Human papillomavirus (HPV) is the most prevalent viral infection of the reproductive tract and is a major cause for cervical cancer [1
]. Cervical cancer was the fourth most common cancer in women and was responsible for 7.5% of all female cancer deaths in 2018 [1
]. Vaccines that protect against HPV are recommended by the World Health Organization (WHO) and have been approved for use in many countries. After a decade delay since U.S. FDA licensure in 2006, China approved the bivalent vaccine (2vHPV) in 2016 [2
], the quadrivalent vaccine (4vHPV) in 2017, and the 9-valent vaccine (9vHPV) in 2018. The HPV vaccination is for use in females aged 9–45 years and it is not free-of-charge [3
]. Up to when this survey finished in December 2018, Shanghai, Guangzhou and Shenzhen are the first group of cities in China where the HPV vaccine was available [4
However, vaccine hesitancy, which is defined by the Strategic Advisory Group of Experts (SAGE) working group of the WHO, refers to delay in the acceptance or refusal of vaccination despite the availability of vaccination services [5
]. Nowadays, this hesitation has been an increasingly common phenomenon globally and is influenced by several factors such as complacency, convenience confidence, and other reasons [6
]. With respect to HPV vaccines, factors such as worries about the side effects, a low perceived efficacy of HPV vaccines and therefore no necessity of being vaccinated, and geographical accessibility and affordability could all contribute to vaccine hesitancy [7
]. Evidence shows that health care providers feel ill-equipped to answer questions or uncertain to talk with those who are reluctant to be vaccinated [8
], which undoubtedly causes lower vaccine uptake rates.
One effective measure to overcome hesitancy among audiences and providers is to make providers thoroughly master knowledge of HPV and HPV vaccines. This way, they can have a good understanding of the benefits and risks of being vaccinated and thus have confidence to recommend vaccination to their patients. Therefore, it is necessary to examine the knowledge, perceptions, and information sources of HPV and its vaccine among health care providers.
Being directly responsible for the recommendation and delivery of HPV vaccines to the public, the importance of health care providers has been emphasized by several studies [9
]. One of the most important factors that influence the providers’ recommendation of HPV vaccination is their experience with and understanding of this vaccination. Therefore, it is worthwhile to explore the providers’ knowledge regarding HPV and HPV vaccine. There have been positive results: more than 90% of providers could correctly answer most of the questions in their surveys [14
]. However, it seems that their knowledge regarding HPV and its vaccine does not always match with their profession. For example, a study conducted among South African doctors [16
] found that the knowledge level of HPV infections was low, and they had poor awareness about HPV and HPV vaccines. Similar results were obtained with doctors in Canada [17
], India [15
], and China [18
In terms of their subjective perception, some physicians tend to perceive that their knowledge is insufficient. When rating their knowledge about the risk of HPV infection and resultant cervical cancer, general practitioners (61%), obstetricians/gynecologists (28%), and pediatricians (56%) felt that their knowledge of this aspect was not sufficiently high [19
]. Physicians’ knowledge and their perceptions are not always consistent and may vary from each other [18
]. By examining the discrepancy between the subjective perception and objective knowledge of health care providers in three representative developed cities in China, we can lay the foundation for bridging this gap. Therefore, the first research question is the following:
RQ1: Are providers’ subjective perceptions consistent with their objective knowledge on HPV and the HPV vaccine? If not, is the variance significant?
With respect to the acquisition of relevant knowledge, most surveys on this topic assessed whether providers’ knowledge is associated with their demographics. Particularly, specialty, hospitals’ attributes, and the experience with HPV and HPV vaccination are viewed as critical variables in physicians’ knowledge. For example, there was a greater possibility that obstetricians/gynecologists knew specific oncogenic strains of HPV than the general practitioners [20
], and a study by Warner and colleagues indicated that providers from institutions or universities and primary care or other have more HPV vaccination knowledge than providers from private care and hospitals, and the more patients providers saw, the more knowledge about HPV they had [21
]. Furthermore, information sources could also be a significant factor that influences the physicians’ actual knowledge about HPV and HPV vaccine [22
]. Therefore, research questions 2 and 3 are the following:
RQ2: Is the knowledge of providers associated with their demographic characters, especially specialty, hospital type, and practical experience? If so, which factors are the most significant?
RQ3. Is the knowledge of providers associated with the source and frequency of information acquisition? If so, which information source predicts the most significant variance?
The purpose of this study was to examine whether the knowledge of health care providers is consistent with their perceptions of HPV and HPV vaccine as well as whether the level of their knowledge is associated with their demographics, particularly their specialty, hospital attributes, practical experience, and the information acquisition frequency in three well-developed big cities of China.
In this study, we analyzed the knowledge, perception of HPV and HPV vaccine, and the use of information sources for relevant resources from the health care providers’ perspective by conducting a large-scale survey with 1394 participants covering three big cities in China. First, we examined whether providers’ knowledge level were consistent with their perceptions about HPV and HPV vaccine; then, the variance of providers’ knowledge level based on their demographic characteristics such as city, specialty, and hospital type were analyzed according to 6 questions for HPV and 4 questions for HPV vaccine; finally, the relationship of providers’ knowledge level regarding HPV and its vaccine and their frequency of different information source use was verified.
Nowadays, it has been emphasized repeatedly that receiving a recommendation from a health care provider is one of the most significant and consistent factors that influence the audience’s decision on HPV vaccination [21
]. However, on the one hand, vaccine hesitancy is pervasive in ordinary people’s views. Concerns such as vaccine safety and the necessity of vaccination are the most reported reasons for vaccine refusal [35
]. Therefore, it is critical for people to determine the benefits of being vaccinated when they receive the recommendation of their health care providers. On the other hand, hesitancy is also widespread in providers’ attitudes and their clinical practice. Moreover, barriers such as embarrassment to discuss sexual health topics with adolescents’ parents and worries about initiating time-consuming or confrontational debates among providers may impede providers’ willingness of recommendation [11
]. Hence, probably only a comprehensive and in-depth understanding of the relevant knowledge can strengthen the motivation of recommendation. Therefore, improving providers’ knowledge on HPV and HPV vaccine could be regarded as a crucial and practical way to reduce both providers and patients’ uncertainties and enhance their belief in vaccination, and this paper is a preliminary attempt for exploring this issue.
Generally, in this study, respondents had good knowledge of HPV and its vaccine, which fairly coincided with their own perceptions about their understanding of these topics.
It is worth noting that far more providers from Shenzhen than from Shanghai and Guangzhou achieved higher HPV knowledge scores. However, it is evident that the medical resources and the level of medical treatment of the latter two cities are superior to those of Shenzhen according to China’s hospital rankings, which are professional and acknowledged widely in China [37
]. Therefore, it seems that the health care providers’ HPV-related knowledge level is not always proportional to the general medical level of their cities. We speculate that the better HPV-related knowledge among health care providers in Shenzhen may due to three reasons. Firstly, it is likely attributable to the geographical location of Shenzhen, as it is located the closest to Hong Kong, where the HPV vaccine was introduced in 2004 [38
] and has been covered by mass media since then; thus, it is reasonable that citizens of Shenzhen acquired relevant information by means of interpersonal communication and some public service advertisements from Hong Kong [39
]. Secondly, it is possibly associated with the medical system. In Shenzhen, the implementation plan for the comprehensive reform of public hospitals was published by the Health and Family Planning Commission on 8 June 2015, making Shenzhen the first pilot city in China to print and distribute the comprehensive reform plan of public hospitals, and since then, a series of community hospitals equipped with sufficient medical staff have been established, which offered valid support for citizens getting vaccinated in adjacent areas. Thirdly, and perhaps the most important factor, Shenzhen has included HPV vaccination in citizens’ medical insurance since 10 April 2018. Therefore, the increasing number of people who get vaccinated could promote the providers’ willingness to learn about HPV and HPV vaccination. Based on these reasons, hospitals and government subdivisions of other cities should consider including HPV vaccination in the medical system to ensure that HPV-related knowledge can be disseminated through organizational communication, so that (i) more comprehensive news on HPV and HPV vaccination will be presented by media and (ii) HPV vaccination will be considered more legitimate by government agencies and more rational by citizens.
With respect to different specialties where respondents worked, it is not surprising that most obstetricians and gynecologists and respondents who worked in preventive health care departments obtained better knowledge scores for HPV and its vaccine, respectively. However, most of the pediatricians obtained lower knowledge scores for both HPV and its vaccine, which would hinder their recommendation of vaccination to the parents of adolescents or teenagers who are the target group for vaccination promotion. Previous studies indicated that the pediatricians’ recommendation is a key factor that strongly influences the vaccination decisions of adolescents and parents for their children at the right age [40
]. However, on one hand, most media coverage, including mass media and social media, aims vaccination information at adult women, such as female college students or female working people, ignoring the younger population to a large extent. On the other hand, it is hard for parents to talk about HPV-related topics with their children. HPV is associated with sexual organs, while in China, parents’ consciousness of sex education is weak [41
] and many parents feel embarrassed to talk about it with their children. This is an issue that deserves attention that the adolescents’ knowledge of HPV and its vaccine might be inaduquate; therefore, studies that investigating the possibilities to improve HPV-related knowledge among pediatricians and to increase the vaccination rate among adolescents are needed.
In terms of the type of hospital, it seems that participants who worked at general and specialist hospitals had the best understanding of HPV (the result was not significant and was therefore not shown in Table 2
), while our results also indicated that they had the lowest understanding of the HPV vaccine. This reverse knowledge gap requires further investigation. Strikingly, even though the providers who worked at community health service centers are the least on getting higher knowledge scores about HPV among three types (not significant), they achieved significantly higher knowledge scores for the HPV vaccine than other groups, which might be attributable to the HPV vaccination policies in China. Our findings imply that there may exist a potential serious lack of knowledge of the “beneficial effects” and “risks”, which means that providers in general hospitals normally have good knowledge about the risk of not vaccinating but insufficient knowledge about the benefits of vaccination. Conversely, health care providers in community hospitals generally had good vaccination-related knowledge, yet they did not understand HPV pathology well. When patients visit general hospitals, they can acquire more clinical knowledge about HPV, but there is a shortage of vaccination-related knowledge, and when they are in a community hospital setting, vaccination-related suggestions are given sufficiently, but the available information about HPV may be absent. Both situations would affect the patients’ willingness and decisions to get vaccinated and would also cause vaccine hesitancy. Accordingly, communication strategies and the distribution of information should be improved. In terms of policies, the range of officially recommended hospitals for vaccination should be expanded, so that vaccinations can also be given at general and specialist hospitals. As regards the distribution of information, it will be beneficial to strengthen the supply of information about HPV vaccination to health care providers in higher-level hospitals to increase the accessibility of vaccination information. In turn, training on the clinical pathology of HPV should be offered to health care providers in community hospitals to improve the capacity of primary hospitals.
Furthermore, regarding the age and title, senior providers generally obtained higher scores on the knowledge of HPV, while intermediate physicians and middle-aged (28–37) respondents obtained higher scores on the knowledge of HPV vaccine. This difference may be caused by the fact that the participants who take charge of vaccination are normally younger. In this case, regular training about HPV should be offered to young and intermediate health care providers, which is a key step for reminding them of their deficiency on the knowledge of HPV pathology and inspiring them to take the initiative in this learning process. By this way, they can not only offer suggestions about vaccines to patients, but also can provide advice on the dangers of HPV. The resulting fears could probably be useful to decrease the potential vaccine hesitancy of the patients.
Health care providers, as professionals, are the transmitters of medical information to the audience. Therefore, their knowledge and perceptions are important factors in influencing vaccine acceptability [43
]. Many studies emphasized the need for more education for providers on HPV-related topics [14
]. In this paper, we noted that interventions should not only aim at raising providers’ knowledge level on HPV and its vaccine, but also should be based on providers’ different characteristics such as specialty and the type of their hospitals, which would benefit them more by equipping them with confidence and adequate knowledge on recommendation of vaccination. Moreover, such interventions can effectively relieve unnecessary concerns in the general public.
Furthermore, the use of more professional information sources was associated with more accurate HPV-related knowledge. Frequent discussions with peers on relevant issues could also be useful. Other information sources, such as media, may be crucial in information seeking, but could not facilitate a higher level of knowledge acquisition. Based on these results, we recommend that the physicians and nurses should search for knowledge from professional journals and other reliable professional sources.
There were some limitations to this study. Due to the nature of the survey link distribution, we did not know the exact number of providers who has received the survey link or in fact browsed the link that we have provided. In addition, those who participated in the survey might be those who were interested in the topic and were more aware of the HPV situation in China and elsewhere. Thus, the results have limited generalizability and should be interpreted carefully. Another limitation of this study is that all the participants in our sample pool were health care providers from developed cities in China. More health care providers might be short of relevant knowledge in underdeveloped cities; we plan to investigate this population in our future studies. Additionally, all data collected in this study were self-reported, and that may generate bias.