In 2022, cervical cancer accounted for approximately 662,301 new cases worldwide, representing 6.9% of all cancers diagnosed in women. Furthermore, it was the fourth leading cause of cancer-related deaths among women1. In China, human papillomavirus (HPV) vaccination is not included in the National Immunization Program, thus creating marked urban–rural disparities: only 5.7% of rural children are vaccinated2. Local publicly funded initiatives have increased vaccination uptake in some cities (e.g., Shenzhen pilot; Jinan first-dose coverage > 90% among eligible girls)3,4. Between 2017 and 2022, first-dose HPV vaccination among females 9–45 years of age rose from 0.01% to 10.15%, but remained far below the World Health Organization (WHO)’s 2030 target of 90% among 15-year-old girls5,6. Beijing’s 2023–2030 action plan prioritizes 9–14-year cohort and provides free voluntary vaccination for first-year female students, alongside targets to strengthen screening and treatment7. To decrease hesitancy, the WHO’s behavioural and social drivers (BeSD) framework guides identification of behavioral and social drivers, and supports brief, timely interventions8. Video- and Short Message Service (SMS)-based prompts have been demonstrated to improve vaccine knowledge, attitudes, and uptake, thus supporting momentary educational approaches in resource-limited settings9,10. For a single-event vaccination behavior such as HPV vaccination, incorporating acceptance determinants at the design stage might increase efficiency and cost-effectiveness.
This study used a quasi-experimental pre-post within-subjects design embedded in a multi-university survey, integrating an intention assessment with a brief educational video to analyze its effects on university students’ willingness to receive the HPV vaccine (Figure S1). The study was implemented across 23 universities in Beijing (from January 10 to February 10 of 2025) and yielded 6,244 valid questionnaires. Identical items on HPV knowledge, attitudes, and willingness were administered immediately before and after a 5-min educational video. We described respondent characteristics, vaccination status, and willingness, and examined heterogeneity and determinants aligned with BeSD domains. Pre-post changes in binary outcomes were assessed with the McNemar test, and changes in multicategory outcomes were assessed with the Stuart–Maxwell test. Associations between explanatory factors and vaccination willingness were analyzed with logistic regression. A two-sided P-value < 0.05 was considered statistically significant. No external control group was included; the outcomes captured immediate within-person change after the single-exposure video. The study was approved by the Medical Ethics Committee of the Beijing Center for Disease Prevention and Control, Beijing, China (Approval No. BJCDC2025011). All participants provided written informed consent.
Respondent characteristics
A total of 6,244 valid questionnaires were collected (Table 1), the average participant age was 18.95 ± 1.82 years. Rural residents accounted for 29.74% of participants, among whom 198 (10.66%) had received the HPV vaccine; this percentage was lower than that among students from Beijing (28.73%) and other urban areas (18.70%). Among female respondents, 974 (27.16%) had been vaccinated (average age 19.52 years). Students whose parents had higher educational qualifications had relatively higher vaccination rates. Respondents with higher monthly living expenses exhibited higher vaccination rates; among those with monthly living expenses ≥ 3,000 CNY, 154 (32.91%) had received the HPV vaccine. Among vaccinated participants, 79.72% had received the nonavalent vaccine (Table S1); 84.35% reported reminders for subsequent doses. The mean service satisfaction score was 4.44 (SD = 0.62) on a 0–5 scale.
Demographic characteristics of the university students by vaccination status and vaccine hesitancy level
Heterogeneity in vaccination willingness
Among participants not yet vaccinated, vaccination willingness was significantly associated with sex, age, place of origin, monthly living expenses, and sexual history (Figure S2). Compared with respondents willing to vaccinate immediately, those who were hesitant or unwilling had distinct characteristics: female sex was associated with markedly lower odds of hesitancy (OR = 0.10, 95% CI: 0.08–0.12, P < 0.01), older age was positively associated with hesitancy or refusal (OR = 1.14, 95% CI: 1.08–1.12, P < 0.01). Rural-origin respondents were associated with lower likelihood of hesitancy or refusal than urban origin (OR = 0.51, 95% CI: 0.35–0.74, P < 0.01). Regarding sexual history, participants without a sexual history (OR = 2.75, 95% CI: 1.91–3.99, P < 0.01) or those who were unwilling to disclose their sexual histories (OR = 2.55, 95% CI: 1.60–4.07, P < 0.01) had elevated likelihood of hesitation or refusal. Among respondents indicating that they were “willing to vaccinate but prefer to wait,” similar associations with female sex (OR = 0.44, 95% CI: 0.39–0.50, P < 0.01) and not being sexually active (OR = 1.78, 95% CI: 1.33–2.39, P < 0.01) were observed and remained significant. Rural (OR = 0.58, 95% CI: 0.44–0.78, P < 0.01) or other-city origin respondents (OR = 0.56, 95% CI: 0.43–0.72, P < 0.01), compared with Beijing origin, were associated with greater inclination to vaccinate immediately.
Determinants of vaccination willingness
We compared unvaccinated individuals—grouped by their willingness to vaccinate—with vaccinated individuals to analyze differences in BeSD-aligned domains. (Table S2). A decline in trust was associated with a significantly decreased likelihood of willingness to vaccinate (OR = 1.26, 95% CI: 1.05–1.15, P = 0.01). Among individuals who were hesitant or unwilling to be vaccinated, individuals with vaccine safety concerns were more likely to exhibit a negative attitude than those who did not (OR = 2.30, 95% CI: 1.62–3.29, P < 0.01). Social processes were also associated with attitudes: respondents who did not receive vaccination recommendations from healthcare professionals were more likely to adopt negative attitudes than the counterparts who had received such advice (OR = 1.94, 95% CI: 1.65–2.30, P < 0.01). Peer influence reinforced these trends: lower peer vaccination rates was associated with lower likelihood of vaccination (OR = 2.18, 95% CI: 1.86–2.58, P < 0.01). Family support played a crucial role: weaker family support was associated with significantly lower likelihood of vaccination, particularly among those who were hesitant or unwilling to be vaccinated (OR = 6.38, 95% CI: 5.20–7.89, P < 0.01). Practical issues also played key roles: low accessibility was associated with significantly more pronounced hesitancy and refusal (OR = 5.22, 95% CI: 3.91–7.00, P < 0.01), and high out-of-pocket vaccination costs were negatively associated with willingness to vaccinate (OR = 1.99, 95% CI: 1.62–2.45, P < 0.01).
Post-intervention changes
The willingness to be vaccinated increased among unvaccinated respondents after they had watched an educational video on HPV-related knowledge (Figure 1A). The proportion of respondents willing to vaccinate immediately increased from 33.50% to 53.44%, whereas that of participants who were entirely unwilling to vaccinate decreased from 0.96% to 0.51%. The intervention promoted the dissemination of HPV-related knowledge (Figure 1B): comprehensive HPV knowledge increased from 32.69% to 40.44% (P < 0.01); knowledge of HPV vaccination timing increased from 74.88% to 78.28% (P < 0.01); recognition of sex-inclusive vaccination increased from 53.41% to 77.03% (P < 0.01); and awareness that screening remains necessary after vaccination increased from 67.60% to 86.64% (P < 0.01). The intervention also improved attitudes toward HPV and HPV vaccination (Figure 1C): among non-vaccinated individuals, HPV risk perception increased from 15.76% to 50.40% (P < 0.01), and vaccine acceptance increased from 81.28% to 93.69% (P < 0.01).
Changes in knowledge, attitudes, and willingness toward HPV vaccination. Changes in HPV vaccination willingness before and after the intervention (A). Changes in HPV-related knowledge levels before and after the intervention (B). Changes in attitudes toward HPV and the HPV vaccine before and after the intervention (C). This figure illustrates the changes in HPV vaccination willingness, knowledge, and attitudes after a 5-min educational video intervention. Initially, participants who were not vaccinated (n = 5,164) were categorized into the following 4 groups according to their willingness to receive the HPV vaccine: ready for vaccination; willing but want to wait; unwilling but want to wait; and unwilling. Additionally, knowledge and attitudes were evaluated with 5 and 6 questions, respectively. After the intervention, participants showed notable improvements in both HPV-associated knowledge and attitudes. *Results with statistical significance. AIDS, acquired immunodeficiency syndrome; HPV, human papillomavirus.
Objective constraints and enablers of change
Objective factors significantly influenced changes in vaccination willingness after the intervention (Table S3). Participants who remained unwilling to vaccinate exhibited significantly lower knowledge acquisition than those whose willingness improved (OR = 0.86, 95% CI: 0.80–0.92, P < 0.01). Participants whose parents supported HPV vaccination showed a marked increase in vaccination willingness (OR = 0.32, 95% CI: 0.14–0.65, P < 0.01). Vaccine affordability emerged as a key factor: compared with individuals who transitioned from unwillingness to willingness, those who perceived HPV vaccination costs as scarcely affordable (OR = 1.68, 95% CI: 1.13–2.54, P = 0.01) or unaffordable (OR = 1.79, 95% CI: 1.19–2.73, P < 0.01) were more likely to remain hesitant or unwilling.
Integrating intention assessment with a brief educational-video momentary intervention produced immediate and measurable improvements in HPV-related knowledge, attitudes, and willingness in a large university sample. However, the study was based on convenience sampling among universities in Beijing, thus potentially limiting the generalizability of the findings. In addition, clustering by university was not adjusted, and the subgroup analyses were exploratory in nature. These issues should be further addressed in future studies with larger and more representative populations. The profile of willingness was shaped by social processes, including healthcare-professional recommendations, peer vaccination uptake, family support, as well as by practical constraints, including accessibility and affordability. Our results indicated that an educational video alone is insufficient for subgroups facing limited access or high out-of-pocket burden. Implementation should therefore pair momentary education with one-click appointment links, campus or near-campus sessions, evening/weekend clinics, automated reminders for series completion, and providing targeted subsidies when affordability is a barrier. Brief provider-recommendation scripts and family-engagement messages can strengthen social cues. Such integration is feasible in university settings and resource-limited contexts, and may accelerate equitable HPV vaccination and cervical cancer prevention.
Supporting Information
Conflict of interest statement
No potential conflicts of interest are disclosed.
Author contributions
Conceived and designed the analysis: Yuxi Liu, Luzhao Feng, Juan Li.
Collected the data: Rujing Shi, Mengmeng Jia.
Performed the analysis: Wenxuan Li, Luodan Suo.
Wrote the paper: Yuxi Liu.
Data availability statement
The data generated in this study are available upon request from the corresponding author.
- Received August 20, 2025.
- Accepted September 5, 2025.
- Copyright: © 2025, The Authors
This work is licensed under the Creative Commons Attribution-NonCommercial 4.0 International License.
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