Introduction

Human papillomavirus (HPV) is the most common sexually transmitted infection globally, causing not only cervical cancer in women but also penile, oropharyngeal, and anal cancers in men1,2. Universal HPV vaccinations for girls and young adult women have been proven cost-effective in numerous countries3. However, vaccination strategies for boys and young adult men have only been implemented in a few regions4,5,6. Evidence suggests that vaccinating men against HPV could provide substantial health benefits7. As male HPV infection significantly contributes to the infection and subsequent disease in women8, male HPV vaccination represents an essential public health strategy that could considerably reduce HPV-related diseases in men and decrease the disease burden in women through herd immunity9,10.

Since the HPV vaccine’s introduction in mainland China in 2016, three licensed HPV vaccines (bivalent, quadrivalent, and nine-valent HPV vaccine) have been available for women aged 9 to 45, but none are approved for men11. Health information and media coverage have predominantly emphasized the benefits of HPV vaccine for women, often referring to it as a cervical cancer vaccine12. This limited information may lead the public, particularly men, to perceive HPV infection primarily as a women’s health issue and the vaccine as ineffective for men, potentially decreasing men’s acceptance of HPV vaccine.

Recent attention in mainland China has focused on HPV vaccine acceptability among girls and young women13,14,15, with few studies on men. Existing studies have shown that men are generally less aware of HPV infection and vaccination than women16,17. Men often have limited awareness of the severity and susceptibility of HPV infection in men18, potentially contributing to lower HPV vaccine acceptability and increasing the risk of HPV infections in women19. Yet, these associations have not been extensively studied in Chinese males.

Although HPV vaccines are not available for men in mainland China, men play an important role in HPV vaccination decisions for their female family members20,21. Highlighting the severity of HPV infection for female partners may enhance men’s HPV prevention behaviors22,23. Current studies in mainland China have revealed that men have knowledge gaps about the HPV infections and HPV-attributable cancers24,25. Little is known about men’s acceptance of the HPV vaccine, or whether personal health beliefs and altruistic beliefs would promote HPV vaccine acceptability among young Chinese adult men.

This study aims to: (1) assess HPV vaccine acceptability and its correlates among young Chinese adult men; and (2) examine the association between personal health beliefs, altruistic beliefs, and HPV vaccination intentions and behavioral attempts in men. Using the Health Belief Model (HBM), we identify health beliefs associated with HPV acceptability, proposing that perceived severity, susceptibility, barriers, and benefits are critical evaluations before engaging in health behavior26.

Methods

Study design and setting

A cross-sectional study was conducted among male university students from December 2020 to January 2021 in Zhejiang, an eastern coastal province of China. Zhejiang hosts 109 institutions of higher education and over 1.2 million college and graduate students, ranking 4th in GDP among Chinese provinces. A multistage cluster sampling method was used to recruit the respondents. According to its geographical location and economic development level, Zhejiang is divided into five geographic regions: north, south, east, west, and central. First, one to two cities from each district were selected (Hangzhou, Wenzhou, Taizhou, Shaoxing, Ningbo, Quzhou, and Jinhua). Second, one to two universities were purposefully chosen from each city: Zhejiang University, Hangzhou Normal University, Wenzhou Medical University, Taizhou University, Shaoxing University, Ningbo University, Quzhou University, and Zhejiang Normal University. Third, several dormitory buildings were randomly selected from each university according to the distribution of majors and grades. Finally, young men were recruited from each selected dormitory through a simple random sampling method.

The Sample size was estimated using the standard formula for a cross-sectional study27.

$$n=\frac{{{\text{ Z}}^{2}}_{\alpha /2}*P*\left(1-P\right) }{{\delta }^{2}}$$

Assuming a maximum population variance of (P = 0.5), a 95% confidence interval (Zα/2 = 1.96), and a 5% margin of error (δ = 0.05), the required sample size was 385. To account for a potential 10% non-response rate or invalid questionnaires, the minimum required sample size was increased to 424 participants. Inclusion criteria for participants were as follows: (1) male gender; (2) current university or college students in Zhejiang Province; (3) smartphone ownership; and (4) capability to independently complete the online questionnaire. Exclusion criterion included the inability to understand or complete the online questionnaire, or refusal to participate.

Data collection

Administrators from selected universities were contacted via telephone to obtain approval and cooperation. Five investigators were recruited from each study site and trained by professional research assistants from Zhejiang University before the survey. Data were collected using the online survey platform Questionnaire Star. According to each school’s schedule, respondents from the randomly selected dormitories were invited to participate. Respondents were informed of the study’s purpose before receiving a printed Quick Response code with detailed instructions for the electronic questionnaire. Anonymity and confidentiality were guaranteed. Completing the questionnaire took approximately 10–15 min. Participation was voluntary, with no monetary compensation or gift given. The questionnaire was pre-tested among 234 participants for clarity, feasibility, and reliability.

Ethics approval and consent to participate

The Zhejiang University School of Public Health Research Ethics Committee approved this study (ZGL202006-08). Participants were fully briefed on the study’s objectives, anonymity, confidentiality, and voluntary nature, and provided informed consent. All methods were performed in accordance with the relevant guidelines and regulations.

Measures

HBM health beliefs

Items assessing HBM health beliefs were adapted from previous literature28,29 to reflect men’s personal health beliefs about HPV infection and vaccination and altruistic beliefs toward female partners. Personal health beliefs included perceived severity, susceptibility, barriers, benefits, and vaccination intention. Altruistic beliefs included perceived severity and susceptibility of male HPV infection for female partner, and perceived benefits of male HPV vaccination for female partner. Each dimension was assessed with three to eight items on a five-point Likert scale (1 = strongly disagree to 5 = strongly agree). Negatively stated items were reverse coded for consistency. Each dimension was scored by taking the average across all items within each dimension.

Socio-demographics and health and risk factor variables

Participants reported their age, ethnicity, education level, major, paternal and maternal education levels, monthly household income (RMB), place of residence, sexual experience, relationship status, history of HPV infection diagnosis, and family history of cervical cancer.

HPV and HPV vaccine awareness

Respondents’ awareness of HPV and HPV vaccine was assessed with two “Yes” or “No” questions: “Have you heard of HPV before today?”, and “Have you heard of the HPV vaccine before today?”. Participants who answered “Yes” were classified as HPV aware and HPV vaccine aware, respectively. Only participants who were aware of HPV vaccine completed the entire questionnaire.

HPV and HPV vaccine knowledge

A 17-item questionnaire was used to assess HPV and HPV vaccine knowledge. Knowledge about HPV was assessed with 12 questions on transmission, susceptible populations, and clinical characteristics. Knowledge of the HPV vaccine was measured with five questions on protective effects and vaccination process. All questions were retrieved and adapted from existing literature14,30 and the World Health Organization (WHO)31, with good reliability (Cronbach alpha = 0.89). Responses were scored as “Yes” (1 point), “No” or “Don’t know” (0 point). Total knowledge scores ranged from 0 to 17, categorized into high level of knowledge (score > 12) and low level of knowledge (score ≤ 12) based on the median total score.

HPV vaccination behavioral attempts

One question was used to measure men’s vaccination behavioral attempts: “Have you ever proactively asked whether men could get the HPV vaccine?” (Yes/No).

Statistical analysis

Statistical analyses were conducted using SPSS version 24.0 (SPSS Inc., Chicago, IL, USA). Continuous variables were described as mean ± standard deviation (SD), while categorical variables were described as numbers and frequencies. Vaccination intentions were analyzed as both continuous and binary variables. A dimension score for vaccination intentions was dichotomized as positive intention (> 3 likely to vaccinate) or negative intention (≤ 3 did not plan to or was unsure about vaccination). A hierarchical multiple linear regression was employed to identify correlates of HPV vaccination intention. Model 1 included demographic variables, knowledge, and health and risk factor variables; Model 2 added personal health belief variables; and Model 3 added altruism belief variables. A multivariable logistic regression analysis, adjusting for all covariates, was used to explore factors associated with HPV vaccination behavioral attempts. Variables for regression models were selected based on HBM and empirical literature19,28,29 using the Enter method. A multicollinearity test excluded educational level due to high collinearity with age.

Results

Sample characteristics

In total, 1937 respondents completed the questionnaire online, with a response rate of 93.6% (Table 1). Respondents’ age ranged from 18 to 30, with a mean age of 20.44 (SD = 2.23). Most respondents (77.6%, 1504/1937) were undergraduates and 20.1% (390/1937) majored in medicine. Nearly half (47.0%, 910/1937) came from urban areas, and 22.7% (439/1937) had a monthly household income of no more than 5000 RMB ($725).

Table 1 Participants characteristics.
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Before the survey, a considerable proportion of respondents had never heard of HPV (44.8%, 867/1937) or the HPV vaccine (47.9%, 928/1937). Ultimately, 1009 of the 1937 men who had heard of HPV vaccine completed the entire questionnaire. More than one-third of respondents (36.9%, 372/1009) reported having a female partner, while only 23.0% (233/1009) reported ever having sexual intercourse. Very few (1.6%, 16/1009) had a history of infection diagnosis, and only 2.5% (25/1009) had a family history of cervical cancer (Table 1).

HPV and HPV vaccine knowledge

Figure 1 shows the proportion of accurate responses to knowledge items. The majority of respondents were aware that HPV infections can cause cervical cancer and that the HPV vaccine can prevent cervical cancer to a certain extent. In addition, 65.2% (658/1009) correctly stated that HPV can also infect men, but only 44.1% (445/1009) recognized that HPV infection is common in daily life. Overall, only 5.1% (51/1009) of respondents answered all 17 HPV and HPV vaccine knowledge questions correctly, and 40.4% (408/1009) exhibited a high level of HPV and HPV vaccine knowledge.

Fig. 1
figure 1

Correct responses to HPV and HPV vaccine knowledge items (n = 1009).

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HBM health beliefs and HPV Vaccination intention and behavioral attempt

Table 2 displays the means and SDs for all health belief variables. Based on factor analysis, the dimension of perceived barriers was divided into perceived gender barriers (including sexual stigmatization and value of male vaccination.) and perceived vaccine barriers (including vaccine safety, side effects, and price). Each HBM dimension had high internal consistency (Cronbach alpha: 0.86–0.97). Men scored relatively high in perceived severity of HPV infection for both themselves and their female partner, perceived benefits of vaccination both for themselves and their female partner, and perceived susceptibility of HPV infection for female partner. They reported relatively low levels of perceived gender barriers and moderate levels of vaccine barriers and perceived susceptibility for themselves. Of 1009 young men, 68.9% (695/1009) reported an intention to vaccinate when available, and 32.6% (329/1009) reported proactively asking whether men could get the HPV vaccine before the survey.

Table 2 HBM health beliefs regarding HPV and HPV vaccination, HPV vaccination intentions, and HPV vaccination behavioral attempts (n = 1009).
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Factors influencing HPV vaccination intentions

The results from hierarchical multiple linear regression analyses are presented in Table 3. In Model 1, men with a high knowledge level had greater vaccination intentions (β = 0.22, p < 0.001). Non-medicine male students expressed a greater willingness to be vaccinated than medicine male students (β = − 0.08, p = 0.009). Altogether, demographic covariates accounted for approximately 4.5% of the variance in vaccination intention (F = 3.52, p < 0.001). In Model 2, perceived susceptibility (β = 0.19, p < 0.001) and perceived benefits (β = 0.42, p < 0.001) were positively associated with vaccination intention, and perceived gender barriers (β = -0.13, p < 0.001) negatively influenced vaccination intention. These variables explained an additional 27.0% of the variance (F = 20.51, p < 0.001), increasing the adjusted R2 to 31.7%. After adjusting for potentially confounding factors, the final Model 3 explained an adjusted total variance of 33.8% (F = 20.08, p < 0.001). The results indicated that greater perceived benefits of male HPV vaccination for female partners (β = 0.14, p < 0.001) were associated with stronger HPV vaccination intentions.

Table 3 Hierarchical multiple linear regression analysis of HPV vaccination intentions among young men (n = 1009).
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Factors associated with HPV vaccination behavioral attempts

In the multivariable logistic regression (Table 4), after adjusting for potential confounding factors, men who came from rural areas (OR = 1.61, 95% CI 1.14–2.28), had a high knowledge level (OR = 1.82, 95% CI 1.33–2.50), had a history of HPV infection diagnosis (OR = 7.51, 95% CI 1.83–30.89), and had a family history of cervical cancer (OR = 2.88, 95% CI 1.08–7.70) were more likely to exhibit vaccination behavioral attempts. Those who perceived greater vaccine barriers were 0.77 times (95% CI 0.63–0.93) less likely to have vaccination behavioral attempts, whereas those who perceived greater benefits of vaccination were 1.87 times (95% CI 1.38–2.53) more likely to make a behavioral attempt. Moreover, vaccination behavioral attempts were higher among men with stronger vaccination intentions (OR = 1.68, 95% CI 1.32–2.14).

Table 4 Multivariable logistic regression analysis of HPV vaccination behavioral attempts for young men (n = 1009).
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Discussion

Global efforts to eliminate cervical cancer also focus on vaccinating boys and young men against HPV. However, little is known about the acceptance of HPV vaccine and its influencing factors among young Chinese men, as it has not yet been approved for men in mainland China. To our knowledge, this study, for the first time, examined the association between personal health beliefs, altruistic beliefs and HPV vaccine acceptability among young Chinese men. We found a relatively high rate of HPV vaccination intentions (68.9%) among young Chinese adult men and highlighted the importance of both personal health beliefs and altruistic beliefs in men’s HPV vaccine acceptability.

Personal health beliefs and altruistic beliefs based on HBM were key factors influencing HPV vaccination intentions among young men in our study. Specifically, perceived susceptibility, perceived benefits, and perceived gender barriers were significantly associated with men’s HPV vaccination intentions. These findings align with previous studies, which have suggested that men with higher perceived susceptibility and perceived benefits were more likely to exhibit HPV vaccination intentions32,33. Our results revealed that perceived gender barriers, including sexual stigmatization and the value of male vaccination, were associated with vaccination intentions, adding to the previous studies on barriers influencing men’s acceptance of HPV vaccine. The “feminization” of HPV may explain young men’s gender barriers to vaccination acceptability34. In mainland China, HPV vaccines are currently approved exclusively for women, and media and health campaigns predominantly target HPV-related health issues for women35. This may inadvertently create the misconception that HPV is solely a health issue for women and so is the vaccine. It is vital to dispel these misconceptions, as such stigmatizing beliefs can potentially reduce men's acceptance of the vaccine.

As expected, greater perceived benefits of male HPV vaccination for female partners were associated with stronger HPV vaccination intentions after considering personal health beliefs and other potential confounding factors. This provides a new perspective for promoting health education on HPV vaccine uptake among target populations. It highlights the significance of “altruistic beliefs” in men’s acceptance of HPV vaccine, emphasizing that both male-specific vaccine benefits and altruistic benefits may further enhance HPV vaccine acceptability among young adult men.

When analyzing factors associated with vaccination behavioral attempts, perceived vaccine barriers, perceived benefits, and vaccination intentions were the most highly related factors. Behavioral intention is widely recognized as a strong indicator of future actions and individuals with a strong intention typically proceed to corresponding behaviors36,37. In mainland China, the absence of HPV vaccination programs for men complicates quantifying the impact of vaccination intentions on actual behaviors. However, recognizing the process between intention and behavior38, we use “HPV vaccination behavioral attempts” to bridge this gap. Men with stronger intentions to receive the HPV vaccine were more likely to actively seek vaccination information. This underscores the importance of accessible information, such as eligibility and available resources for male HPV vaccination, in promoting vaccination uptake. Future research should assess not only men’s willingness to receive HPV vaccination but also their actual behaviors, providing empirical evidence to support the gradual expansion of HPV vaccination programs in mainland China.

The young adult men in our study exhibited relatively high intentions (68.9%) to get vaccinated against HPV, which is higher than the proportion reported by Jia among male college students at Chinese colleges and universities39 but lower than that found by Dai among students from seven Chinese universities40. Moreover, 32.6% of participants had proactively asked whether men could get the HPV vaccine before the survey, indicating the demand for HPV vaccines among young men in mainland China. HPV infection is often considered to be a disease that predominately affects women but is underappreciated in men41. Related research has shown that HPV infections are also common among men in China, and the most prevalent types of HPV infection are similar between men and women in some regions42,43. Additionally, one prior study investigated the genotypes of genital HPV among male individuals attending a sexually transmitted disease clinic at Beijing Ditan Hospital, showing that the most prevalent HPV types observed could be covered by the available HPV vaccines44. Thus, future consideration needs to be given to extending vaccination targets in China to include adolescent and young adult men.

The findings also indicate that young adult men continue to lack knowledge and need basic information about HPV and HPV vaccine. We found that most male college students were unaware of the HPV transmission route, susceptible population, and common diseases that HPV may cause in men. However, they generally demonstrated a relatively good understanding of the role of HPV vaccines in protecting women. These results reaffirmed that health information concerning HPV and HPV vaccines has been geared toward women. Future health education should explicitly address the effects of HPV infection on men and its transmission between partners to improve HPV knowledge among men.

This study acknowledges several limitations. First, the cross-sectional study design limits our ability to infer the causal relationship between personal health beliefs, altruistic beliefs, and HPV vaccine acceptability. The self-reported data might be susceptible to recall bias and social desirability bias. Second, we did not measure actual vaccination behavior since HPV vaccines have not been approved for men in mainland China. While vaccination intentions and behavioral attempts may be subject to social desirability bias, our findings will be essential for health education and interventions to promote HPV vaccination among young men when the vaccine becomes available for them in mainland China. Third, our study did not adequately account for the potential differences between heterosexual men and gay and bisexual men due to the sensitivity of sexual orientations. This bias has been minimized by classifying men based on their relationship status, specifically whether they have a female partner. We also did not differentiate between students in clinical majors and those in other medical fields, leading to an increased proportion of medical students. This may not fully capture the diversity of students across different disciplines in China. Finally, the subjects of this study were highly educated university students, which may limit the generalizability of our findings. Future studies need to be conducted among more diverse and broader populations to validate these findings.

Conclusions

Our study underscores the importance of both personal health beliefs and altruistic beliefs in promoting HPV vaccine acceptability among young Chinese men. We found that perceived susceptibility, perceived benefits, perceived gender barriers, and perceived benefits of male HPV vaccination for female partners were significantly associated with men’s HPV vaccination intentions. Public health campaigns should focus on addressing gender barriers and highlighting the benefits of HPV vaccination for both men and their female partners. Tailored health education efforts emphasizing both personal health benefits and relational altruism could enhance HPV vaccine uptake among young men in mainland China.