This cross-sectional study was conducted from October 1 to November 20, 2024. The research team sent out electronic questionnaires through the online platform “Questionnaire Star” and collected data.¹ The survey period aligned with the academic calendar to maximize participation and minimize disruptions during examinations (11, 12). The survey was administered and monitored by trained research assistants, with follow-up reminders sent weekly to non-respondents.

The questionnaire was designed using validated scales adapted to the sociocultural context of China. It comprised three sections:

(1) Demographics: Age, education level (associate degree, undergraduate, postgraduate), household registration (urban/rural), academic major (medical/non-medical), and only-child status.

(2) Reproductive Health Status (6): Validated scales assessed dysmenorrhea (Cronbach’s = 0.79), irregular menstruation (α = 0.82), and breast disease (α = 0.81).

(3) Health Education and HPV Vaccine Hesitancy: The WHO Vaccine Hesitancy Scale was culturally adapted through forward-backward translation and pilot testing (α = 0.77). Health education participation was measured using a 5-point Likert scale.

The WHO scale underwent forward-backward translation by bilingual public health experts and cultural adaptation via focus group discussions (n = 20). Pilot testing (n = 100) informed revisions to ambiguous terms (e.g., “vaccine safety”). Exploratory factor analysis (EFA) with Promax rotation identified three latent factors: reproductive health knowledge (α = 0.79), healthcare access perceptions (α = 0.82), and digital literacy (α = 0.71). Confirmatory factor analysis (CFA) confirmed model fit (RMSEA = 0.06, CFI = 0.93, TLI = 0.91).

A nationally representative sample of 1,050 female college students was recruited from 12 provinces in China (Fujian, Guangdong, Sichuan, Henan, Zhejiang, Shandong, Liaoning, Yunnan, Shaanxi, Jiangsu, Hubei, and Heilongjiang), selected via stratified random sampling to reflect geographic diversity (coastal vs. inland) and urban–rural population distribution (urban: 62.9%, rural: 37.1%). The 37.1% rural sample proportion aligns with the 2023 National Census showing 36.7% of college students holding rural household registration (χ² = 0.21, p = 0.646). The sample size was calculated based on a 95% confidence level (Z = 1.96), an expected prevalence of reproductive health issues of 50% (to maximize variability), and a margin of error of ±3%, resulting in a minimum requirement of 1,067 participants. Our final sample (n = 1,013) aligns closely with this target. Provinces were stratified based on the National Bureau of Statistics’ classification of socioeconomic development tiers (Tier 1 to Tier 3). This approach ensured proportional representation of China’s diverse student population, covering key demographic variables such as household registration (urban/rural), academic major (medical/non-medical), and education level. To address potential clustering effects, multilevel logistic regression was applied (school-level ICC = 0.19), which statistically adjusts for intra-cluster correlations and enhances the generalizability of findings to the broader population of CFCs. Similar sampling strategies with comparable sample sizes (n ≈ 1,000) have been validated in nationally representative studies on youth health behaviors (10, 13). Of 1,050 distributed questionnaires, 1,013 valid responses were retained (96.5% response rate). Participants’ mean age was 20.4 years (SD = 1.8), with balanced representation of medical (48.9%) and non-medical majors (51.1%).

Inclusion Criteria: Full-time female students aged 18–30 years. Willingness to provide informed consent. Ability to complete the questionnaire independently.

Exclusion Criteria: Withdrawal during study. Incomplete or inconsistent responses (e.g., missing data >10%).

Data was analyzed using IBM SPSS Statistics 22.0 integrated with R 4.2.3. Missing values (<2.1% per variable) were addressed via multiple imputation. Missing data (<2.1% per variable) were imputed using fully conditional specification (FCS) via the R `mice` package, with 10 iterations and predictive mean matching. Descriptive statistics included frequencies with Wilson score 95% confidence intervals (CIs). Group differences were assessed using Pearson’s χ² tests (Yates ‘correction where appropriate) and Fisher’s exact tests. Multivariable logistic regression models adjusted for age, household registration, and academic major, with results reported as adjusted odds ratios (aORs) and 95% CIs. Intraclass correlation coefficients (ICC) confirmed significant school-level clustering (ICC = 0.19, p < 0.001), justifying multilevel modeling. Model adequacy was verified via Hosmer–Lemeshow goodness-of-fit tests (p > 0.05) and variance inflation factors <1.8. The Benjamini-Hochberg procedure controlled the false discovery rate (FDR = 0.05). Statistical significance was set at two-tailed p < 0.05. Missing data mechanisms were verified using Little’s MCAR test (χ² = 12.34, p = 0.195), supporting the missing-at-random assumption. Multiple imputation was performed with 20 iterations using predictive mean matching.

Approval was obtained from the Institutional Review Boards of Xiamen Donghai Institute (No. XDHI-2024-033) and Pingshan District Central Hospital (No. PSCH-2024-112). All participants provided written informed consent, and data were anonymized.

The cross-sectional design was selected to capture contemporaneous associations between sociodemographic factors and reproductive health outcomes. Stratified sampling ensured representation of China’s urban–rural divide and academic diversity. The inclusion of medical and non-medical students facilitated comparative analyses of health literacy impacts. Ethical compliance and rigorous statistical methods aligned with international standards for reproducibility and validity.

Table 1 presents the demographic characteristics of 1,013 participants. The sample was predominantly composed of undergraduates (47.2%) and associate-degree students (48.3%), with limited representation of postgraduates (4.5%). Urban students (62.9%) and only children (56.7%) were overrepresented, reflecting China’s urban-centric higher education distribution (14). Medical and non-medical majors were balanced (48.9% vs. 51.1%), enabling comparative analyses.

Table 2 highlights the prevalence of reproductive health disorders: dysmenorrhea (48.5, 95% CI: 45.4–51.6), breast disease (38.8%, 35.8–41.9), and irregular menstruation (36.1%, 33.1–39.1). Emotional instability (49.5%) and lower abdominal pain (48.7%) were the most frequent menstrual symptoms. These rates correspond to global trends but surpass those in high-income Asian countries (6). This pattern is consistent with stress-mediated physiological responses documented in academic cohorts (15).

Table 3 reveals that only 46.1% of students participated in health education programs, with online platforms dominating health information access (52.4%). This discrepancy mirrors institutional shortcomings in health promotion delivery. Online platforms dominated health information access (52.4%), raising concerns about misinformation risks (16). Moreover, the data shows that the participants’ preferred health topics are healthy sexual behavior.

Table 4 highlights that 62.6% of CFCs are vaccinated against HPV, while 37.4% remain unvaccinated due to concerns about side effects (45.4%), fear of injection pain (37.4%), and financial constraints, with only 32.5% willing to self-fund the vaccine.

Table 5 delineates significant sociodemographic determinants of reproductive health outcomes among CFCs. Multivariate analysis revealed that postgraduate students exhibited substantially higher dysmenorrhea prevalence compared to undergraduates (60.9% vs. 50.8%; aOR = 1.6, 95% CI: 1.2–2.1), potentially attributable to cumulative academic stressors, particularly those associated with postgraduate entrance examinations (17). Furthermore, rural household registration emerged as a significant risk factor, with rural students demonstrating elevated rates of both dysmenorrhea (56.9% vs. 43.5%; aOR = 1.8, 95% CI: 1.4–2.3) and irregular menstruation (50.8% vs. 27.5%; aOR = 2.1, 95% CI: 1.7–2.6), likely reflecting systemic disparities in healthcare access and nutritional deficiencies (18). Notably, academic major demonstrated a significant association with breast disease prevalence, with non-medical students exhibiting higher rates compared to their medical counterparts (46.1% vs. 31.1%; aOR = 1.9, 95% CI: 1.5–2.4), thereby underscoring the protective role of medical literacy in fostering preventive health behaviors. These findings collectively highlight the complex interplay between sociodemographic factors and reproductive health outcomes in this population.

Tables 6–9 analyze HPV vaccination disparities. Urban students had significantly higher vaccination rates (78.5% vs. 45.7%, aOR = 4.3), consistent with socioeconomic gradients in vaccine accessibility (13). Medical students exhibited lower uptake (58.0% vs. 74.3%, aOR = 2.1), contradicting health literacy assumptions but aligning with clinical skepticism about vaccine safety (19). Rural students prioritized low-cost options (χ² = 136.21, p < 0.001), highlighting financial barriers (18).

Table 6 reveals significant disparities in HPV vaccination behaviors and perceptions among CFCs (all p < 0.01). The analysis highlights three critical dimensions: vaccination uptake, awareness of adverse events, and willingness for self-funded vaccination. As shown in Table 6, medical students demonstrated lower HPV vaccination rates despite higher awareness of adverse events (58.0% vs. 74.3%, p < 0.001), suggesting a paradox between knowledge and behavior.

Table 7 reveals significant associations between household registration, only child status, academic major and HPV vaccination uptake (p < 0.001 for all predictors).

Table 8 shows adjusted associations between demographics and self-financed HPV vaccine hesitancy among 566 CFCs. Academic major was a key predictor (Wald = 25.444, p < 0.001), with medical students less hesitant than non-medical students (OR = 0.519, 95% CI: 0.402–0.670), likely due to higher health literacy. Household registration (p = 0.107) and only-child status (p = 0.230) were not significant, though urban students trended toward higher hesitancy (OR = 1.262, 95% CI: 0.951–1.675). These findings emphasize the role of academic background in vaccine decisions and highlight the need for targeted interventions for non-medical students, aligning with global evidence on health literacy’s impact.

Table 9 provides valuable insights into the sociodemographic determinants of HPV vaccine cognition among CFCs. Education level shows significant associations with all HPV vaccine cognition variables (p < 0.001). Higher education levels likely correlate with better vaccine awareness and trust, consistent with global studies (20, 21). Rural students distrusted domestic vaccines (χ² = 145.24, p < 0.001), while urban students preferred imported vaccines. Urban–rural disparities are evident, with urban students demonstrating higher trust in imported vaccines (χ² = 136.01, p < 0.001) and greater price acceptance (χ² = 26.18, p < 0.001). This aligns with the urban–rural healthcare divide in China. Only children exhibit higher trust in domestic vaccines (χ² = 145.24, p < 0.001) and perceived vaccine efficacy (χ² = 171.42, p < 0.001). This may reflect parental investment in healthcare for only children, a phenomenon unique to China’s one-child policy era. Non-medical students deemed the 9-valent HPV vaccine prohibitively expensive (χ² = 102.22, p < 0.001). Medical students show higher trust in medical recommendations (χ² = 10.82, p = 0.029) and lower hesitancy toward HPV vaccination (χ² = 16.19, p = 0.003). This underscores the protective role of medical literacy in health decision-making.

Health education plays a pivotal role in shaping reproductive health behaviors and outcomes among female college students. This section synthesizes data from Tables 1–9 to provide a comprehensive analysis of the current state of health education, its impact on reproductive health, and the challenges and opportunities for improvement.

Table 3 reveals a significant disparity between the demand for health education and actual participation. While 82.4% of participants endorsed the need for mandatory health education courses, only 46.1% reported participating in such programs. Students expressed a strong interest in specific reproductive health topics, including sexual physiology and development (43.2%), healthy sexual behavior (42.1%), and sexual psychology (41.5%). These preferences underscore the need for targeted educational interventions that align with students’ interests and address gaps in knowledge. The primary source of health knowledge for students was online platforms (52.4%), followed by books (25.1%), peers (7.9%), family (6.9%), and school (4.5%).

Table 9 highlights the role of health education in addressing vaccine hesitancy, particularly for the HPV vaccine. Despite higher awareness of adverse events among medical students (χ² = 17.23, p < 0.001), their HPV vaccination rates were lower (58.0% vs. 74.3%, aOR = 2.1). Urban–rural disparities in vaccination were evident, with urban students having higher HPV vaccination rates and greater trust in imported vaccines. Rural students were more likely to accept low-cost options, reflecting financial barriers.

Demographic disparities: Urban–rural and educational gradients profoundly shape reproductive health outcomes among CFCs.

Structural barriers: Limited healthcare access, financial constraints, and institutional neglect exacerbate reproductive health risks, particularly for rural and non-medical students.

Health education gaps: A significant mismatch between demand for health education and actual participation rates, coupled with the prevalence of digital misinformation, undermines effective reproductive health management.

The high prevalence of dysmenorrhea (48.5%), breast disease (38.8%), and irregular menstruation (36.1%) mirrors global patterns among young women, yet the pronounced urban–rural and educational gradients highlight systemic inequities. Postgraduate students exhibited the highest dysmenorrhea rates (60.9%, aOR = 1.6), a finding consistent with studies linking prolonged academic stress to hypothalamic–pituitary–adrenal axis dysregulation (8). The pressure to secure postgraduate admission and competitive careers in China’s high-stakes education system may exacerbate physiological stress, underscoring the need for institutional mental health support (17).

Rural students faced elevated risks of dysmenorrhea (56.9% vs. 43.5%, aOR = 1.8) and irregular menstruation (50.8% vs. 27.5%, aOR = 2.1), reflecting structural barriers such as limited access to gynecological care and nutritional deficiencies (14). Rural healthcare infrastructure in China remains underdeveloped, with fewer specialists and preventive programs compared to urban centers (22). This disparity aligns with global evidence that low-resource settings perpetuate reproductive health inequities through delayed diagnoses and inadequate treatment (18).

The paradox of medical students’ lower HPV vaccination rates (58.0% vs. 74.3%, aOR = 2.1) challenges the assumption that health literacy uniformly promotes preventive behaviors, this aligns with Larson, who found that healthcare professionals’ heightened awareness of rare adverse events may foster hesitancy (19). In China, this phenomenon may be intensified by media coverage of vaccine scandals (e.g., the 2018 Changchun Changsheng vaccine incident), which eroded public trust in domestic pharmaceuticals (13). The medical students’ paradox may reflect the ‘Changsheng vaccine crisis effect’ – 68% of participants recalled media coverage of the 2018 vaccine scandal, potentially amplifying risk perception among clinically trained individuals (10). To address this, medical curricula should integrate modules on risk communication, emphasizing population-level benefits of vaccination over individual-level risks. While medical training enhances knowledge, it may also foster hyper-awareness of rare adverse events, echoing findings that healthcare workers exhibit heightened vaccine hesitancy due to clinical skepticism (19).

Urban–rural divides in HPV vaccination (78.5% vs. 45.7%, aOR = 4.3) and trust in vaccines (79.3% urban vs. 20.7% rural for imported vaccines) reflect broader socioeconomic stratification. Rural students’ reliance on low-cost options (59.2% accepted ≤1,000 RMB vaccines) underscores financial barriers, consistent with studies in low-income populations where cost outweighs perceived benefits (23). The urban–rural disparity in HPV vaccination mirrors trends in India (24) but exceeds rates in South Korea (25), highlighting China’s unique structural barriers, likely due to the hukou system’s healthcare access restrictions. Contrary to expectations, medical students’ lower HPV vaccination rates (58.0% vs. 74.3%) mirror findings among US healthcare workers, suggesting clinical training may amplify risk perception (19). These findings emphasize the need for tiered pricing or subsidies to align vaccine accessibility with socioeconomic realities (2).

The stark mismatch between health education demand (82.4%) and participation (46.1%) signals systemic failures in program design and delivery. Passive online resources dominate health information access (52.4%), yet digital platforms are rife with unverified content, as seen in studies of menstrual health misinformation on social media (16). This paradox—high digital engagement but low formal participation—calls for interactive, peer-led education models that resonate with Gen Z’s media consumption habits (26).

Rural students’ reliance on family for menstrual knowledge (62.9%) perpetuates intergenerational gaps in reproductive health literacy. In contrast, urban students’ use of digital resources (55.7%) risks exposure to commercialized or inaccurate content. These patterns align with the Health Belief Model (HBM), where cues to action (e.g., family advice) and perceived barriers (e.g., mistrust in online information) shape health behaviors (7, 27). To address this, schools should collaborate with trusted community figures (e.g., local healthcare workers) to deliver culturally sensitive education (13).

To address the gaps in health education the following strategies are recommended. These strategies aim to improve reproductive health outcomes.

Institutional Reforms: Universities should prioritize the development of comprehensive, culturally adapted health education programs that address students’ specific needs and preferences. Programs should be mandatory and integrated into the curriculum to ensure broader participation and consistent delivery (28).

Digital Literacy Enhancement: Given the reliance on online platforms, initiatives to enhance digital literacy are crucial. Universities should provide training on how to critically evaluate online health information and distinguish between credible and unreliable sources.

Targeted Interventions: Health education programs should be tailored to address the unique needs of different student groups, particularly rural household registration and non-medical academic major students. This could include workshops, peer education programs, and partnerships with healthcare providers to deliver accurate and accessible information (21).

Vaccine Education and Accessibility: Efforts to reduce vaccine hesitancy should include educational campaigns that address common misconceptions and fears about vaccines. Additionally, financial assistance programs, such as subsidies or tiered pricing, should be implemented to improve vaccine accessibility, particularly for rural students.

Monitoring and Evaluation: Regular monitoring and evaluation of health education programs are essential to ensure their effectiveness and identify areas for improvement. Feedback from students should be actively sought and used to refine program content and delivery methods.

By implementing these strategies, universities can enhance the effectiveness of health education programs, ultimately improving reproductive health outcomes for female college students.

Targeted Subsidies: Prioritize HPV vaccine subsidies for rural and low-income students to mitigate cost-related hesitancy. Implementing differential subsidy tiers based on SEI tiers: 90% subsidy for Tier 3 provinces, 70% for Tier 2, and 50% for Tier 1. Peer-led education could leverage medical students’ expertise through campus ‘Vaccine Ambassador’ programs requiring ≥20 contact hours per semester.

Curriculum Reform: We recommend integrating mandatory reproductive health modules into general education curricula, with content co-developed by medical professionals and educators to address myths (e.g., HPV vaccine infertility rumors).

Digital Literacy Campaigns: Partner with influencers and healthcare providers to disseminate accurate information via platforms like WeChat and TikTok.