccine. Some Chinese research has shown that knowledge of HPV and HPV vaccine among junior high school students^23,24 and adolescents²⁵ is very low but willingness to be vaccinated is high and associated with awareness of the effects of vaccination, concern about cervical cancer,²³ education about HPV and HPV vaccines,²⁴ and having received sexual health education.²⁵ Knowledge of HPV and HPV vaccination among boys also tends to be lower than that of female peers.^22–25

The main objective of this study was to assess knowledge of HPV and its vaccine, willingness to be vaccinated against HPV and factors influencing it, and factors affecting boys’ reluctance to be vaccinated among junior high school boys who were aware of the HPV vaccine. Until now, no studies have examined HPV vaccination intentions among male junior high school students in China. Our results provide evidence that government decision-makers could use to promote HPV vaccination among male junior high school students and for future HPV vaccine-related intervention programs.

Method

Study population

The data were derived from a study conducted in 2023 in Zhejiang Province, an eastern coastal province of China. The study subjects were junior high school students enrolled in grades 1–3 (ages 12–15) who participated voluntarily. Exclusion criteria were students or their parents who refused to participate in the survey or who could not participate in the survey due to health reasons at the time of the survey.

Sample size was calculated using the formula $\mathit{N}=\frac{Z_{\alpha }^2\times \mathit{p}\times \mathit{q}}{d^2}$ for cross-sectional studies. According to previous studies, approximately 15% of junior high school students have heard of HPV and approximately 18% have heard of the vaccine.^25,26 Power analyses indicated that a sample size of 2,242 study participants should be recruited.

Questionnaire development and survey implementation

Referring to the national and international literature,^22–24 the framework of the questionnaire was determined and a new preliminary questionnaire was developed. After consulting six experts on HPV vaccination, we conducted individual, in-depth, qualitative interviews with six male and six female junior high school students to obtain their opinions on the questionnaire and survey methodology. The questionnaire was refined and a survey manual was developed. Eleven municipalities in Zhejiang Province were divided into three categories according to per capita gross domestic product²⁷ in 2021: high, medium, and average. From March to May 2023, one municipality in each of these three categories was randomly selected. From each sampled municipality, one urban district and one county were sampled, and one junior high school was sampled in each urban district and county, for a total of six junior high schools. For each junior high school, 390 students were selected, with 130 students in each of grades 1 to 3; classes were selected as a unit, selecting sufficient classes in each grade to meet the 130 requirement; if there were insufficient students, an additional class was selected at random.

The teacher in charge of the sampled class was trained how to explain to the parents and students the purpose and significance of the survey, the survey method, the privacy policy, and the use of the information in the questionnaire, and to emphasize that the survey was voluntary and that nonparticipation would have no negative consequences for the students. These explanations were also placed at the beginning of the questionnaire.

After obtaining written parental consent, the investigator gave parents a QR code for the questionnaire. Students scanned the QR code with their cell phones after school to view the questionnaire; students read the research explanation at the beginning of the questionnaire and checked “yes” if they were willing to participate. Students completed the questionnaire independently, and the questionnaire could not be accessed for changes after submission. This study was approved by the Ethics Review Committee of the Zhejiang Provincial Center for Disease Control and Prevention.

Measures

The HPV general knowledge measure consisted of six statements: HPV is divided into high- and low-risk types according to its carcinogenicity; persistent high-risk HPV infection is the main cause of cervical cancer; HPV infection can be asymptomatic; HPV infection is mainly transmitted through sexual intercourse; the earlier the age of sexual intercourse, the higher the risk of HPV infection; and men are also infected with HPV. The possible responses for the six statements were correct, incorrect, and don’t know, with correct answers receiving a score of 1 and incorrect or don’t know answers receiving a score of 0. The score range was 0–6. Based on the frequency distribution, the measure was categorized into three groups, i.e., groups 0, 1–4, and 5–6. Cronbach’s alpha for this measure was 0.883.

The infection consequences measure consisted of seven statements: HPV infection causes cervical cancer, vaginal cancer, penile cancer, oral cancer, anal cancer, vulvar cancer, and genital warts, with the options for each of the seven statements being correct, incorrect, or don’t know; a correct answer was assigned a score of 1 and an incorrect or don’t know answer assigned a score of 0. The score range was 0–7. Based on the distribution trends, the measure was categorized into subgroups 0, 1–5, and 6–7. Cronbach’ alpha for this measure was 0.952.

The vaccine-preventive effect measure consisted of three statements: HPV vaccine prevents HPV infection; prevents the corresponding cancers caused by HPV; and HPV-induced cervical cancer is a vaccine-preventable disease. The options for each of the three statement were correct, incorrect, or don’t know, and were scored 1 for a correct answer and 0 for an incorrect or don’t know answer. The scores ranged from 0 to 3. Based on the distribution trends, the measure was categorized into subgroups 0, 1, 2, and 3. Cronbach’s alpha value for this measure was 0.759.

Statistical analysis

Statistical analysis was performed using SPSS 26.0. Rates were compared using the chi-square test. Variables that were significant in univariate analyses were included in multivariate logistic regression analyses, which adopted a backward elimination procedure with a p-value >.10 as the removal criterion. Odds ratios (ORs) and 95% confidence intervals (CIs) were used to describe the relationship between dependent and outcome variables, and p < .05 was used to indicate significant differences.

Results

Demographic characteristics of junior high school students aware of HPV vaccine

In the six schools in three municipalities, 4,089 students were surveyed (1,786 boys, 2,303 girls). Of the boys, 618 reported being aware of the HPV vaccine, giving a male HPV vaccine knowledge rate of 34.6% (618/1786).

Our analyses focused on the 618 male students who reported being aware of the HPV vaccine in the analysis, with 34.5%, 33.0%, and 32.5% of them being in grades 1–3, respectively; 40.9% were the only child in their family; 67.5% were from rural areas; the families of 85.9% had an average economic status; and 49.2% of the mothers and 50.1% of fathers were educated to high school level or above (Table 1).

Table 1. Demographic characteristics of male junior high school students aware of the HPV vaccine.

Variable	Number(N = 618)	Percentage(%)
Year
One	213	34.5
Two	204	33.0
Three	201	32.5
Only one child in the family
Yes	253	40.9
No	365	59.1
Living area
Rural	417	67.5
Town	201	32.5
Mother’s education
Junior high school and below	295	47.7
Senior high school and above	304	49.2
Don’t know	19	3.1
Father’s education
Junior high school and below	287	46.4
Senior high school and above	317	51.3
Don’t know	14	2.3
Family’s economic status
High income	33	5.3
Middle income	531	85.9
Low income	54	8.7

The χ² test showed a significant difference between type of hometown (χ² = 9.547, p = .002) and willingness to be vaccinated against HPV, while there were no significant differences between the distributions of other demographic characteristics and willingness to be vaccinated against HPV.

Main reason for refusing the HPV vaccination

Of the 618 junior high school boys who were aware of the HPV vaccine, 432 were willing to receive the HPV vaccine and 186 were unwilling to receive it. The main reasons for unwillingness were lack of sufficient knowledge of it (n = 51, 27.4%), believing that one would not contract HPV (n = 45, 24.2%), its cost (n = 25, 13.4%), and concern about adverse effects (n = 20, 10.8%). See Table 2 for details.

Table 2. Top reason for not wanting to be HPV vaccinated among male junior high school students aware of HPVvaccinse.

Category	Number（N = 186）	Percentage（%）
Not very knowledgeable about vaccines	51	27.4
Worried about the preventive effect of the vaccine	17	9.2
Worried about the dverse reactions to vaccines	20	10.8
Excessive price of the vaccine	25	13.4
Not going to get sick	45	24.2
Others	28	15.1

Characteristics related to HPV and HPV vaccine

Of the boys, 52.6% had heard of someone getting cancer, 80.6% had heard of cervical cancer, 26.4% scored 1–4 and 38.5% scored 5–6 on the HPV general knowledge measure, 24.1% scored 1–5 and 36.2% scored 6–7 on the HPV infection consequences measure, 15.4% scored 1, 23.3% scored 2, 40.6% scored 3 on the HPV vaccine preventive effect measure, 73.6% knew that HPV vaccine is already available in China, 41.1% believe that men also need to be vaccinated against HPV, 61.0% knew someone close to them who had been vaccinated against HPV, 33.0% thought it was possible for them to be infected with HPV, 36.1% were worried about cervical cancer in their female partner, 75.1% answered that their school provided health education related to HPV and HPV vaccine, and 89.6% believed that health education in schools related to HPV and HPV vaccine is necessary (Table 3).

Table 3. Bivariate analysis for correlates of HPV vaccine willingness among junior high school boys aware of HPV Vaccine.

Variable	Total		Unwilling	Willing	χ^2 Value			P Value
	N = 618%)		N = 186%)	N = 432%)
Having heard of anyone getting cancer
Not having heard	293(47.4)	103(55.4)		190(44.0)	6.771			.009
Having heard	325(52.6)	83(44.6)		242(56.0)
Having heard of cervical cancer
Not having heard	120(19.4)	47(25.3)		73(16.9)	5.822			.016
Having heard	498(80.6)	139(74.7)		359(83.1)
HPV general knowledge measure
0	217(35.1)	77(41.4)		140(32.4)	13.825			.001
1–4	163(26.4)	58(31.2)		105(24.3)
5–6	238(38.5)	51(27.4)		187(43.3)
HPV infection consequences measure
0	245(39.6)	93（50.0）		152（35.2）	12.358			.002
1–5	149(24.1)	40（21.5）		109（25.2）
6–7	224(36.2)	53（28.5）		171（39.6）
HPV vaccine preventive effect measure
0	128(20.7)	93(50.0)		35(8.1)	150.447			<.001
1	95(15.4)	30(16.1)		65(15.0)
2	144(23.3)	30(16.1)		114(26.4)
3	251(40.6)	33(17.7)		218(50.5)
HPV vaccine is already available in China
Incorrect/Unknown	163(26.4)	104(55.9)		59(13.7)	119.557			<.001
Correct	455(73.6)	82(44.1)		373(86.3)
Men need HPV vaccination too
Incorrect/Unknown	364(58.9)	149(80.1)		215(49.8)	49.437			<.001
Correct	254(41.1)	37(19.9)		217(50.2)
Has anyone around been vaccinated against HPV
No/Unknown	241(39.0)	126(67.7)		115(26.6)	92.420			<.001
Yes	377(61.0)	60(32.3）		317(73.4)
Possibility of HPV infection
Impossible/Unknown	414(67.0)	148(79.6)		266(61.6)	19.041			<.001
Possible	204(33.0)	38(20.4)		166(38.4)
Being worried about cervical cancer in partner
Not/Unknown	395(63.9)	146(78.5)		249(57.6)	19.041			<.001
Yes	223(36.1)	40(21.5)		183(42.4)
Whether the school provides health education related to HPV prevention and HPV vaccine
No	154(24.9)	63(33.9)		91(21.1)		11.397		.001
Yes	464(75.1)	123(66.1)		341(78.9)
The need for health education about HPV prevention and HPV vaccine in schools
No	64(10.4)	35(18.8)		29(6.7)			81.942	<.001
Yes	554(89.6)	151(81.2)		403(93.3)

Bivariate and multivariate analysis of the willingness to be vaccinated

Bivariate analyses showed that nearly all factors were associated with willingness to receive the HPV vaccine (see Table 3 for details).

Variables that were significant in bivariate analysis were included in multivariate logistic regression and the results indicated that associations remained for hearing that someone close to them had cancer, believing that men also need to be vaccinated against HPV, knowing that someone close to them had been vaccinated against HPV, being worried about cervical cancer in their female sexual partner, and for the subgroup with a score of 6–7 on the HPV infection consequences measure versus the subgroup with a score of 0 (see Table 4 for more statistics and other details).

Table 4. Multivariate analysis of HPV vaccination willingness among junior high school boys who are aware of HPV vaccine.

	Adjusted OR（95%CI）	P Value
Having heard of anyone getting cancer
Not having heard	1
Having heard	1.92(1.22–3.04)	0.005
Men need HPV vaccination too
Know	1	0.014
Don’t know	1.84(1.13–3.01)
Has anyone around been vaccinated against HPV
No	1
Yes	2.05(1.31–3.23)	0.002
Being worried about cervical cancer in partner
Not/unclear	1
Yes	2.76(1.65–4.62)	<0.001
HPV infection consequences measure
0	1
1–5	1.22(0.71–2.11)	0.467
6–7	2.12(1.17–3.81)	0.013
HPV vaccine preventive effect measure#
0	1
1	1.34(0.65–2.75)	0.431
2	2.01(1.00–4.04)	0.050
3	2.68(1.31–5.47)	0.007

#Multivariate analysis after removal of the “HPV infection consequences measure.”

Spearman’s rank correlation test showed a significant correlation between the HPV vaccine preventive effect measurement and the HPV infection consequences measure (p < .0010). Thus, next, the variables of the HPV infection consequences measure were removed from the multivariate analysis model. The results showed that the subgroup with scores of 2 and 3 on the HPV vaccine preventive effect measure were more willing to be vaccinated with compared to those with score 0, and other variables remained significant.

Discussion

This study investigated the relationship between male junior high school students’ HPV-related information, knowledge, attitude, and willingness to be vaccinated against HPV in three municipalities in Zhejiang Province, China. In this population, 34.6% knew about the HPV vaccine, higher than the 15–18% among junior high school students reported in other regions of China^23,24,28 and higher than that of college students in Chengdu, Sichuan Province (24.1%)²⁹ and male college students in Xiamen, Fujian Province (18.3%),³⁰ but lower than that of male college students in Beijing (75.3%).³¹ With the recent promotion and popularization of HPV vaccine in China, knowledge of it among junior high school students has significantly increased. HPV vaccine awareness among junior high school boys is still low, which may be because the vaccine has not been on the market in China for very long, and there is still insufficient publicity and education in this population; it may also be because the vaccine is widely viewed as a strategy to prevent cervical cancer and is currently only available to females in China. Worldwide, more than 40 countries have included boys in their national immunization programs.¹³ Effort is needed to include HPV vaccination for boys in China.

Only 41% of students were aware of the need for male students to be vaccinated against HPV. One Chinese study reported that both boys and girls are often unaware that boys can be infected with HPV.¹⁹ Middle school boys are rarely aware that the vaccine prevents not only cervical cancer but also anal cancer and genital warts caused by HPV.²³ There is also a lack of social awareness of the problems associated with HPV infection in males.³² Male students may believe that they are not at risk for cervical cancer or other HPV vaccine-preventable diseases, and are less likely to pay attention to the topic because they believe that they cannot be infected. Male students may also be unaware that their infections can be sexually transmitted to their sexual partners. It is necessary to emphasize that junior high school students can also be infected with HPV, the possible consequences of HPV infection, and the fact that men and women can transmit HPV through sexual intercourse. All three types of HPV vaccine are now available in China and 73.6% of the subjects were aware of it. In multivariate analysis, this factor was no longer associated with willingness to receive HPV vaccination, perhaps because the vaccine is still only used in the female population in China. In the HPV prevention campaign targeting junior high school boys, in addition to emphasizing that boys can also be infected with HPV and cause a variety of diseases,⁵ it is important to educate boys about the need to take protective measures when having sex in the future. The use of condoms during sexual intercourse is essential and effective for preventing HPV transmission and infection.³³

Knowledge about HPV, the consequences of infection, and the preventive effect of the vaccine was even low among boys aware of the HPV vaccine and 20–40% of the six questions measuring general HPV knowledge, seven questions measuring the consequences of HPV infection, and three questions measuring the preventive effect of HPV vaccine had scores of 0. Although there were deficiencies in this knowledge, the percentage of those who were willing to be vaccinated against HPV was relatively high, similar to surveys conducted among Chinese university students.^20,29,30 This could be explained by the fact that the Chinese government has implemented a free vaccination policy for children that provides 12 vaccines, including BCG, hepatitis B, and DPT vaccines, and almost all students have received various free vaccines during their childhood, believing that vaccination can prevent related diseases. One study showed that a better understanding of vaccination is associated with a greater willingness to be vaccinated against HPV.³⁴ We analyzed only the willingness to be vaccinated among students aware of the vaccine. As 62% of the students were not aware of it, it can be assumed that among these students, the level of knowledge of the three measures mentioned above may be even lower, along with their willingness to be vaccinated. Students being aware of the HPV vaccine³¹ and greater knowledge of the vaccine³⁵ increase their willingness to receive it. Future projects to increase vaccination among male junior high school students should strengthen the dissemination of knowledge of HPV and the HPV vaccine.

In multivariate analysis, there was an association between the perception of the consequences of HPV infection and willingness to be vaccinated. This finding is similar to that of a survey of Chinese university students.³¹ There is a linear relationship between willingness to be vaccinated and cognitive measures of vaccine efficacy. HPV prevention education for junior high school boys should give students a deeper understanding of the consequences and seriousness of HPV infection and the benefits of vaccination for related diseases, as well as the potential health risks that the unvaccinated may face.³⁶

Knowing that someone close to them is vaccinated against HPV is also an important influence of students’ willingness to be vaccinated. Knowing that classmates, friends, or family members are vaccinated can motivate students to trust vaccination. A Chinese study showed that HPV vaccination of close friends and relatives influences students’ willingness to be vaccinated against HPV.³⁷ Advocacy by students who have already been vaccinated against HPV may have a greater impact in promoting HPV vaccination.

Hearing that a close friend or relative had cancer facilitates HPV vaccination intention and similar results have been found in Chinese college students.¹⁸ Male students who have heard that their friends and relatives have had cancer may have a greater understanding of the cruelty of cancer and will actively think about finding ways to prevent it. Boys who are concerned about their female sex partners getting cervical cancer are more likely to be willing to get the HPV vaccine; note, however, that this constitutes only 36.1% of students. There is a general lack of knowledge about HPV and the vaccine among Chinese families, with one study showing that only 22.6% and 10.2% of the parents of Chinese junior high school students, respectively, had heard of HPV or were aware of the vaccine²¹; school health education increases knowledge about HPV and the vaccine and promotes vaccination among junior high school students.³⁸ Students are very receptive to HPV and vaccine promotion and education, and schools are the most cost-effective setting for passing on this knowledge,²⁸ with 75% of junior high school students reporting receiving such health education at school, while 90% felt there was a need for such education, indicating that there is still an unmet need. Students who have received sex education and have a higher level of sexual knowledge are more likely to be vaccinated against HPV.^23,25 HPV is mainly transmitted sexually¹ and school-based HPV prevention education can be integrated into adolescent sexual health and HIV/STI prevention education promoted in Chinese schools. It may be more cost-effective to promote HPV vaccination together with sex education and HIV/STI prevention education.²⁸

We found that the main reasons cited by students who were reluctant to receive the HPV vaccine were a lack of knowledge about the vaccine, belief that they would not get the disease, concerns about the effectiveness of the vaccine and side effects, and the cost. An international review found that the main barriers to HPV vaccination among boys and young men are a lack of knowledge, misconceptions about the safety and effectiveness of the vaccine, and the opportunity to discuss HPV with health care providers.³⁹ To promote HPV vaccination in junior high school boys, in addition to publicizing its efficacy and safety, it is also important to raise awareness of the risk of infection, as the current study found that only one third of boys thought they were at risk for contracting HPV, whereas the literature indicates that under base case assumptions, the average lifetime probability of acquiring HPV is 84.6% for women and 91.3% for men.⁴⁰ The price of the vaccine is also an important factor, as the students’ parents will have to bear the cost.^21,22

Our sample was drawn from six junior high schools in six counties in three municipalities in Zhejiang Province, and the following factors need to be considered when interpreting the results. First, this was a cross-sectional survey, which has limitations in inferring causality. Second, the population targeted in the analysis was students aware of the HPV vaccine, and a large number of students not aware of it were not included in the analysis; this group of students’ HPV knowledge and willingness to receive the vaccine may be even lower. Third, students self-reported their willingness to be vaccinated, which does not necessarily mean that students would actually receive the vaccine. The HPV vaccine for males is not yet available in China. Finally, the insufficient information collected by the questionnaire may affect the interpretation of our results. For example, students’ willingness to be vaccinated is influenced by their parents, knowledge of vaccines, attitudes toward vaccination, and their families’ ability to afford vaccines but we did not address these factors.

In conclusion, our results suggest that junior high school boys in Zhejiang Province have low awareness about HPV and the HPV vaccine but a more positive attitude toward vaccination. In the future, the promotion and use of this vaccine for junior high school boys can be combined with sex education and HIV/STI prevention education to provide comprehensive accurate health information. This would help raise students’ awareness of the risks of HPV infection and help students understand HPV, the consequences of infection, the preventive effect and safety of the vaccine, and the fact that boys can also be infected by the virus. Actual HPV vaccinees among the students themselves could be mobilized to enhance willingness to be vaccinated against HPV.

Institutional review board statement

The study was conducted according to the guidelines of the Declaration of Helsinki, and approved by the Institutional Review Board, Zhejiang provincial center for disease prevention and control (No.2023-024- 01).

Acknowledgments

We are grateful to all the junior high school students who agreed to participate in this study. Thanks also go to their supervisors.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Data availability statement

All of the data and materials that support the findings of this study are available from the corresponding author upon reasonable request.

Additional information

Funding

The work was supported by 2022 Zhejiang Provincial Medical and Health Research Programme[No.2022KY724].