Influential factors and willingness to advocate for HPV vaccination among male nursing interns in China

This study surveyed 1,980 male nursing interns, with 72.29% willing to encourage those around them to receive the HPV vaccine. This rate is lower than that found in national multicenter surveys of male university students (90%) [21], male nurses in Shaanxi Province (85.29%) [22], and males in foreign studies (82-92%) [23]. Compared to employed male nurses, nursing interns may be more focused on their studies and the development of clinical skills, potentially paying less attention to public health promotion. This intense focus on academic and clinical skill acquisition can lead to a narrower scope of practice, where immediate patient care and mastering technical competencies take precedence over broader public health initiatives. Consequently, the time and mental resources available for promoting public health, such as advocating for HPV vaccination, may be limited. Additionally, they may not have received the same level of health education and practical experience as employed nurses, which could lead to less comprehensive knowledge about the HPV vaccine [24].

Compared to other large-scale national multicenter cross-sectional studies, this study focused on typical cities in inland China. Despite improvements in economic development and the allocation of medical and health resources in these cities, there remains a gap compared to the average levels in developed coastal cities. For instance, a study conducted in western China found that the HPV vaccination rate among university students was significantly lower than in the more developed eastern coastal regions [25]. This disparity may influence the willingness of local male nursing interns to promote the HPV vaccine. It also underscores the imbalance in public health resources and the dissemination of health information between regions, highlighting the need for targeted efforts in future HPV vaccine immunization programs.

Compared to literature reviews on the willingness of males in developed countries to recommend the HPV vaccine, China’s HPV vaccine-related policies were initiated later. Many developed countries, such as the United States and the United Kingdom, have already included the HPV vaccine in their national immunization programs and provide free vaccines to eligible populations. For instance, the United States initiated its HPV vaccination program in 2006 and began recommending the vaccine for males in 2011, incorporating extensive public education campaigns, school-based vaccination initiatives, and widespread availability in healthcare facilities [26]. Similarly, the United Kingdom launched its program in 2008 and extended it to males in 2019, which has resulted in high vaccination coverage rates due to systematic strategies that facilitate widespread public education and access to vaccination services [27].In contrast, China’s HPV vaccination program began approximately a decade later. This delay, combined with less coordinated policies, has resulted in lower vaccination rates and awareness, especially in less developed inland regions. Although awareness of the HPV vaccine has gradually increased in recent years, the lack of extensive policy support and universal education means that overall understanding and willingness to recommend the HPV vaccine among males in China is not as high as in developed countries. These systematic differences highlight the importance of comprehensive public education and accessible vaccination programs in improving vaccine uptake and coverage, particularly for male beneficiaries.

The findings of this study demonstrate that older age and higher monthly household income are significant factors in increasing male interns’ willingness to promote the HPV vaccine, aligning with the research outcomes of Deng et al. [2] and Wang et al. [12]. As individuals age, they typically place greater importance on health and possess a more comprehensive understanding of health risks and preventive measures, thereby acknowledging the critical role of vaccines in preventing HPV [28]. Additionally, higher monthly household income signifies a greater financial capacity to bear the costs associated with vaccination. In the mainland Chinese market, there are five HPV vaccines available: the bivalent imported vaccine Cervarix^® (GlaxoSmithKline), the quadrivalent Gardasil^® and the nine-valent Gardasil^® 9 (both produced by Merck), and the domestic bivalent vaccines Cecolin^® (Xiamen Innovax) and Walvax^® (Walvax Biotechnology). The cost of the three-dose series ranges from 1000 to 4000 RMB [29]. Moreover, the vaccine is not yet covered by the medical insurance system, so most people need to pay out of pocket for vaccination.Considering that the average monthly disposable income in China was approximately 3,268 RMB nationwide, with urban areas at about 4,319 RMB and rural areas at about 1,808 RMB in 2023,these costs represent a substantial financial burden [30]. Additonally, our study showed that families with monthly incomes below 5,000 RMB had only 65.12% vaccination willingness, which increases significantly to 93.10% in families with incomes above 13,000 RMB. This indicates that the high out-of-pocket costs are unaffordable for many households, particularly those with lower incomes, indirectly affecting the willingness to promote the vaccine, especially among interns with limited financial resources [31].Currently, the HPV vaccine is not fully included in the National Immunization Program (NIP), individual provinces in China have issued implementation plans aimed at accelerating the elimination of cervical cancer, targeting high HPV vaccination coverage by 2030.Moreover, the recent approval of a two-dose schedule for the nine-valent HPV vaccine for females aged 9–14 by the National Medical Products Administration (NMPA) marks a significant step forward in reducing financial and logistical barriers to vaccination. This policy change is expected to make the vaccination process more affordable and convenient, thereby increasing the vaccination rate among Chinese people. In recent years, gender-neutral vaccination (GNV) programs have become increasingly common. By the end of 2019, 33 WHO member countries had started vaccinating boys, with six countries planning to implement GNV in 2020/21 [32]. In China, although current vaccination programs have not yet fully achieved gender neutrality, the introduction of two affordable domestically-produced HPV vaccines also suggests that China should consider prioritizing the implementation of GNV. This approach would not only achieve gender equality and improve protection against HPV infections and related diseases for both males and females but also enhance the program’s resilience as vaccination coverage rates change. Furthermore, the implementation of GNV could significantly increase vaccination rates among males, thereby providing herd immunity to protect unvaccinated females and reducing the incidence of HPV-related cancers.

The study results indicate that participation in the diagnosis and treatment of HPV-related diseases, a positive attitude towards the HPV vaccine, and strong perceived behavioral control are key factors influencing male clinical interns’ willingness to actively promote the HPV vaccine. These findings align with those reported by Zhang et al. [33] and Yi et al. [34]. Engagement in the diagnosis and treatment of HPV-related diseases provides male clinical interns with a deeper understanding of HPV transmission, disease progression, and its potential impacts on individual health. This hands-on experience enhances their comprehensive understanding of the disease and the importance of preventive measures. International studies similarly demonstrate that clinicians involved in cervical cancer screenings are more likely to recommend HPV vaccination compared to general family medicine clinicians [35]. Therefore, it is imperative for teaching hospitals to offer more opportunities for nursing interns to participate in HPV-related clinical practices and to organize clinical case discussions with experienced physicians sharing their insights. Such practice-oriented education is crucial in modern medical training, as it improves interns’ practical skills and clinical judgment, better preparing them as future healthcare providers who can effectively promote HPV vaccination and reduce HPV-related disease incidence and transmission.

The multivariate analysis indicates that attitude has the most significant impact on interns’ willingness to promote the HPV vaccine. For male nursing interns, a positive attitude typically arises from trust in the vaccine’s preventive efficacy, a thorough understanding of its importance, and the comprehensive knowledge gained through medical education and practice [36]. Consequently, medical schools should integrate detailed content about HPV and its vaccines into their curricula, covering mechanisms of action, preventive effects, and public health significance. Furthermore, regular training sessions and seminars on HPV vaccines should be organized, inviting field experts to share the latest research findings and practical experiences, thereby enhancing interns’ positive attitudes towards vaccine promotion.

Notably, this study found that the level of HPV knowledge did not significantly correlate with the willingness to promote the vaccine, contrary to the findings of Dai et al. [21]. While this finding contrasts with the majority of the existing literature, which often emphasizes the importance of HPV knowledge in vaccine promotion, it can be attributed to the specific context and background of male nursing interns. Existing studies predominantly focus on general populations or university students who may not have the same level of medical training. Our research indicates that male nursing interns, due to their comprehensive medical education, have already attained a high level of HPV knowledge, making further increases in knowledge less impactful on their willingness to promote the vaccine. Therefore, their knowledge level is no longer the primary driver for promoting the HPV vaccine. Instead, other factors, such as perceived behavioral control, may play a more decisive role in this process.The experiences accumulated during their internships, including patient communication, successful HPV vaccine recommendations, and the methods and strategies learned from mentors, can enhance their perceived behavioral control [13]. These experiences help them better address potential challenges in promoting the HPV vaccine, such as vaccine hesitancy and misconceptions. Additionally, the availability of necessary resources plays a significant role in perceived behavioral control [37]. Teaching hospitals should provide interns with ample educational resources and practical opportunities, while also offering material and logistical support, such as vaccine supplies and vaccination clinics, which are foundational for implementing effective vaccine promotion strategies. This comprehensive support system, encompassing both educational resources and material support, not only increases interns’ capabilities and confidence in promoting the HPV vaccine but also strengthens their perception of being able to successfully do so.