Original article

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A national survey on HPV vaccination status among 42,800 female physicians and nurses

in China, 2021

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Short title: A national survey on HPV vaccination status

Chenyang Pei1, 2, Dian Zeng3, Yuanli Liu1* and Jing Ma3*

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1School of Health Policy and Management, Chinese Academy of Medical Sciences & Peking Union Medical

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College, Beijing, China; Heidelberg Institute of Global Health, Faculty of Medicine and University Hospital,
Heidelberg University, Heidelberg, Germany; 3School of clinical medicine, Tsinghua University, Beijing, China

ORCID ID
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Chenyang Pei: https://orcid.org/0000-0003-0819-8034

Dian Zeng: https://orcid.org/0000-0002-5592-9584

Yuanli Liu: https://orcid.org/0000-0002-3437-1155

Jing Ma: https://orcid.org/0000-0002-9132-0741

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Correspondence to:

Yuanli Liu
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School of Health Policy and Management, Chinese Academy of Medical Sciences & Peking Union Medical

College, Beijing, China; 2School of clinical medicine, Tsinghua University, Beijing, China
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Email: [email protected]

Jing Ma
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School of clinical medicine, Tsinghua University, Beijing, China

Email: [email protected]
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Disclaimers:

This preprint research paper has not been peer reviewed. Electronic copy available at: https://ssrn.com/abstract=5345765
 Acknowledgements

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This study was supported by the Chinese Academy of Medical Sciences Innovation Fund for Medical Sciences

under Grant [2021-I2M-1-046].

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Author contributions

C.P.: concept and design; acquisition, analysis, or interpretation of data; critical revision of the manuscript for

important intellectual content; and statistical analysis. D.Z.: concept and design; drafting of the manuscript; and

ev
statistical analysis. J.M.: critical revision of the manuscript for important intellectual content; administrative, technical,

or material support; and supervision and final approval of the version to be published. Y.L.: critical revision of the

manuscript for important intellectual content; procurement of funding; administrative, technical, or material support;

r
and supervision and final approval of the version to be published. All authors agree to be accountable for all aspects

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of the work and have read and approved the final version of the manuscript.
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Disclosure of interest

The authors report there are no competing interests to declare.

Data availability statement

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All relevant data provided in this study are available from the corresponding authors upon request.
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This preprint research paper has not been peer reviewed. Electronic copy available at: https://ssrn.com/abstract=5345765
 1 Original article

A national survey on HPV vaccination status among 42,800 female physicians and

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2

3 nurses in China, 2021

4 Chenyang Pei1, 2, Dian Zeng3, Yuanli Liu1* and Jing Ma3*

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5

6 1School of Health Policy and Management, Chinese Academy of Medical Sciences & Peking Union Medical
7 College, Beijing, China; 2Heidelberg Institute of Global Health, Faculty of Medicine and University Hospital,
8 Heidelberg University, Heidelberg, Germany; 3School of clinical medicine, Tsinghua University, Beijing, China

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9

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10 Correspondence to:

11 Yuanli Liu

12 School of Health Policy and Management, Chinese Academy of Medical Sciences & Peking Union Medical

13
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College, Beijing, China; 2School of clinical medicine, Tsinghua University, Beijing, China

14 Email: [email protected]

15 Jing Ma
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16 School of clinical medicine, Tsinghua University, Beijing, China

17 Email: [email protected]

18
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19 Abstract

20 Objective. Human papillomavirus (HPV) vaccination is the most effective method to prevent cervical cancer. This
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21 study aimed to investigate the status of HPV vaccination and associated factors among Chinese females.

22 Methods. Between January and March 2021, we conducted a large national survey among female doctors and

23 nurses in 181 public tertiary hospitals across all 31 provinces of China. In the survey, we asked three questions:
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24 “Have you ever received an HPV vaccination? If yes, what type and in which year?” We described and compared

25 the proportion of vaccination coverage according to occupation, age, geographic region, education, marital status,

26 among other factors.

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27 Results. Of the 42,800 participants, 6,185 reported receiving HPV vaccination, of whom 2,046 were physicians

28 and 4,121 were nurses. Younger age, never married or divorced, higher education, better self-reported health status,
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29 western region, working at the Obstetrics and Gynecology or Surgery department, working at the cancer hospitals,

30 and nulliparous were more likely to receive the HPV vaccination. The proportion of the types of vaccines received

This preprint research paper has not been peer reviewed. Electronic copy available at: https://ssrn.com/abstract=5345765
 31 by these health professionals was 50.3% for the 4-valent HPV vaccine, 33.7% for the 9-valent HPV vaccine, 9.0%

32 for the 2-valent HPV vaccine (made abroad), and 7.0% for the 2-valent HPV vaccine (made in China).

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33 Conclusion. Understanding the characteristics of the likelihood of receiving HPV vaccination among female

34 physicians and nurses in China indicates their awareness of the risk for cervical cancer, which could help us better

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35 develop primary prevention strategies.

36

37 Keywords: Human papillomavirus vaccination; Cervical cancer prevention; Female physicians and nurses;

38 Influencing factor; Nationwide survey

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39

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40 Highlights:

41  First national study on self-reported HPV vaccination coverage among Chinese women across all p

42 rovinces.

43 
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HPV vaccine uptake was higher in younger, unmarried, educated, healthy, and nulliparous individuals.

44  Those working in Ob/Gyn, Surgery department, or cancer hospitals were more likely to be vaccinated.
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45  HPV vaccination rate (14.45%) among Chinese healthworkers was even lower than the general population

46 in high-income nations.

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This preprint research paper has not been peer reviewed. Electronic copy available at: https://ssrn.com/abstract=5345765
 48 INTRODUCTION

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49 The human papillomavirus (HPV), a small deoxyribonucleic acid virus that infects the skin and mucosa [1],

50 remains one of the most prevalent viral infections worldwide [2]. Genital HPV infection rates can exceed 75%

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51 over a lifetime [3]. In China, the prevalence of high-risk HPV infection among females is 19.0% and varies widely

52 across regions, from 12.2% in the northwestern region to 23.8% in the northern region [4]. A previous study [5]

53 has linked approximately 91.0% of reported cervical cancer cases to HPV infection. In 2020, cervical cancer was

54 the fourth most common cancer among females worldwide, with an estimated 6,040,000 new cases [6]. In China,

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55 32,000 new cases of cervical cancer were reported in 2016, with 10,000 deaths reported annually. In 2016, cervical

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56 cancer was the 8th most common cause of cancer-related death among females [7].

57 HPV vaccination can prevent 70–90% of cervical cancers [8, 9]. In August 2020, the World Health

58 Assembly adopted the Global Strategy for Cervical Cancer Elimination, which states that all countries must reach

59
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and maintain an incidence rate of < 4 per 100,000 females and proposes a tertiary prevention strategy, including

60 HPV vaccination, cervical cancer screening, and management of the detected disease [1]. By June 2020, more than
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61 half of the members of the World Health Organization had introduced HPV vaccines, with the highest coverage

62 rates in Australia and New Zealand (77% and 62%, respectively), followed by Europe and North America, with

63 the lowest coverage rates in Asia [10]. The 2-valent HPV (2vHPV) vaccine was first introduced to mainland China
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64 in August 2016, followed by the 4-valent HPV (4vHPV) vaccine in 2017 and the 9-valent-HPV (9vHPV) vaccine

65 in 2018 [11]. In December 2019, the Chinese Food and Drug Administration granted a license for the first
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66 domestically developed 2vHPV vaccine in China [12]. Despite the introduction of the vaccine, HPV vaccination

67 rates in China remain low; 21.6 million doses of HPV vaccines were administered to 9–45-year-old females during

68 2018–2020, an estimated full-series cumulative coverage rate of 2.24% [13]. Several studies in China have
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69 revealed a high willingness among female healthcare professionals to receive the HPV vaccine. However, the

70 actual vaccine uptake in this group has remained low [14-16]. This discrepancy between positive attitudes and

71 behaviors can be attributed to several factors. First, the high demand for the HPV vaccine has resulted in a shortage
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72 of vaccines in the Chinese market [17]. Additionally, most healthcare professionals in China lack sufficient

73 knowledge about the HPV vaccine, have concerns regarding its safety and effectiveness, and lack trust in its

74 sources [15, 16, 18]. Furthermore, they perceive the HPV vaccine to be expensive [16, 19]. These factors
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75 collectively impede the translation of positive attitudes and the willingness to vaccinate.

This preprint research paper has not been peer reviewed. Electronic copy available at: https://ssrn.com/abstract=5345765
 76 Healthcare providers play a crucial role in promoting the uptake and use of HPV vaccines and other

77 cervical cancer prevention services, owing to their greater access to health information resulting from education

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78 and training [20, 21]. Providing high-quality advice by healthcare professionals can significantly increase the

79 number of females receiving HPV vaccination [22, 23]. Additionally, females rely on healthcare providers to

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80 obtain reliable information on HPV vaccines [24, 25]. Consequently, healthcare professionals must possess

81 comprehensive knowledge and have a positive attitude toward HPV vaccination to ensure the provision of accurate

82 health education to females. Furthermore, female health professionals play a crucial role in promoting HPV

83 vaccination among the public, as their vaccination behaviors may influence HPV vaccination decisions [26-31].

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84 Given their potential influence, it is necessary to examine HPV vaccination status among female healthcare

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85 professionals.

86 In China, several studies have focused on awareness of and attitudes toward HPV vaccination [26, 32-

87 34]. HPV vaccination rates are commonly estimated from the number of doses reported in a given locality;

88
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however, these may differ from the actual vaccination rates [13, 35]. Data on self-reported HPV vaccination

89 coverage rates based on nationwide field surveys remain lacking. Furthermore, the current status of HPV
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90 vaccination among female healthcare professionals in China and other countries remains inadequately researched,

91 necessitating further studies to better understand the extent of HPV vaccination in this population.

92 This study used data from the China Healthcare Improvement Evaluation Survey (CHIES), administered to 181
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93 tertiary public hospitals in 31 provinces of China, to explore the HPV vaccination status and associated factors

94 among female health professionals for future vaccination strategies.

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95 MATERIALS AND METHODS

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96 Ethics statements

97 This study was approved by the Ethics Committee of the Institute of Medical Biology of the Chinese Academy of

98 Medical Sciences (approval number: IPB-2020-23). All participants provided informed consent before
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99 participation.
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This preprint research paper has not been peer reviewed. Electronic copy available at: https://ssrn.com/abstract=5345765
 100
101

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102 Study design and setting

103 The CHIES, a national survey targeting physicians, nurses, and patients, has been administered annually to 136–

104 214 tertiary public hospitals since 2015 [36]. Herein, we used data from a cross-sectional physician and nurse

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105 survey of the most recent CHIES conducted from January 2021 to March 2021 and sampled 181 tertiary public

106 hospitals, including 57 general hospitals, 33 cancer hospitals, 32 maternal and child health hospitals, 46 traditional

107 Chinese medicine hospitals, and 13 other specialty hospitals in 31 provinces of China. The questionnaire was self-

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108 administered using a smartphone platform (WeChat, Singapore, China). Physicians and nurses used their cellular

109 phones to complete the questionnaire through a centralized public account called “Healthy China”, which is

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110 government-owned.

111 Participants

112
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At each hospital, only registered clinical physicians and nurses were included in the survey. Physicians and nurses

113 were selected from the entire staff list at each hospital using stratified random sampling. The strata were divided
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114 according to professional titles (junior, middle, and senior). This approach was adopted due to the

115 interconnectedness of the professional title variable with pertinent factors, such as the age, educational background,

116 and years of experience of health professionals. Given its composite nature, professional titles were deemed a
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117 salient criterion for stratification, thus bolstering the overall representativeness of the study. We aimed to obtain

118 completed questionnaires from at least 150 physicians and 150 nurses at each hospital. The planned sample size

119 was 54,300, and the actual number of respondents was 62,930. The current study focused on the HPV vaccination
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120 status among female physicians and nurses from 181 tertiary hospitals. The maximum age for HPV vaccination is

121 45 years; thus, 5,892 female health professionals aged > 45 years were excluded from the final analysis.
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122 Variables

123 The CHIES included questions about the respondents’ demographics (age, marital status, and education), work
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124 information (hospital type, occupation, department, and region), clinical information (reproductive history and

125 self-reported health status), and self-reported HPV vaccination status (vaccinated or unvaccinated and type and

126 time of vaccination).

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127 HPV vaccination history was defined using the following question: “Have you ever been vaccinated before?”

This preprint research paper has not been peer reviewed. Electronic copy available at: https://ssrn.com/abstract=5345765
 128 Respondents who indicated “yes” and “no” were classified into the vaccinated and unvaccinated groups,

129 respectively. In the vaccinated group, two additional questions were asked: 1) “What type of HPV vaccine have

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130 you ever received?” The responses included 2vHPV (domestic), 2vHPV (abroad), 4vHPV (abroad), and 9vHPV

131 (abroad). 2) “What year did you receive the HPV vaccine?”

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132 Quality control

133 An online data collection system administered on smartphones was used to enhance the quality control of the

134 survey using predefined real-time data validation rules. The validation function was embedded in the electronic

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135 questionnaire to verify the logic and integrity of the results.

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136 Statistical analyses

137 HPV vaccination coverage rates among respondents with different sociodemographic (age, marital status, and

138
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education), work-related (occupation, hospital type, department, and region), and clinical (self-reported health

139 status and reproductive history) characteristics were reported. The χ2 test was used to compare HPV vaccination
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140 coverage rates among all the aforementioned factors and to evaluate differences in the distribution of respondent

141 characteristics across physicians and nurses. Univariable and multivariable logistic regression analyses were

142 performed to determine associations between HPV vaccination (vaccinated/unvaccinated) and the following

143 factors: age group (18–26, 27–31, 32–36, or 37–45 years), marital status (never married, married, or
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144 divorced/widowed), educational level (associate degree or less, college degree, master’s degree, doctoral degree,

145 or higher), reproductive history (have not given birth, have previously given birth), occupation (physician or
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146 nurse), hospital type (general, maternal and child health, traditional Chinese medicine, cancer, or other specialty

147 types), department (internal medicine, surgery, obstetrics and gynecology, pediatric, emergency, cancer, traditional

148 Chinese medicine, or others), region (east China, middle China, or west China), and self-reported health status
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149 (very poor, poor, regular, good, or very good).

150 In the subgroup analysis, we stratified the participants into two groups based on their occupation:
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151 physicians and nurses. A subgroup analysis was performed to further assess the association between HPV

152 vaccination coverage rates in the multivariable models and population characteristics. The strength of the

153 association was measured using odds ratios (ORs) and 95% confidence intervals (CIs).
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154 All figures were created using GraphPad Prism, version 8.4.0 (GraphPad Software, San Diego, CA, USA). All

155 statistical analyses were conducted using STATA, version 16.0 (StataCorp LLC, College Station, TX, USA).

This preprint research paper has not been peer reviewed. Electronic copy available at: https://ssrn.com/abstract=5345765
 156 Statistical significance was set at p < 0.05.

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157 RESULTS

158 Sample

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159 A total of 42,800 participants were included in this study, of whom 13,804 (32.25%) were doctors and 28,996

160 (67.75%) were nurses (Figure 1). Table 1 lists the characteristics of the participants based on occupations. The

161 proportions of different HPV vaccination types are presented in Figure 2, and the numbers of participants

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162 vaccinated by year are in Figure 3. All variables differed within the groups, except for region. The highest numbers

163 were observed in the general population and among nurses aged 27–31 years, whereas the highest numbers among

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164 doctors were found in those aged 37–45 years. In all groups, > 70% of the participants were married, and < 40%

165 self-reported good or very good health status. In the entire population, approximately 90% had an education level

166 of college or higher, approximately 80% had a master's degree or higher, and over 80% had a college degree. The

167
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largest proportion of participants in all subgroups was from eastern China. Similarly, across all subgroups, nearly

168 one-quarter of the participants worked in the internal medicine department, and one-third worked in general
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169 hospitals. More than 60% of doctors and nurses had previously given birth.

170 HPV vaccination status

171 Of the 42,800 participants, 14.45% (6,185/42,800) reported receiving HPV vaccination, of whom 14.95%
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172 (2,046/13,804) were physicians and 14.21% (4,121/28,996) were nurses. In the entire population, the differences

173 in vaccination rates were significant after stratifying the patients into groups based on age, occupation, education,
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174 self-reported health status, marital status, region, department, hospital type, and reproductive history (p < 0.05;

175 Table 3). The largest proportion of vaccinated individuals received the 4vHPV vaccine (50.30%), followed by the
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176 9vHPV (33.71%) and 2vHPV (15.99%) vaccines (Figure 2). From 2014 to 2020, the number of vaccinated

177 individuals increased annually (Figure 3).

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178 Associated factors of HPV vaccination coverage rates

179 The results of the multivariable logistic regression analysis are presented in Table 3. For all healthcare

180 professionals, age, marital status, education, self-reported health status, region, department, hospital type, and
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181 reproductive history were associated with HPV vaccination coverage rates (p < 0.05). Compared with those in the

182 age group of 18–26 years, those in the age groups of 27–31 (OR = 0.60; 95% CI, 0.55–0.66), 32–36 (OR = 0.52;

This preprint research paper has not been peer reviewed. Electronic copy available at: https://ssrn.com/abstract=5345765
 183 95% CI, 0.47–0.58), and 37–45 (OR = 0.45; 95% CI, 0.40–0.51) were less likely to undergo HPV vaccination.

184 Furthermore, participants who were married (reference: unmarried, OR = 0.76; 95% CI, 0.69–0.83), worked in the

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185 western region (reference: east China, OR = 0.75; 95% CI, 0.70–0.80), worked in traditional Chinese medicine

186 hospitals (reference: general hospital, OR = 0.68; 95% CI, 0.62–0.73), and had previously given birth (reference:

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187 have not given birth, OR = 0.72; 95% CI, 0.65–0.79) were less likely to receive HPV vaccination. Conversely,

188 those who had a college degree (reference: associate degree or less, OR = 1.50; 95% CI, 1.36–1.66), master’s

189 degree (reference: associate degree or less, OR = 1.68; 95% CI, 1.45–1.95), doctoral degree or higher (reference:

190 associate degree or less, OR = 1.89; 95% CI, 1.58–2.25), worked in surgery (reference: internal medicine, OR =

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191 1.10; 95% CI, 1.00–1.21), obstetrics and gynecology (reference: internal medicine, OR = 1.22; 95% CI, 1.10–

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192 1.36), cancer (reference: internal medicine, OR = 1.55; 95% CI, 1.30–1.86), other type of department (reference:

193 internal medicine, OR = 1.26; 95% CI, 1.16–1.36), and worked in surgery (reference: internal medicine, OR =

194 1.23; 95% CI, 1.13–1.33) were more likely to undergo HPV vaccination.

195
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In the subgroup analysis of the multivariable model, age, marital status, region, department, type of

196 hospital, and reproductive history were associated with HPV vaccination coverage among physicians, whereas
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197 varying levels of education had no influence on HPV vaccination coverage. Factors associated with HPV

198 vaccination rates among the nursing population were the same as those among all health professionals. Self-

199 reported health status did not affect any subgroup.

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200 DISCUSSION

201 This study aimed to examine the factors associated with HPV vaccination among female physicians and nurses in
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202 China. To our knowledge, this is the most extensive study to date on self-reported HPV vaccination status among

203 Chinese females and the first nationwide survey of HPV vaccination that focused on female physicians and nurses

204 in China.
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205 The overall self-reported HPV vaccination coverage rate of Chinese female physicians and nurses was 14.45%,

206 and the largest proportion of the vaccinated group received the 4vHPV vaccine, followed by the 9vHPV and

207 2vHPV vaccines. The HPV vaccination coverage rates were associated with age, marital status, education, region,
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208 department, hospital type, and reproductive history.

209 In this study, the self-reported HPV vaccination rate among Chinese female physicians and nurses aged
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210 18–45 years in 2021 was 14.45%, which was lower than that reported for physicians and nurses in Beijing in 2018

211 (27.30%) [26]. The discrepancy in vaccination rates may be due to the overall education and income levels of

This preprint research paper has not been peer reviewed. Electronic copy available at: https://ssrn.com/abstract=5345765
 212 physicians and nurses in Beijing, which are higher than the national average. The coronavirus disease pandemic

213 has disrupted access to care, clinic appointments, and routine vaccine deliveries [37-39]. Several studies have

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214 reported significant declines in HPV vaccination rates in many countries during the pandemic, which could also

215 have contributed to the lower HPV vaccination rates observed herein [40, 41]. Our results also showed that the

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216 HPV vaccination rate in female physicians and nurses in China was higher than that in the general Chinese

217 population. Song et al. estimated that the HPV vaccination rate in females aged 9–45 years in China in 2020 was

218 2.24% [13]. Liu et al. also estimated that 4.19% of females aged 9–45 years in Shanghai received their first dose

219 of the HPV vaccine, and 2.83% received all necessary doses [35]. These figures are lower than the 14.45%

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220 determined in this study. This difference may be related to the higher levels of health literacy [42] and awareness

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221 of the HPV vaccine [43] among healthcare staff relative to the general population in China. However, the HPV

222 vaccination rate among female physicians and nurses in China is lower than that among the general population in

223 higher-income countries [10].

224
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The proportion of individuals who received 4vHPV vaccines was higher than that of those who received

225 9vHPV vaccines, possibly due to the lower price, abundant supply, earlier launch, and wider vaccination age range
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226 (4vHPV: 20–45 years; 9vHPV: 16–26 years) of the 4vHPV vaccine than the 9vHPV vaccine [44, 45]. The number

227 of female physicians and nurses in China who received the HPV vaccination increased annually from 2014 to

228 2020, consistent with the growth trend reported in Spain [46]. Further, as multiple HPV vaccines have become

229 available in China since the end of 2017, the number of female physicians and nurses in China who have received
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230 HPV vaccinations has doubled annually.

231 The current study’s findings indicate that vaccinated individuals tend to be younger, unmarried, have
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232 higher education levels, have not given birth, and work in the eastern region, obstetrics and gynecology or cancer

233 departments, and cancer hospitals. Self-reported health status and occupation (physician or nurse) were not

234 significantly associated with the HPV vaccination status.

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235 In the present study, the HPV vaccination rates among female physicians and nurses decreased as age

236 increased, consistent with the results of previous studies [47-49]. The effectiveness of antibodies induced following
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237 HPV vaccination decreases with increasing age [50, 51], which may affect vaccination behavior in older age

238 groups. Another possible reason is that young females have greater literacy regarding cervical cancer prevention.

239 [52, 53]

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240 This study showed a positive correlation between the HPV vaccination coverage rates and educational

241 level, consistent with the findings of other studies [54, 55]. Individuals with higher educational levels have

This preprint research paper has not been peer reviewed. Electronic copy available at: https://ssrn.com/abstract=5345765
 242 significantly greater awareness of and trust in HPV vaccines than those with lower educational levels. [56, 57]

243 Findings from current and previous studies have suggested that targeted interventions for HPV vaccination are

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244 warranted for those with lower education levels.

245 Furthermore, our findings also indicated that the HPV vaccination rate among married female physicians

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246 and nurses was lower than that among those who had never been married. The HPV vaccination rates of female

247 physicians and nurses who had given birth were lower than those of female physicians and nurses who had never

248 given birth. Thompson et al. found that married females were less likely to be interested in HPV vaccination than

249 never-married females [58]. Specifically, married females were more likely to report that they did not require an

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250 HPV vaccine [58]. The effect of HPV vaccines is somewhat reduced following HPV exposure [59], which affects

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251 the interests of married females and females who have given birth regarding HPV vaccination. Pregnancy

252 planning, pregnancy, and family economic pressures may also contribute to low HPV vaccination rates among

253 married females [60].

254
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Herein, the HPV vaccination rate of female physicians and nurses in the western regions of China was

255 significantly lower than that in the eastern regions, which may reflect the low economic level, low vaccine
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256 availability [61], and poor awareness and understanding of HPV vaccines [62] among females in the western

257 regions of China.

258 Notably, the HPV vaccination coverage rate of physicians and nurses working in cancer hospitals or

259 departments was the highest compared to that in other types of hospitals or departments. Females working in
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260 obstetrics and gynecology departments also had a high HPV vaccination rate. The greater rates of vaccinations in

261 the cancer and obstetrics departments suggest that physicians and nurses in these departments and hospitals have
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262 better clinical knowledge of cervical cancer and more contact with patients with cervical cancer, leading to higher

263 acceptance of HPV vaccines.

264 Our study has some limitations. First, the sample hospitals were tertiary public hospitals and did not
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265 include primary medical units; thus, the results may not be generalizable to all female Chinese physicians and

266 nurses. Second, recall bias might have affected the responses to the survey because the participants might not have
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267 accurately recalled their vaccination history. Third, as in all cross-sectional studies, the findings cannot explain

268 the causal relationship between HPV vaccination coverage rates and associated factors, which requires further

269 investigation.
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270 Assessing the HPV vaccination status of female healthcare workers has practical implications in

271 identifying knowledge and attitude gaps that may impede vaccination efforts. Interventions and ensuring that

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 272 healthcare professionals possess adequate knowledge and positive attitudes toward HPV vaccination will enable

273 them to deliver accurate health education to females. Therefore, future efforts should focus on assessing and

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274 understanding the barriers to and facilitators of HPV vaccination in the healthcare workforce. In addition,

275 integrating targeted educational programs and effective public health strategies into the National HPV Vaccine

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276 Promotion Program is crucial. This integration will enhance healthcare workers' knowledge about cervical cancer

277 prevention, increasing trust in and acceptance of HPV vaccines among the general public.

278 CONCLUSIONS

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279 In this study, we report, for the first time, the overall self-reported HPV vaccination coverage rate among Chinese

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280 female physicians and nurses. Only 14.45% of participants reported being vaccinated against HPV, indicating

281 lower HPV vaccination rates in this population than in the general population of higher-income countries. Age,

282 marital status, education, region, department, hospital type, and reproductive history were significantly associated
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283 with HPV vaccination coverage, underscoring the need to develop improved strategies that target specific

284 populations. Physicians and nurses play vital roles in promoting HPV vaccination to the public; therefore, they
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285 should increase their awareness and practice of HPV vaccination to increase the number of recommendations,

286 ultimately increasing the vaccination coverage rate.

287

288
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289 Disclaimers:

290 Acknowledgements
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291 This study was supported by the Chinese Academy of Medical Sciences Innovation Fund for Medical Sciences

292 under Grant [2021-I2M-1-046].

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293

294 Author contributions

295 C.P.: concept and design; acquisition, analysis, or interpretation of data; critical revision of the manuscript for
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296 important intellectual content; and statistical analysis. D.Z.: concept and design; drafting of the manuscript; and

297 statistical analysis. J.M.: critical revision of the manuscript for important intellectual content; administrative,

298 technical, or material support; and supervision and final approval of the version to be published. Y.L.: critical
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299 revision of the manuscript for important intellectual content; procurement of funding; administrative, technical, or

300 material support; and supervision and final approval of the version to be published. All authors agree to be
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This preprint research paper has not been peer reviewed. Electronic copy available at: https://ssrn.com/abstract=5345765
 301 accountable for all aspects of the work and have read and approved the final version of the manuscript.

302

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303 Disclosure of interest

304 The authors report there are no competing interests to declare.

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306 Data availability statement

307 All relevant data provided in this study are available from the corresponding authors upon request.

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 308 REFERENCES

309 1. World Health Organization. Cervical cancer elimination initiative; 2020. Available from: . Geneva

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310 2. de Sanjosé S, Diaz M, Castellsagué X, Clifford G, Bruni L, Muñoz N, Bosch FX. Worldwide prevalence
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411 its vaccine among women and medical professionals in Shenzhen analysis. Mod Diagn Treat 2019; 26:3683–4
412 44. Chen LX, Deng HY, Gu D, Zheng H, Meng ZN, Liang JR, et al. Cognition and influencing factors of 2-
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414 city. Henan J Prev Med 2021; 32:594–9
415 45. Yao PX, Ning CX, Xia F, He YF. On the problems and countermeasures in the HPV vaccination service.
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417 46. Ramírez M, de la Fuente J, Andía D, José Hernández J, Fiol G, Torné A. HPV vaccination coverage in
418 women between 15 and 55 years old in Spain: Temporal trend during the period 2007–2020. Int J Gynaecol Obstet
419 2022; 158:705–13
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422 48. Thompson EL, Vamos CA, Vázquez-Otero C, Logan R, Griner S, Daley EM. Trends and predictors of
423 HPV vaccination among U.S. College women and men. Prev Med 2016; 86:92–8
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 425 students. J Community Health 2012; 37:1136–44
426 50. Sow PS, Watson-Jones D, Kiviat N, Changalucha J, Mbaye KD, Brown J, Bousso K, Kavishe B,
427 Andreasen A, Toure M, et al. Safety and immunogenicity of human papillomavirus-16/18 AS04-adjuvanted

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428 vaccine: A randomized trial in 10–25-year-old HIV-Seronegative African girls and young women. J Infect Dis
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431 Nur Azurah AG, Fong SM, et al. Immunogenicity of the 9-valent HPV vaccine using 2-dose regimens in girls and
432 boys vs a 3-dose regimen in women. JAMA 2016; 316:2411–21

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433 52. Basu P, Hassan S, Fileeshia F, Mohamed S, Nahoodha A, Shiuna A, Sulaiman AI, Najeeb N, Saleem
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439 vaccination behavior among medical staff and attendees of immunization clinics in Beijing city. Chin J Public
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441 55. Giambi C, Donati S, Declich S, Salmaso S, Ciofi Degli Atti MLC, Alibrandi MP, Brezzi S, Carozzi F,
442 Collina N, Franchi D, et al. Estimated acceptance of HPV vaccination among Italian women aged 18–26 years.

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443 Vaccine 2011; 29:8373–80
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445 and HPV vaccination: An international comparison. Vaccine 2013; 31:763–9
446 57. Friis K, Lasgaard M, Osborne RH, Maindal HT. Gaps in understanding health and engagement with
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448 citizens. BMJ Open 2016; 6:e009627 er
449 58. Thompson EL, Vamos CA, Sappenfield WM, Straub DM, Daley EM. Relationship status impacts
450 primary reasons for interest in the HPV vaccine among young adult women. Vaccine 2016; 34:3119–24
451 59. Szarewski A, Poppe WAJ, Skinner SR, Wheeler CM, Paavonen J, Naud P, Salmeron J, Chow SN, Apter
452 D, Kitchener H, et al. Efficacy of the human papillomavirus (HPV)-16/18 AS04-adjuvanted vaccine in women
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453 aged 15–25 years with and without serological evidence of previous exposure to HPV-16/18. Int J Cancer 2012;
454 131:106–16
455 60. Li CQ, Sun HJ, Zhang Y. HPV vaccination intention and its influencing factors among women aged 18
456 to 45 years in Changge. J Appl Prev Med 2022; 28:150–2
457 61. You DY, Han LY, Li L, Hu JC, Zimet GD, Alias H, Danaee M, Cai L, Zeng F, Wong LP. Human
458 papillomavirus (HPV) vaccine uptake and the willingness to receive the HPV vaccination among female college
459 students in China: A multicenter study. Vaccines 2020; 8:31
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460 62. Zhao XL, Wang Y, Liu ZH, Duan XZ, Hu SY, Wang YY, et al. Knowledge and its influencing factors
461 of cervical cancer screening and human papillomavirus vaccines among 19201 Chinese population. Chin J Cancer
462 Prev Treat 2022; 29:623–9,49
463
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This preprint research paper has not been peer reviewed. Electronic copy available at: https://ssrn.com/abstract=5345765
 464 Table 1. Characteristics of the 42,800 female doctors and nurses in the national survey

465 Table 2. Factors associated with HPV vaccination status among all female health professionals in the study (N =

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466 42,800).

467 Table 3. Associations between related factors and HPV vaccination coverage rates stratified by occupation.

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468 Figure 1. Flowchart of the patient selection process.

469 Figure 2. Type of HPV vaccine received (N = 6,185). HPV, human papillomavirus.

470 Figure 3. Year the HPV vaccine was received (N = 6,185). HPV, human papillomavirus.

471

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 Table 1. Characteristics of the 42,800 female doctors and nurses in the national survey

ed
All
Doctors Nurses
Characteristic participants N χ2 p-value
N1 = 1,3804 N2 = 2,8996
= 42,800
Age (years)

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18–26 5,256 (12.28) 340 (2.46) 4,916 (16.95) 2,800.000 < 0.001
27–31 13,819 (32.29) 3,777 (27.36) 10,042 (34.63)
32–36 12,721 (29.72) 4,626 (33.51) 8,095 (27.92)
37–45 11,004 (25.71) 5,061 (36.66) 5,943 (20.50)
Marital status

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Never married 10,967 (25.62) 2,747 (19.90) 8,220 (28.35) 351.703 < 0.001

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Married 30,880 (72.15) 10 743 (77.83) 20,137 (69.45)
Divorced/widowed 953 (2.23) 314 (2.27) 639 (2.20)
Education
Associate’s degree or less 4,426 (10.34) er36 (0.26) 4,390 (15.14) 28,000.000 < 0.001
College degree 26,658 (62.29) 2,762 (20.01) 23,896 (82.41)
Master’s degree 8,627 (20.16) 7,925 (57.41) 702 (2.42)
Doctorate degree or higher 3,089 (7.22) 3,081 (22.32) 8 (0.03)
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Self-reported health status
Very poor 553 (1.29) 170 (1.23) 383 (1.32) 846.468 < 0.001
Poor 3,945 (9.22) 1,458 (10.56) 2,487 (8.58)
Regular 23,221 (54.25) 8,471 (61.37) 14,750 (50.87)
Good 11,150 (26.05) 3,103 (22.48) 8,047 (27.75)
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Very good 3,931 (9.18) 602 (4.36) 3,329 (11.48)

Region
East China 18,684 (43.65) 6,122 (44.35) 12,562 (43.32) 4.005 0.135
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Middle China 9,656 (22.56) 3,077 (22.29) 6,579 (22.69)

West China 14,460 (33.79) 4,605 (33.36) 9,855 (33.99)
Department
Internal medicine 10,213 (23.86) 3,301 (23.91) 6,912 (23.84) 2,400.000 < 0.001
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Surgery 6,451 (15.07) 549 (3.98) 5,902 (20.35)

Obstetrics and gynecology 5,944 (13.89) 2,301 (16.67) 3,643 (12.56)
Pediatrics 2,886 (6.74) 1,084 (7.85) 1,802 (6.21)
Emergency
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1,527 (3.57) 270 (1.96) 1,257 (4.34)

Cancer 1,011 (2.36) 307 (2.22) 704 (2.43)
Traditional Chinese
1,863 (4.35) 820 (5.94) 1,043 (3.60)
Medicine
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Others^ 12,905 (30.15) 5,172 (37.47) 7,733 (26.67)

Hospital type
General 14,154 (33.07) 4,116 (29.82) 10,038 (34.62) 360.423 < 0.001

This preprint research paper has not been peer reviewed. Electronic copy available at: https://ssrn.com/abstract=5345765
 Maternal and child health 8,505 (19.87) 3,414 (24.73) 5,091 (17.56)
Traditional Chinese medicine 10,033 (23.44) 3,110 (22.53) 6,923 (23.88)

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Cancer 7,128 (16.65) 2,093 (15.16) 5,035 (17.36)
Other special types* 2,980 (6.96) 1,071 (7.76) 1,909 (6.58)
Reproductive history 182.347 < 0.001
Has no child 15,559 (36.35) 4,390 (31.80) 11,169 (38.52)

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Has already given birth 27,241 (63.65) 9,414 (68.20) 17,827 (61.48)
Data are presented as n (%).
^Includes radiology, anesthesiology, and stomatology departments.
*Includes stomatological, cardiovascular, and plastic surgery hospitals.

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 Table 2. Factors associated with HPV vaccination status among all female health professionals in the

ed
study (N = 42,800).
Number vaccinated Univariable analysis Multivariable analysis
Factor
(%) OR (95% CI) p-value OR (95% CI) p-value
Age (years)

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18–26 1,337/5,256 (25.44) Ref Ref
27–31 2,149/13,819 (15.55) 0.54 (0.50, 0.58) < 0.001 0.60 (0.55, 0.66) < 0.001
32–36 1,543/12,721 (12.13) 0.40 (0.37, 0.44) < 0.001 0.52 (0.47, 0.58) < 0.001
37–45 1,156/11,004 (10.51) 0.34 (0.32 ,0.38) < 0.001 0.45 (0.40, 0.51) < 0.001
Occupation

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Physician 2,064/13,804 (14.95) Ref Ref
Nurse 4,121/28,996 (14.21) 0.94 (0.89, 1.00) 0.042 0.92 (0.83, 1.02) 0.129

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Marital status
Never married 2,457/10,967 (22.40) Ref Ref
Married 3,593/30,880 (11.64) 0.46 (0.43, 0.48) < 0.001 0.76 (0.69, 0.83) < 0.001
Divorced/widowed 135/953 (14.17)
er 0.57 (0.47, 0.69) < 0.001 1.00 (0.82, 1.23) 0.995
Education
Associate’s degree
592/4,426 (13.38) Ref Ref
or less
College degree 3,794/26,658 (14.23) 1.07 (0.98, 1.18) 0.130 1.50 (1.36, 1.66) < 0.001
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Master’s degree 1,286/8,627 (14.91) 1.13 (1.02, 1.26) 0.018 1.68 (1.45, 1.95) < 0.001
Doctorate degree
513/3,089 (16.61) 1.29 (1.13, 1.47) < 0.001 1.89 (1.58, 2.25) < 0.001
or higher
Self-reported health
status
Very poor 63/553 (11.39) Ref Ref
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Poor 540/3,945 (13.69) 1.23 (0.93, 1.63) 0.138 1.17 (0.88, 1.54) 0.287
Regular 3,285/23,221 (14.15) 1.28 (0.98, 1.67) 0.066 1.15 (0.88, 1.50) 0.320
Good 1,662/11,150 (14.91) 1.36 (1.04, 1.78) 0.023 1.13 (0.86, 1.48) 0.372
Very good 635/3,931 (16.15) 1.50 (1.14, 1.97) 0.004 1.23 (0.93, 1.63) 0.140
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Region
East China 2,992/18,684 (16.01) Ref Ref
Middle China 1,436/9,656 (14.87) 0.92 (0.86, 0.98) 0.012 0.95 (0.89, 1.02) 0.167
West China 1,757/14,460 (12.15) 0.73 (0.68, 0.77) < 0.001 0.75 (0.70, 0.80) < 0.001
Department
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Internal medicine 1,269/10,213 (12.43) Ref Ref

Surgery 932/6,451 (14.45) 1.19 (1.09, 1.3) < 0.001 1.10 (1.00, 1.21) 0.044
Obstetrics and
913/5,944 (15.36) 1.28 (1.17, 1.4) < 0.001 1.22 (1.10, 1.36) < 0.001
gynecology
Pediatrics 398/2,886 (13.79) 1.13 (1, 1.27) 0.052 1.10 (0.97, 1.26) 0.146
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Emergency 213/1,527 (13.95) 1.14 (0.98, 1.34) 0.095 1.15 (0.98, 1.35) 0.078
Cancer 169/1,011 (16.72) 1.41 (1.19, 1.69) < 0.001 1.55 (1.30, 1.86) < 0.001
Traditional
218/1,863 (11.70) 0.93 (0.8, 1.09) 0.382 0.92 (0.79, 1.08) 0.300
Chinese medicine
Others 2,073/12,905 (16.06) 1.35 (1.25, 1.45) < 0.001 1.26 (1.16, 1.36) < 0.001
Pr

Hospital type
General 2,069/14,154 (14.62) Ref Ref
Maternal and child
1,290/8,505 (15.17) 1.04 (0.97, 1.13) 0.259 0.96 (0.88, 1.05) 0.407
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This preprint research paper has not been peer reviewed. Electronic copy available at: https://ssrn.com/abstract=5345765
 Traditional
1,038/10,033 (10.35) 0.67 (0.62, 0.73) < 0.001 0.68 (0.62, 0.73) < 0.001
Chinese medicine

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Cancer 1,243/7,128 (17.44) 1.23 (1.14, 1.33) < 0.001 1.23 (1.13, 1.33) < 0.001
Other special types 545/2,980 (18.29) 1.31 (1.18, 1.45) < 0.001 1.12 (1, 1.25) 0.049
Reproductive history
Has no child 3,222/15,559 (20.71) Ref Ref
Has already given
2,963/27,241 (10.88) 0.47 (0.44, 0.49) < 0.001 0.72 (0.65, 0.79) < 0.001
birth

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HPV, human papillomavirus; OR, odds ratio; CI, confidence interval; Ref, reference.

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 Table 3. Associations between related factors and HPV vaccination coverage rates stratified by occupation.
Physicians (N1 = 13,804) Nurses (N2 = 28,996)
Factor Number Number

ed
OR (95% CI) p-value OR (95% CI) p-value
vaccinated (%) vaccinated (%)
Age (years)
1,225/4,916
18–26 112/340 (32.94) Ref Ref
(24.92)
0.58 (0.45, 1,381/10,042

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27–31 768/3,777 (20.33) < 0.001 0.58 (0.52, 0.64) < 0.001
0.75) (13.75)
0.43 (0.33,
32–36 633/4,626 (13.68) < 0.001 910/8,095 (11.24) 0.54 (0.48, 0.61) < 0.001
0.57)
0.36 (0.27,
37–45 551/5,061 (10.89) < 0.001 605/5,943 (10.18) 0.50 (0.43, 0.57) < 0.001
0.47)
Marital status
1,797/8,220
Never married 660/2,747 (24.03) Ref Ref

v
(21.86)
1,352/10,743 0.71 (0.61, 2,241/20,137
Married < 0.001 0.78 (0.69, 0.88) < 0.001
(12.58) 0.83) (11.13)

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1.04 (0.75,
Divorced/widowed 52/314 (16.56) 0.796 83/639 (12.99) 0.96 (0.75, 1.24) 0.770
1.46)
Education
Associate’s degree or
5/36 (0.24) Ref 587/4,390 (13.37) Ref
less
1.10 (0.40, 3,423/23,896
College degree 371/2,762 (13.43)
er 3.02)
1.21 (0.44,
0.855
(14.32)
1.48 (1.34, 1.64) < 0.001

Master’s degree 1,176/7,925 (14.84) 0.712 110/702 (15.67) 1.79 (1.42, 2.26) < 0.001
3.31)
Doctorate degree or 1.38 (0.50,
512/3,081 (16.62) 0.534 1/8 (12.5) 1.49 (0.18, 12.38) 0.710
pe
higher 3.79)
Self-reported health status
Very poor 21/170 (12.35) Ref 42/383 (1.02) Ref
1.04 (0.64,
Poor 202/1,458 (13.85) 0.875 338/2,487 (13.59) 1.22 (0.87, 1.73) 0.250
1.69)
1.02 (0.64, 2,042/14,750
Regular 1,243/8,471 (14.67) 0.922 1.19 (0.86, 1.65) 0.304
1.63) (13.84)
ot

1.00 (0.62, 1,166/8,047

Good 496/3,103 (15.98) 0.988 1.17 (0.84, 1.63) 0.348
1.61) (14.49)
1.08 (0.64,
Very good 102/602 (16.94) 0.782 533/3,329 (16.01) 1.29 (0.92, 1.82) 0.137
1.80)
tn

Region
1,972/12,562
East China 1,020/6,122 (16.66) Ref Ref
(15.7)
0.86 (0.76,
Middle China 442/3,077 (14.36) 0.023 994/6,579 (15.11) 1.00 (0.91, 1.08) 0.912
0.98)
rin

0.76 (0.68, 1,155/9,855

West China 602/4,605 (13.07) < 0.001 0.74 (0.69, 0.81) < 0.001
0.86) (11.72)
Department
Internal medicine 425/3,301 (12.87) Ref 844/6,912 (12.21) Ref
1.24 (0.97,
Surgery 97/549 (17.67) 0.093 835/5,902 (14.15) 1.09 (0.98, 1.21) 0.097
1.59)
ep

Obstetrics and 1.34 (1.13,

364/2,301 (15.82) 0.001 549/3,643 (15.07) 1.16 (1.01, 1.32) 0.034
gynecology 1.59)
1.20 (0.97,
Pediatrics 154/1,084 (14.21) 0.092 244/1,802 (13.54) 1.04 (0.88, 1.23) 0.650
1.49)
0.72 (0.47,
Emergency 25/270 (9.26) 0.131 188/1,257 (14.96) 1.25 (1.05, 1.48) 0.013
Pr

1.10)
1.45 (1.042,
Cancer 50/307 (16.29) 0.027 119/704 (16.9) 1.59 (1.28, 1.97) < 0.001
2.01)
Traditional Chinese 0.81 (0.63,
86/820 (10.49) 0.089 132/1,043 (12.66) 1.02 (0.84, 1.25) 0.823
medicine 1.03)

This preprint research paper has not been peer reviewed. Electronic copy available at: https://ssrn.com/abstract=5345765
 1.27 (1.11, 1,210/7,733
Others 863/5,172 (16.69) < 0.001 1.25 (1.13, 1.38) < 0.001
1.45) (15.65)
Hospital type

ed
1,421/10,038
General 648/4,116 (15.74) Ref Ref
(14.16)
Maternal and child 0.85 (0.73,
503/3,414 (14.73) 0.029 787/5,091 (15.46) 1.03 (0.92, 1.16) 0.555
health 0.98)
Traditional Chinese 0.60 (0.51,

iew
315/3,110 (10.13) < 0.001 723/6,923 (10.44) 0.71 (0.65, 0.79) < 0.001
medicine 0.69)
1.26 (1.09,
Cancer 401/2,093 (19.16) 0.002 842/5,035 (16.72) 1.21 (1.10, 1.34) < 0.001
1.45)
1.05 (0.88,
Other special types 197/1,071 (18.39) 0.573 348/1,909 (18.23) 1.15 (1.00, 1.32) 0.044
1.27)
Reproductive history
2,263/11,169
Has no child 959/4,390 (21.85) Ref Ref

v
(20.26)
0.77 (0.66, 1,858/17,827
Has already given birth 1,105/9,414(11.74) 0.001 0.71 (0.63, 0.79) < 0.001
0.89) (10.42)

re
HPV, human papillomavirus; OR, odds ratio; CI, confidence interval; Ref, references.

er
pe
ot
tn
rin
ep
Pr

This preprint research paper has not been peer reviewed. Electronic copy available at: https://ssrn.com/abstract=5345765
 ed
Figure 1.

iew
r ev
er
pe
ot
tn
rin
ep
Pr

This preprint research paper has not been peer reviewed. Electronic copy available at: https://ssrn.com/abstract=5345765
 ed
Figure 2.

iew
r ev
er
pe
ot
tn
rin
ep
Pr

This preprint research paper has not been peer reviewed. Electronic copy available at: https://ssrn.com/abstract=5345765
 ed
Figure 3.

iew
r ev
er
pe
ot
tn
rin
ep
Pr

This preprint research paper has not been peer reviewed. Electronic copy available at: https://ssrn.com/abstract=5345765