This study was conducted from June 16 to July 16, 2024, at Guangdong Medical University in Dongguan, China. This study employed a convenience sampling method to conduct a cross-sectional survey on the Chinese online survey platform “Wenjuanxing”.¹ The questionnaire was distributed to full-time students through WeChat. The inclusion criteria were as follows: (1) full-time enrolled students; (2) completion and successful submission of all mandatory questionnaire items, excluding questions skipped due to branching logic. The exclusion criteria were as follows: (1) a response time of less than 180 s; (2) inconsistencies in and illogical responses to some answers; and (3) failure to provide accurate academic and professional information.

The sample size was calculated a priori using the following formula on the basis of an error α of 0.05 and a permissible error δ of 0.05:

Where n represents the sample size required for the survey, Z 1 − α / 2 2 is the standard normal deviation of α, and p denotes the expected prevalence or positive rate of the survey, specifically referring to the HPV vaccination rates among Chinese college students. In this study, the proportion p was conservatively set at 0.5 to ensure the calculation of the largest minimum sample size. To account for the potential impact of invalid questionnaires, the sample size for this study was conservatively increased by 20%. Consequently, the final minimum sample size was 461 male and 461 female college students, resulting in a total minimum sample size of 922 participants.

A total of 5,384 individuals participated in the survey. After 456 responses (199 due to completion time <180 s; 45 for logical inconsistencies; 212 for unverifiable academic/professional information) were excluded, 4,928 valid questionnaires were retained (validity rate: 91.53%). Among these, 3,297 were female and 1,631 were male college students.

The study was conducted in accordance with the Declaration of Helsinki and approved by the Clinical Research Ethics Committee of the Affiliated Hospital of Guangdong Medical University (Approval No. PJKT2023-126). The study participants read and signed an online informed consent form. Potential study participants were informed that participation in the study was voluntary and that they could withdraw their decision to participate at any time.

Survey data were collected via the “Wenjuanxing” platform (see Footnote 1), which provides direct export functionality to SPSS Statistics Data Files (.sav format). After the exclusion, invalid samples were removed according to the predefined exclusion criteria. The curated dataset was subsequently analyzed via SPSS version 28.0 (IBM Corporation, Armonk, NY, USA). Continuous variables are presented as the means ± SDs, and categorical variables are presented as n (%). Univariable analyses were used to assess associations between variables (demographics, HPV knowledge, HL, and various dimensions of VHS) and college students’ WTP for the HPV vaccine. For univariable analyses, continuous variables were compared via independent samples t tests or analysis of variance (ANOVA); categorical variables were analyzed via Pearson’s chi-square tests; for nonnormally distributed data, Mann–Whitney U tests or Kruskal–Wallis tests were applied. The variables with p < 0.05 in the univariable analyses were entered into a binary logistic regression model to identify independent predictors of college students’ WTP for the HPV vaccine. Adjusted odds ratios (ORs) with 95% confidence intervals (CIs) were computed, with statistical significance set at p < 0.05. Finally, Nagelkerke’s R² was used to assess the goodness-of-fit of the binary logistic regression model.

In this study, 66.9% (n = 3,297) of the participants were female and 33.1% (n = 1,631) were male college students. The mean age of the respondents was 20.69 ± 1.78 years. Among them, 55.2% (n = 2,721) resided in rural areas, 74.0% (n = 3,666) were medical-related majors, and 66.2% (n = 3,266) were enrolled in government health insurance programs. Additionally, 77.8% (n = 3,835) reported an average monthly consumption between 1,000 and 2,000 CNY (i.e., $140.65–$281.29, exchange rate benchmark date: June 16, 2024, converted at 1 USD = 7.11 CNY, hereinafter the same). Awareness of HPV was notably high, with 97.6% (n = 4,814) of participants reporting familiarity with the virus.

Furthermore, 78.2% (n = 3,852) expressed a willingness to receive the HPV vaccine, whereas 28.8% (n = 1,344) had either been vaccinated or had scheduled an appointment for vaccination (Table 1).

College students demonstrated marginally suboptimal HPV knowledge (mean = 12.44 ± 2.95 vs. passing the threshold of 12.8) and high eHL levels (overall mean = 31.65 ± 5.12; item-level mean = 3.96 > 3–a cutoff value) (Table 1).

VHS analysis revealed distinct characteristics across dimensions: the necessity dimension demonstrated a mean score of 7.25 ± 3.16, which was below the critical threshold of 12. The importance dimension had significantly higher scores (20.69 ± 3.32), exceeding the critical threshold of 15. Notably, the safety dimension had a mean score of 10.54 ± 2.58, which was higher than the critical threshold of 9 (Table 1).

This survey revealed that 67.6% (n = 3,329) of the college students were willing to pay for the HPV vaccine out of pocket. Among them, 87.2% (n = 2,902) preferred to receive the nine-valent HPV vaccine (imported) (Figure 1).

Table 3 reveals notable differences in college students’ WTP and APRs (calculated between the lowest and highest price points) for various HPV vaccines. Specifically, the APRs (in CNY) identified for the bivalent HPV vaccine (domestic), bivalent HPV vaccine (imported), quadrivalent HPV vaccine (imported), and nine-valent HPV vaccine (imported) were [308.75, 459.72] [i.e., ($43.42, $64.66)], [510, 683.33] [i.e., ($71.73, $96.11)], [804.81, 995] [i.e., ($113.19, $139.94)], and [942.42, 1204.8] [i.e., ($132.55, $169.46)], respectively. The OPPs (equivalent ‘too cheap/too expensive’ perception proportions at this price) of these HPV vaccines were 376.67 CNY ($52.98), 610.00 CNY ($85.79), 877.50 CNY ($123.42), and 1061.19 CNY ($149.25), respectively. Notably, the market price of the nine-valent HPV vaccine (imported) was 1331.00 CNY (i.e., $187.20), which exceeds the APR for the college student population, whereas the market prices of the other vaccines fall within the acceptable range.

Additionally, to more clearly understand male college students’ price sensitivity toward different HPV vaccines, 4 cumulative response curves were generated from the data. Plots of the data for the van Westendorp PSM are presented in Figure 2.

For example, for the nine-valent HPV vaccine (imported), the APR (in CNY) was [942.42, 1204.8] [i.e., ($132.55, $169.46)]; that is, while consumers would consider a price higher than 1204.8 CNY ($169.46) to be too expensive, a price lower than 942.42 CNY ($132.55) would likewise imply considerable loss of potential consumers owing to their concerns about the quality of the product. The current market price of 1,331 CNY represents a 126.2 CNY ($17.75) premium over the maximum affordable price threshold for college students (1,204.8 CNY), demonstrating a significant affordability barrier. Furthermore, we found that the OPP (the intersection of the “too cheap” and “too expensive” curves) was approximately 3.5%, which means that 96.5% of the participants believe that when the price is approximately 1061.19 CNY ($149.25), it is neither too expensive nor too cheap. Moreover, at the OPP, provider sustainability and universal coverage requirements are balanced. The current market price exceeds the balance point by 269.81 CNY ($37.95), demonstrating a significant price premium. The APP (the intersection of the “cheap” and “expensive” curves) was 1069.1 CNY ($150.37), indicating that at this price point, the number of consumers who perceive the price is slightly equal to the number who view it as good value (Figure 2).

Notably, with respect to price sensitivity, customers exhibit heightened responsiveness to price variations when the APP and OPP of a product converge. This observation revealed that the nine-valent vaccine (imported) demonstrated the highest sensitivity among the four comparable HPV vaccine products.

This study reveals a critical paradox in HPV vaccine uptake among Chinese college students. Despite a high willingness to receive (78.2%) and pay for the HPV vaccine (67.6% willing to self-fund), the actual vaccination rate remains notably low (28.8%), underscoring a substantial gap between intention and action. This observed intention–behavior gap is a hallmark of vaccine hesitancy, a complex and globally recognized phenomenon (25, 26). These findings are consistent with previous studies in China reporting similar disparities in HPV vaccine acceptance versus actual uptake (10, 27–29). Notably, while the magnitude of the gap in our study aligns with national observations, the specific barriers contributing to hesitancy both domestically and internationally (e.g., safety concerns, cost issues, knowledge gaps) need to be analyzed to understand both universal factors and context-specific factors (30, 31). Therefore, there is an urgent need for evidence-based targeted interventions specifically addressing the drivers of HPV vaccine hesitancy to address the persistent disparities between intentions and vaccinations and to increase HPV vaccination rates among college students.

This study revealed that as consumption levels increase, college students’ WTP for HPV vaccines also gradually increases, which aligns with the results of existing research (10, 32). International comparisons revealed similar patterns; studies in Bangladesh and Thailand revealed that HPV vaccine acceptance was significantly positively correlated with income levels (33, 34), whereas young people with higher socioeconomic status in Switzerland also demonstrated greater vaccination uptake (35). Even the relatively low-priced domestic bivalent HPV vaccine represents a considerable expense for college students, however, especially compared with middle- and high-income countries (36). When the vaccine price is within a reasonable range, both the vaccination rate and WTP for the HPV vaccine tend to be relatively high (18), as evidenced by the 90% vaccination rate among countries such as Portugal schoolgirls benefiting from free national immunization programs (36), which contrasts with China’s 14.02% first-dose coverage at most (7). Therefore, policy interventions aimed at reducing vaccine prices may be effective, as demonstrated by the successful implementation of free vaccination programs in 115 countries (36).

Additionally, this study revealed a greater WTP for the HPV vaccine among government-insured participants, which aligns with existing research in China (37) and international findings showing that health insurance in the U.S. greatly increased the likelihood of being vaccinated against HPV (38). Existing evidence shows that insurance enrollment reduces VH-related behaviors by improving perceived necessity and lowering financial barriers (39). Integrating HPV vaccines into medical insurance and prioritizing student enrollment could thus increase uptake through cost reduction and preventive health reinforcement.

The results of this study confirm that HL and HPV knowledge positively predict WTP for HPV vaccination. This finding aligns with several national and international studies reporting similar positive associations between HL, vaccine knowledge, and willingness to accept various vaccinations, including HPV (40–42). Research has shown that HL is associated with healthier behaviors and vaccination uptake (43, 44). Additionally, students with greater HPV knowledge demonstrated higher HL levels (45). Greater HL and HPV knowledge improves the understanding of the benefits and risks of the HPV vaccine, reduces misconceptions and vaccine hesitancy, and increases the WTP for preventative strategies. Targeted education that improves HPV knowledge simultaneously improves HL, suggesting that dual-focused interventions could effectively increase vaccine acceptance rates.

The study revealed that the perceived necessity for HPV vaccination most significantly influenced college students’ WTP, which aligns with previous studies’ findings (9, 39, 46). Notably, this phenomenon mirrors vaccine hesitancy patterns observed among Chinese guardians of adolescents, where 21.1% delayed vaccination due to uncertainty about necessity (22). In this study, while most participants recognized its importance, those dismissing vaccination due to a perception of strong immunity or good health or a lack of government mandate showed a reduced WTP. Cross-nationally, European studies indicate that “complacency” (e.g., low risk perception) contributes to 38% of hesitant individuals maintaining refusal status over time, particularly in populations with high education levels (47). Campus education should emphasize that the risk of HPV infection is not determined by individual health and should promote the value of vaccination despite the absence of mandatory programs.

The importance dimension significantly and positively influenced college students’ WTP for the HPV vaccine, which aligns with the findings of previous studies (10). The central role of perceived importance in driving WTP resonates with broader international findings on vaccine confidence frameworks, particularly the WHO’s Behavioral and Social Drivers (BeSD) model, where belief in a vaccine’s effectiveness, personal relevance, and perceived importance serve as critical global determinants influencing vaccination decisions (48). Specifically, college students who perceived that the HPV vaccine effectively prevents diseases such as cervical cancer and improves both their own health and their family’s health reported a greater WTP. Within the domestic context, studies among guardians of adolescents also highlight that recognizing the importance of vaccines significantly reduces hesitancy (22). Promoting awareness of the personal and societal benefits of the vaccine remains crucial.

College students’ concerns about the safety of the HPV vaccine negatively impacted their WTP. Despite robust evidence supporting the safety and efficacy of the vaccine, public apprehension remains prevalent (22, 49, 50). Safety concerns are the primary factor contributing to vaccine hesitancy, which is not only prevalent among this student population but has also been widely reported in domestic studies (e.g., concerns about side effects remain a major barrier) (28, 51, 52) and is internationally recognized as one of the key pillars of the “3C” model of vaccine hesitancy (complacency, convenience, confidence) (50, 53). Increasing trust in vaccine safety and healthcare expertise is vital for improving vaccination rates.

van Westendorp PSM analysis revealed that while the market prices of other vaccine types generally aligned with the APRs, multiple studies internationally and within China have confirmed that the nine-valent vaccine consistently exceeds both optimal pricing thresholds and affordability limits for consumers, including college students (19, 54, 55). Consistent with patterns observed in other countries (56), comparative surveys in China have revealed that domestic vaccines maintained lower acceptable prices (CNY 910.63–2,866.96) than their imported counterparts did (CNY 1,689.80–3,252.43) (57). Notably, a 2021 national survey of healthcare workers reported median willingness-to-pay values (CNY 1,250–1,400) that were below the prevailing market prices (58). Although historical price acceptability gaps have narrowed for most HPV vaccines since 2018 (27), mirroring trends seen elsewhere as vaccine markets mature (59), the nine-valent vaccine continues to demonstrate persistent market price resistance in the Chinese context. This suggests sustained consumer sensitivity to its premium pricing strategy and that appropriate price reductions may significantly boost the uptake of the nine-valent vaccine.

The van Westendorp PSM effectively quantified HPV vaccine price sensitivity and consumer value perceptions, enabling the development of precise pricing strategies for policymakers. To increase accessibility, government interventions should prioritize cost-optimized subsidies to integrate the nine-valent HPV vaccine into medical insurance schemes, thereby mitigating persistent affordability disparities. According to the results of our econometric analysis, we propose a tiered subsidy framework targeting college students: (1) a compensation of 269.81 CNY ($37.95) to achieve near-OPP thresholds or (2) a minimum subsidy of 126.20 CNY ($17.75) ensuring expenditure alignment with the APRs derived from the van Westendorp PSM.