To our knowledge, this current study was the first web-based educational intervention study of HPV vaccination among female college students in the Chinese mainland. Compared with previous studies, this web-based education was independent of time and space and appeared to be as effective as traditional education intervention. Also, it would be easier to promote this educational intervention because of the widespread use of mobile technology [15]. Moreover, this study explored not only the immediate effects after the intervention, but also the long-term effects on both vaccination intention and vaccination behavior after a one-month interval. Last, we adopted an interactive narrative to educate students, rather than just textual or graphic information, to help boost students’ willingness to get the HPV vaccine and their vaccination behavior [16].
Consistent with our hypothesis, after seven days of education, female college students in the intervention group showed a significant increase in awareness and knowledge of HPV, HPV-related diseases, and HPV vaccination. This scenario indicated that web-based education could draw the attention of female college students to related issues. Previous studies showed that education was reliable and effective in improving HPV-related knowledge among college students [17, 18] and increasing their willingness to vaccinate against HPV [19]. Notably, although lower than the intervention group, we also observed an increased awareness and knowledge regarding HPV vaccines among the control group, which might be attributed to the following reasons. First, filling out the questionnaire may help to popularize the concept of the HPV vaccine, leading to self-learning. Second, the HPV vaccine has been available in the Chinese mainland for more than 5 years, and a large amount of information was readily available to assist students in their self-study [5, 20, 21].
Despite improving HPV vaccine-related knowledge, our study’s cumulative HPV vaccine appointment/vaccination rate was meager one month after the 7-day intervention. A study conducted among African American girls found similar results in that changes in knowledge did not lead to behavioral action [22]. This suggests that when implementing health education for the HPV vaccine, we should not only talk about the knowledge but also provide information about vaccination behaviors and techniques, such as where to get vaccinated and how to get the HPV vaccine. Moreover, the present study was conducted during the COVID-19 pandemic, and it was difficult for the participants to implement vaccination. Thus, many students did not receive the HPV vaccine despite their willingness to do so. Additionally, there is a need to consider the supply and accessibility issues of HPV vaccines since HPV vaccines are not yet available in many rural areas in the Chinese mainland [23], and some regions were forbidden from distributing the HPV vaccine during the COVID-19 pandemic. Finally, this study followed up for only one month; future studies with longer follow-up are needed to observe changes in the behavior of the study subjects.
It was worth noting that the intervention group’s motivation to get vaccinated and encourage friends increased significantly immediately after the intervention and decreased after one month. A PPT-oriented educational study conducted among middle school girls showed that the perceived level in the intervention group was obviously lower than that immediately after the intervention due to the lack of a boosting health education during the 1-year interval [24]. These findings suggested that a single, short-term health education does have a positive effect on female college students’ attitudes toward HPV vaccination; however, this effect gradually diminished over time. Thus, a long-term health education strategy integrated into the school-based curriculum might significantly improve HPV vaccination uptake. Currently, the prevention of HIV/AIDS has been integrated into the sexual health education curriculum for school students in the mainland of China [25]. As HPV is also a sexually transmitted infection, it is recommended to include HPV-associated health education in students’ sexual health education curriculum.
In the current study, only 2.2% of female college students had received HPV vaccination before the survey, which was much lower than female college students in Beijing (9.5%) [26], Hong Kong (13.3%) [27], and the developed eastern regions of China (13.7%) [10]. Meanwhile, 33.1% of the responders reported being willing to vaccinate themselves, much lower than the national average (53.5%) [10]. In this study, students with highly educated parents seemed to be more willing to receive the HPV vaccination. Parents are the key decision-makers for their children’s HPV vaccination has been widely reported [28, 29], highlighting the significance of training for parents along with training for students. Moreover, students who reported having sexual experience were more likely to initiate HPV vaccination, possibly because sexual experiences led to more knowledge and awareness of sexually transmitted diseases and their associated knowledge [30]. In this study, only 1.7% of female college students had sexual experience before the survey, significantly lower than the reported 17.8% in previous studies [10]. This may be because the current study participants were female freshmen, who might have more conservative sexual attitudes than upper-year students. Notably, in our study, 21.0% of students reported not receiving any sexual education before the survey, indicating that sexual education still needs to be strengthened in mainland China.
HPV vaccination is relatively expensive for most college students in the presented study, which leads to various affordability issues with the increasing demand for HPV vaccination. Currently, the available imported bivalent, quadrivalent, and 9-valent HPV vaccines in the Chinese mainland cost about 600 CNY, 800 CNY, and 1,300 CNY each dose, respectively, and are too expensive to afford for most college students [31]. Besides, the domestic bivalent HPV vaccine has been approved for marketing [32]. It costs 329 CNY per dose, which is much lower than the imported HPV vaccines, making it expected to increase the vaccination rate of students. In the meantime, authorities should also consider including HPV vaccines in the Chinese national immunization program to solve low vaccination rates due to the high price of HPV vaccines. In addition, concerns about the adverse events, safety, and efficacy of the vaccine are also reasons students are reluctant to get vaccinated. Many studies have proven the safety and efficacy of the HPV vaccine [32,33,34], and its adverse events have been clarified [35]. Therefore, further education should enhance the safety, efficacy, and adverse events of HPV vaccines for female college students to eliminate their doubts and promote their vaccination against HPV.
Nevertheless, the study has several limitations. First, this study enrolled only two universities from two cities, which cannot accommodate representative female college students in Western and Central China. Future studies with broader coverage and larger sample sizes are needed to provide evidence for HPV vaccination promotion. Second, since all questionnaires were self-reported, some results should be interpreted with caution, especially questions about sexual activities. Third, all students in the intervention group were included in the post-intervention analysis but did not assess the completion and quality of student learning, thus potentially underestimating the effect of the intervention. Fourth, a significantly higher proportion of students in the intervention group had received sexual health education than in the control group (81.8% vs. 74.9%, p = 0.010) before health education, which may underestimate the effect of the intervention. Last, the study was conducted during the COVID-19 outbreak, and there were barriers to HPV vaccination, resulting in no significant behavioral changes observed in this study.
