Effects of Health Information Communication Based on Social Media Usage in Promoting HPV Vaccination Intention in China
Abstract
With the gradual promotion of the human papillomavirus (HPV) vaccine in mainland China, social media has been suggested as an important channel for disseminating HPV-related information and promoting vaccination behaviors. This study explored the mechanism that health information communication based on social media usage affects HPV vaccination intention, i.e., examining the mediating effects of external factors (information credibility and information satisfaction) and internal factors (personal health beliefs) between social media use and HPV vaccination intention, and examining the potential moderating effect of subjective norms and health literacy on the key independent variables and the outcome variables. A total of 2552 cross-sectional sample data (through random sampling and based on the 95% confidence level with population size > 100,000) were collected through an online questionnaire in April 2022. The results based on mediating analyses indicated that information credibility, information satisfaction, and health belief all positively mediated the relationship between social media use and HPV vaccination intentions (p < 0.001). In addition, subjective norms and health literacy separately moderated the relationship between social media use and information credibility and between social media use and information satisfaction. This study provides insights for the community to promote HPV vaccination intention by utilizing social media information communication. Specifically, we identify that information satisfaction, information credibility, and health beliefs are positively associated with social media use, thereby contributing to healthy behaviors.
1. Introduction
Human papillomavirus (HPV) vaccination is one of the most successful public health achievements [1]. According to the 2020 Global Cancer Report jointly released by the World Health Organization and the International Research on Cancer (WHO/IARC), cervical cancer is now the fourth most common cancer in women worldwide, with an incidence rate of 6.6% and a mortality rate of 7.5%, and almost all cervical cancer (99%) is associated with HPV infection [2]. Since 2006, three kinds of HPV vaccines including Cervarix, Gardasil-4, and Gardasil-9 have been approved worldwide [3]. Cervarix (applicable to women aged 9–45), Gardasil-4 (applicable to women aged 20–45), and Gardasil-9 (applicable to women aged 16–45) have been approved by China’s National Medical Products Administration (CNMPA) separately since 2016, 2017, and 2018 [4]. In mainland China, the uptake of the HPV vaccine has remained to be suboptimal [4]. The WHO has set a target of a 90% HPV vaccination rate for women aged 9–15 years by 2030, while the current stock market penetration rate in China is less than 6% [5]. HPV vaccine was introduced in mainland China 10 years later than in other countries, and few studies in China have considered the factors influencing HPV vaccination [6, 7]. The prolonged progression from HPV infection to tumors poses challenges for clinical studies [8, 9], hindering widespread marketing and awareness of the HPV vaccine in mainland China.
In mainland China, free HPV vaccination is being promoted since August 2020. Many provinces and cities have carried out free vaccination of the HPV vaccine among female students in primary and secondary schools [10]. In January 2023, the National Health Commission, the Ministry of Education, the Ministry of Civil Affairs, and other 10 departments jointly issued the “Action Plan to Accelerate the Elimination of Cervical Cancer (2023–2030),” which clearly pointed out that by 2025, HPV vaccination services will be promoted in all pilot projects for females of appropriate age in mainland China [11]. With the promotion of the HPV vaccine across the country, the price cost is increasingly no longer a concern that restricts Chinese females of appropriate age from receiving the HPV vaccine. As long as the HPV vaccine is widely publicized among the public, it is believed that the public will accept the HPV vaccine and actively vaccinate.
In the “Healthy China Action” (2019–2030), it is clearly pointed out that it is necessary to build an all-media mechanism for the release and dissemination of health science knowledge and the use of new media such as WeChat, Weibo, mobile clients, and short videos to promote “Internet + precise health science popularization” [12]. Social media serves as an important conduit for healthcare information [13]. The report from the China Network Information Center (CNNIC) reveals that more than 1 billion people in China now use social media and messenger platforms, and nearly 70% of the total Chinese population uses social media regularly [14]. For example, WeChat is the most commonly used social media, which owns 1.26 billion Chinese users, with about 750 million users using it every day. Among the articles on the WeChat official accounts platform viewed by these users, health and wellness articles are among the top three information articles in the reading volume. Topics related to HPV and its vaccine frequently appear in WeChat hot articles that have been read more than 100,000 times [15]. Individuals’ use of social media largely influences their HPV vaccination intentions [16]. The popular science promotion of official accounts of mainstream media, the topic guidance of Internet celebrity bloggers, and the exchange and discussion of netizens have promoted the HPV vaccine issue to gain great attention on social media, and various forms of popular science information have also greatly improved women’s understanding and attention to HPV vaccine [17]. People seek needed information on social media not only to obtain knowledge but also for social interaction with others sharing similar questions and concerns [18]. Every time a new HPV vaccine is launched, it has triggered hot discussions on social media such as WeChat and Weibo. Information dissemination and opinion exchange on social media platforms play an important role in HPV vaccine awareness and vaccination promotion.
It can be seen that conducting HPV-related research in China holds unique value and significance. China has the largest population base in the world, making research on HPV infection and vaccination potentially impactful, which not only provides researchers with abundant data samples but also implies that any effective intervention measures or policy adjustments could positively affect a large number of people. In recent years, the Chinese government has demonstrated a strong policy orientation toward HPV vaccination, such as promoting free vaccination programs and raising public awareness. This provides a unique policy environment and social atmosphere for this study, facilitating the exploration of the impact of policy factors on HPV vaccination rates. Although China has made some progress in HPV vaccination, the vaccination rate is still far below the target set by the WHO. This poses both a challenge and a research opportunity. By conducting in-depth studies on factors influencing vaccination rates, scientific evidence can be provided for developing more effective intervention strategies. Furthermore, with the widespread adoption of the internet, social media has become a crucial channel for information dissemination in China. Social media plays a pivotal role in the spread of HPV-related information. Studying how Chinese social media influences the dissemination of HPV-related information and public attitudes is significant for improving vaccination rates.
Researchers have begun to investigate the relationship between social media and HPV vaccination in recent years. With specific regard to the effects on vaccine knowledge and attitudes, some studies have found that people engaging with health information via social media have an enhanced awareness of HPV vaccination and increased HPV knowledge [19, 20], while others found no such results [21, 22]. Similarly, in the case of effects on vaccination intention and behavior, some studies have found that social media components better facilitate HPV vaccination intention [23]. In contrast, others have failed to find similar results [24, 25]. The usual possibility underlying the inconsistent findings is that most studies solely explore individual-level factors and ignore the influence of external environments. External environments influencing willingness to receive HPV vaccination include factors such as access to healthcare services, availability of accurate information and education about HPV and the vaccine, societal attitudes and norms toward vaccination, recommendations from healthcare providers, and government policies and regulations related to vaccination programs [4, 22, 26, 27]. In addition, peer influence and social networks can also play a role in shaping individuals′ decisions regarding HPV vaccination. Parents, peers, and other important people are known to be regular users of social media for health information [28, 29]. They are also potential key stakeholders in the vaccination decision-making process. The suggested vaccination age should be around 9–45 years, but it is better to be administered before 26 years. That could be the reason why parents and peers play a part in decision-making, support, influence, communication, and advocacy related to vaccination for teenagers [30]. It follows that an integrative model of behavioral prediction is needed to describe the effects of internal and external factors based on social media use on HPV vaccination. Behavior theories (e.g., knowledge, attitude, practice, health belief model, and theory of planned behavior) have been frequently used to examine the psychological mechanisms of vaccination [31–34]. However, these studies have only investigated the internal attitudes toward health behavior, and thus it is difficult to provide a holistic theoretical explanation integrating internal and external factors.
With comprehensive consideration of improving the public’s HPV knowledge literacy and vaccine attitudes and in turn, increasing vaccination intention through social media use, we propose to detect the roles of external factors and internal attitudes in affecting the relationship between social media use and HPV vaccination. Especially, this research explores the following issues: (1) examining the effects of information-related external factors in linking social media use and HPV vaccination intention, (2) testing the effects of internal health beliefs in linking social media use and HPV vaccination intention, and (3) examining the factors that adjust the effect of social media use on information-related external factors.
2. Theoretical Framework and Hypotheses Development
2.1. Social Media Use and HPV Vaccination Intention
Social media use refers to the frequency with which individuals engage with social media platforms in their daily lives, as well as their level of dependence on these platforms. This considers the interaction frequency and interdependency between individuals and social media, reflecting the significance and impact of social media in their lives [35, 36]. Social media use not only influences healthy habits but also the individual’s health-related attitudes and intentions.
Social media is also associated with health behaviors. By transforming medical vocabulary into ordinary chat, social media such as microblogs could promote efficiency in vaccine education and communication [37]. For example, a study in Korea indicated that individuals often sought information about the HPV vaccine through computers, thereby more willingly accepting vaccination [38]. A study utilizing online survey data from both the United States and China highlighted that exposure to conflicting information on social media was more strongly linked to reduced intentions to receive HPV vaccination among participants from the United States compared to those from China. In contrast, social norms that endorse HPV vaccines showed a stronger positive association with intentions to receive HPV vaccination among Chinese participants than among those from the United States [39]. There is also a study showing that participation in HPV-related social media content was associated with increased awareness and knowledge but not with increased uptake of the vaccine [40]. Overall, the literature lacks systematic and rigorous research on the effects of social media on HPV-related knowledge, attitudes, and behaviors. Further investigation is crucial as social media continues to emerge as a significant source of health information.
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Q1: What is the effect of social media use on HPV vaccination intention?
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H1: Social media use significantly affects people’s HPV vaccination intention.
2.2. Health Beliefs, Social Media Use, and HPV Vaccination Intention
The health belief model is frequently utilized to forecast audience health behaviors, which contains six domains of an individual’s self-efficacy, perceived susceptibility, perceived severity, perceived barriers, perceived benefits, and cues to action [41]. Perceived susceptibility, perceived severity, and perceived benefits are selected as internal influencing factors affecting individual willingness to receive HPV vaccination in this study, because they directly relate to how individuals perceive the threat of HPV infection and the effectiveness of vaccination. Perceived susceptibility reflects an individual’s belief about their chances of contracting HPV. Those who perceive themselves as susceptible to HPV are more likely to consider vaccination as a protective measure. It directly influences their motivation to prevent the perceived threat. Perceived severity refers to an individual’s perception of the seriousness of the consequences of contracting HPV. Awareness of the potential severity of HPV-related diseases (such as cervical cancer) can significantly influence their decision to get vaccinated. Higher perceived severity generally increases the motivation to engage in preventive behaviors such as vaccination. Perceived benefits involve an individual’s assessment of the effectiveness and benefits of HPV vaccination in reducing the risk of infection and related health problems. If individuals perceive vaccination as beneficial in terms of reducing their risk of HPV and associated diseases, they are more likely to be motivated to get vaccinated [34, 41, 42]. These three factors (susceptibility, severity, and benefits) are crucial because they collectively shape an individual’s risk perception and cost-benefit analysis regarding vaccination.
By contrast, the other three factors (perceived barriers, cues to action, and self-efficacy) primarily affect an individual’s readiness to act on their decision to get vaccinated rather than influencing their initial perception of risk and benefit. While important, barriers such as cost, inconvenience, or fear of side effects typically come into play after individuals have already decided to get vaccinated based on their risk perception and perceived benefits. Cues to action (such as doctor’s recommendations or media campaigns) prompt action but do not directly shape an individual’s internal perception of risk and benefit as susceptibility, severity, and benefits do. Self-efficacy concerns an individual’s confidence in their ability to successfully complete the vaccination process. It becomes relevant once the decision to vaccinate has been made based on perceived susceptibility, severity, and benefits [43–45]. Therefore, perceived susceptibility, perceived severity, and perceived benefits are selected as internal influencing factors because they are fundamental in shaping an individual’s initial decision-making process regarding HPV vaccination, driven by their assessment of personal risk and the potential benefits of vaccination in reducing that risk.
Sharing health information in online communities can enhance perceived benefits and lessen perceived barriers [46]. In addition, parental social media use leads to a higher perceived susceptibility and a lower perceived barrier [47]. Previous research [48, 49] has identified positive correlations between information communication behaviors and perceptions of risk and self-efficacy. Yoo et al. [50] found that individuals′ use of social media for searching and disseminating health-related information positively impacts their perceptions of risk, which, in turn, affects their willingness to engage in health behaviors. Therefore, it is necessary to study the mechanisms that influence the effect of social media on the dissemination of HPV-related information to improve the HPV vaccination rate [51]. Since current studies mostly focus on the correlation between social media and health behaviors, the relationships between social media and the dimensions of health beliefs are unclear, and additional research exploring the impact of social media use on health beliefs is warranted [52].
Some studies have focused on vaccine hesitancy which is defined as patient-level reluctance to receive the vaccination or a delay in vaccine acceptance despite their availability [53, 54]. It is found that the barriers to HPV vaccination intention predominantly encompass factors such as the lack of perceived susceptibility, insufficient comprehension of HPV and vaccine-related information, apprehensions regarding the safety, efficacy, and affordability of the HPV vaccine, as well as concerns regarding the absence of associated medical insurance coverage among women, particularly young women [4, 26, 27, 39]. Some studies have explained the effects of health beliefs on specific health-related issues, such as vaccination intention [55], health preventive campaigns [56], health risks in tourism [57], myopia preventive practice [58], and so forth.
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Q2: What role do health beliefs play in peoples’ HPV vaccination intention based on social media use?
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H2. Social media use significantly affects people’s health beliefs, including perceived susceptibility (H2a), perceived severity (H2b), and perceived benefits (H2c), toward HPV vaccination.
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H3. Health beliefs, including perceived susceptibility (H3a), perceived severity (H3b), and perceived benefits (H3c) play mediating roles between social media use and HPV vaccination intention.
2.3. Information Credibility, Information Satisfaction, Social Media Use, and HPV Vaccination Intention
Information satisfaction and information credibility reflect the attitudes and values of the audience, further contributing to the establishment of health beliefs and behaviors. Information credibility refers to the degree to which information is perceived as accurate, reliable, and trustworthy by individuals or users [59]. Information satisfaction, on the other hand, refers to the extent to which individuals or users feel content or pleased with the information they have accessed or received [60]. A study from rural China demonstrates that more frequent social media consumption boosts individuals’ information satisfaction and credibility [61].
During social media use, factors such as user interaction and media dependence [62], the timing of tweet postings [63], and users′ interest in relevant topics [64] can all affect information credibility. Information seeking through social media is becoming increasingly important for consumers′ purchasing decisions [65]. Ozkara et al. [66] found that users′ perceived “enjoyment,” “time distortion,” “curiosity,” and “perceived control” dimensions of online information search had a positive impact on information satisfaction. It can be said that the usage of social media significantly affected peoples’ information credibility and information satisfaction of these two external factors.
Social media allows individuals to create and share information without any formal review process or supervision [67, 68]. Both true and false healthcare information may be included in online platforms to persuade and guide people to accept or reject vaccinations [69]. Some studies have revealed that attitudes toward information are important references for decision-making. Cosenza et al. [70] found that information sources and content with high reliability can bring users a sense of dependence and make users less suspicious of the information. When the credibility of the source is high, the trust of the audience will increase, and the audience will have more confidence in the authenticity of the information [71]. Authoritative information can reduce the uncertainty of decision-making results for seekers [72]. Zhang et al. [73] have suggested that individuals are more likely to develop positive behavioral intentions when they are satisfied with the information. Faller et al. [74] found that patients who were dissatisfied with the information they received reported higher levels of anxiety, depression, and lower quality of life, regardless of gender. Iskandarsyah et al. [75] demonstrated that breast cancer patients with high satisfaction with the information reported stronger beliefs in personal control. In addition, Shang [76] noted that when older adults perceive health information on social media as highly accessible and trustworthy, it can facilitate the formation and reinforcement of positive health beliefs, such as confidence in the effectiveness of preventive measures or treatments.
Given that much research has already addressed factors such as healthcare access, vaccine affordability, and societal attitudes [26, 31, 33], focusing on information credibility and information satisfaction provides a novel contribution to the field. It addresses a gap in understanding how the perceived quality and satisfaction with health information influence vaccination decisions, which can offer new insights and practical recommendations. By concentrating on information-related factors, the study can delve deeply into how the quality and reliability of information influence HPV vaccination intentions. This focused perspective allows for a more detailed and nuanced understanding of the role that health information on social media usage plays in shaping vaccination attitudes.
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Q3: What role does information credibility play in peoples’ HPV vaccination intention based on social media use?
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H4. Social media use significantly affects people’ perceived information credibility (H4a) and information satisfaction (H4b).
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H5. Information credibility (H5a) and information satisfaction (H5b) play mediating roles between social media use and HPV vaccination intention.
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H6. Social media use significantly affects peoples’ HPV vaccination intention through the chain mediating effect of information credibility and health beliefs, including perceived susceptibility (H6a), perceived severity (H6b), and perceived benefits (H6c).
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H7. Social media use significantly affects peoples’ HPV vaccination intention through the chain mediating effects of information satisfaction and health beliefs, including perceived susceptibility (H7a), perceived severity (H7b), and perceived benefits (H7c).
2.4. Subjective Norm, Health Literacy, Social Media Use, and Information Communication
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Q4: What role does subjective norm play between social media use and information credibility?
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H8. Subjective norm moderates the impact of social media use on information credibility.
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Q5: What role does health literacy play between social media use and information satisfaction?
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H9. Health literacy moderates the impact of social media use on information satisfaction.
Based on the above literature reviews, the conceptual framework of this study is illustrated in Figure 1.
3. Methods
A cross-sectional online survey was conducted on Wenjuanxing (WXJ), China’s largest nonproprietary online survey platform, in April 2022. In WeChat, the social media platform with the largest number of users (more than 1.3 billion people) in China, through snowball sampling, the researchers randomly distributed the URL link and two-dimensional code of the survey questionnaire to the friends they knew, and then asked them to forward the questionnaire to other participants through WeChat to expand the scope of questionnaire distribution. Although the HPV vaccine is mainly given to women, the researchers also wanted to know the extent of men’s understanding of the vaccine, so some male participants were selected when handing out questionnaires. To avoid repetitive answers, it was set so that users with the same IP address and the same computer/mobile phone equipment could only open the questionnaire one time. There was a disclaimer in the debriefing reminding the respondents that the study was a piece of academic research. We stressed anonymity and privacy protection and encouraged participants to exit any time they felt uncomfortable.
3.1. Participants
The sample comprised of 2611 participants, and 59 respondents were excluded based on questionnaire quality checks (e.g., excessive speed of response and contradictory responses to reverse worded questions must be eliminated). The majority of the participants were female (78%) and aged between 16 and 45 years old (89%). Over half of the participants had a high school diploma (64%) and their income status reached 2000 RMB per month (86%). Participants are widely distributed in various cities, including first-tier cities (15%), new first-tier cities (22.7%), second-tier cities (20.7%), and third-tier cities (20.1%). Table 1 displays the demographic profile of the final effective 2552 participants.
| n | % | |
|---|---|---|
| Gender | ||
| Male | 588 | 22.3 |
| Female | 1984 | 77.7 |
| Age (years) | ||
| ≤ 16 | 6 | 0.2 |
| 16–26 | 1562 | 61.2 |
| 27–45 | 708 | 27.7 |
| > 45 | 276 | 10.8 |
| Education level | ||
| ≤ High school diploma | 909 | 35.6 |
| = Bachelor’s degree | 1492 | 57 |
| ≥ Graduate degree | 188 | 7.4 |
| Monthly income (RMB) | ||
| ≤ 2000 | 350 | 13.7 |
| 2000–5000 | 1311 | 51.4 |
| 5001–10000 | 757 | 29.7 |
| > 10,000 | 134 | 5.3 |
| Region | ||
| First-tier cities | 383 | 15 |
| New first-tier cities | 580 | 22.7 |
| Second-tier cities | 529 | 20.7 |
| Third-tier cities | 514 | 20.1 |
| Hong Kong, Macao, and Taiwan | 233 | 9.1 |
| Overseas | 133 | 5.2 |
| Others | 180 | 7.1 |
3.2. Measures
The questionnaire contained two parts. The first part is questions about demographic information including gender, age, education level, income, and region of the participants. The second part is questions measuring participants’ perceptions of health information communication based on social media usage and their HPV vaccination intention, including the independent variable social media use; mediating variables information credibility, information satisfaction, perceived susceptibility, perceived severity, and perceived benefits; moderating variables health literacy and subjective norm; and the outcome variable HPV vaccine intention. The measurement items used in this study were adjusted based on established measure scales (items detailed in Table 2). The questionnaire was first developed in English and then translated into Chinese. Back-translation was conducted by a bilingual third-party company to ensure the accuracy of the translation. Before the formal distribution of the questionnaire, we made a pretest among 50 individuals and optimized the wording of the questions to make them more suitable for the reading and comprehension habits of Chinese people. All scales use the Likert 5-point scale (1 [strongly disagree] to 5 [strongly agree]). The Cronbach’s alpha of the total effective sample in 9 variables ranged from 0.862 to 0.910 (> 0.70), indicating the acceptable credibility of the survey.
| Variable | Survey instrument statements | References |
|---|---|---|
| Social media use | Using social media is my daily activity | Ellison, Steinfield, and Lampe [90] |
| Using social media makes me happy | ||
| When I stop using social media for a while, I begin to feel removed from society | ||
| Social media is a part of my life | ||
| I’d be disappointed if social media shut down | ||
| Information credibility | Information about the HPV vaccine on social media platforms is fair | Meyer [91] |
| Information about the HPV vaccine on social media platforms is unbiased | ||
| Information on the HPV vaccine on social media platforms is complete | ||
| Information on the HPV vaccine on social media platforms is accurate | ||
| Information about the HPV vaccine on social media platforms is reliable | ||
| Information satisfaction | The content about HPV vaccination is in line with my interests and values | Han et al. [69] |
| The content about HPV vaccination is detailed | ||
| Overall, I am satisfied with the information about the HPV vaccine in social media | ||
| Perceived severity | HPV infection will affect my social life | Patty et al. [92] |
| HPV infection will affect my marriage | ||
| HPV infection will affect my lifelong happiness | ||
| HPV infection can threaten my life | ||
| Perceived susceptibility | Many people are at risk of HPV infection | Patty et al. [92] |
| Anyone can be infected with HPV | ||
| I am at risk of getting HPV in the future | ||
| My possibility of getting HPV in the future is not ruled out | ||
| Perceived benefits | HPV vaccination will protect me from HPV infection | Patty et al. [92] |
| HPV vaccination can prevent diseases such as cervical cancer | ||
| HPV vaccination can improve safe sex | ||
| HPV vaccination is generally beneficial | ||
| Health literacy | I know where to get information about the HPV vaccine | Enwald et al. [93] |
| I am willing to get information about the HPV vaccine from different sources | ||
| I get reliable information about the HPV vaccine from social media easily | ||
| I get information about the HPV vaccine from the internet easily | ||
| I apply the obtained information to myself and those around me | ||
| Subjective norm | People who influence my behavior think I should be vaccinated for HPV | Reno and Dempsey [79] |
| Someone important to me thinks I should be vaccinated for HPV | ||
| Vaccination intention | I will consider an HPV vaccination | Reno and Dempsey [79] |
| I plan to get an HPV vaccination | ||
| I believe I will get the HPV vaccination | ||
4. Results
4.1. Regression Analysis (H1, H2, and H4)
We assumed that social media use significantly affected people’s HPV vaccination intention (H1), people’s health beliefs (H2), people’s perceived information credibility, and information satisfaction (H4). Linear regression based on SPSS (Version 26.0) was utilized to test these hypotheses. The model was specified with social media use as the predictor of HPV vaccination intention and included three dimensions of health beliefs, information credibility, and information satisfaction as mediators, as well as control variables of age, gender, educational level, and monthly income, included as dummy variables as presented in Table 3.
| Variable | Model 1 | Model 2 | ||||
|---|---|---|---|---|---|---|
| Beta | t | p | Beta | t | p | |
| Control variable | ||||||
| Female | 0.037 | 0.424 | 0.157 | 0.119 | 0.875 | 0.046 ∗ |
| ≤ 16 ages | −0.219 | −1.715 | 0.073 | −0.198 | −1.216 | 0.191 |
| 16–26 ages | 0.144 | 1.238 | 0.097 | 0.225 | 1.168 | 0.038 ∗ |
| 27–45 ages | 0.378 | 2.235 | 0.026 ∗ | 0.386 | 2.248 | 0.017 ∗ |
| ≤ 2000 RMB | −0.317 | −1.772 | 0.038 ∗ | −0.322 | −1.816 | 0.034 ∗ |
| 2000–5000 RMB | −0.268 | −1.934 | 0.044 ∗ | −0.298 | −1.927 | 0.041 ∗ |
| 5001–10000 RMB | −0.039 | −1.115 | 0.186 | −0.076 | −1.228 | 0.127 |
| ≤ high school diploma | −0.231 | −0.088 | 0.019 ∗ | −0.256 | −0.037 | 0.015 ∗ |
| Bachelor’s degree | −0.070 | −0.021 | 0.133 | −0.078 | −0.023 | 0.126 |
| Research variable | ||||||
| Social media use | 0.379 | 2.528 | 0.001 ∗∗∗ | |||
| Information credibility | 0.388 | 2.731 | 0.001 ∗∗∗ | |||
| Information satisfaction | 0.391 | 3.516 | 0.001 ∗∗∗ | |||
| Perceived severity | 0.359 | 1.983 | 0.001 ∗∗ | |||
| Perceived susceptibility | 0.381 | 2.675 | 0.001 ∗∗∗ | |||
| Perceived benefit | 0.387 | 2.699 | 0.001 ∗∗∗ | |||
| Model fit | ||||||
| R2 | 0.06 | 0.31 | ||||
| Adjusted R2 | 0.02 | 0.26 | ||||
| F | 1.28 | 7.13 | ||||
| p | 0.273 | 0.001 | ||||
- Note: Dependent variable: HPV vaccination intention. Control variables are included as dummy variables. The reference category for gender is male, the reference category for age is > 45 ages, the reference category for monthly income is > 10,000 RMB, and the reference category for educational level is > graduate degree.
- ∗p ≤ 0.05.
- ∗∗p ≤ 0.01.
- ∗∗∗p ≤ 0.001.
The results revealed that the path from social media use to HPV vaccination intention was significant (β = 0.379, p < 0.001). The paths from social media use to perceived severity (β = 0.361, p = 0.001), perceived susceptibility (β = 0.372, p < 0.001), and perceived benefit (β = 0.378, p < 0.001) were all significant, and the paths from perceived severity (β = 0.359, p = 0.001), perceived susceptibility (β = 0.381, p < 0.001), and perceived benefit (β = 0.387, p < 0.001) to HPV vaccination intention were all significant. The path from social media use to information credibility was significant (β = 0.329, p = 0.002), and the path from information credibility to HPV vaccination intention was significant (β = 0.388, p < 0.001). The path from social media use to information satisfaction was significant (β = 0.376, p < 0.001), and the path from information satisfaction to HPV vaccination intention was significant (β = 0.391, p < 0.001). The paths from information credibility to perceived severity (β = 0.327, p = 0.003), perceived susceptibility (β = 0.331, p = 0.002), and perceived benefit (β = 0.378, p < 0.001) were all significant, and the paths from information satisfaction to perceived severity (β = 0.328, p = 0.002), perceived susceptibility (β = 0.333, p = 0.002), and perceived benefit (β = 0.340, p = 0.001) were all significant. The results showed that each direct path among the independent variables, mediator variables, and dependent variables was significant (p < 0.05), indicating that mediation tests can be further conducted, and the results supported H1, H2, and H4.
In terms of control variables, social media use is more likely to influence HPV vaccination intentions in females than in males. Compared to people above age 45, people within the age groups of 16–45 are more likely to accept HPV vaccination. People with lower monthly incomes such as below 5000 RMB are less likely to be vaccinated against HPV than those with higher incomes such as above 10,000 RMB. People with a bachelor and above degree are more willing to get vaccinated than people with less education.
4.2. Mediation Analysis (H3, H5, H6, and H7)
First, the SPSS process (Model 4), which is based on the bias-corrected percentile bootstrap CI method, was applied to test the separate mediating roles of information credibility, information satisfaction, and three dimensions of health beliefs [94]. The bootstrap test was conducted with a sample size of 5000 at a 95% confidence interval recommended by Cheung and Lau [95].
The results showed that the indirect effect of the path with perceived severity as the mediating variable between social media use and HPV vaccination intention was 0.071 (95% CI: [0.057, 0.088]), the indirect effect of the path with perceived susceptibility as the mediating variable between social media use and HPV vaccination intention was 0.077 (95% CI: [0.062, 0.094]), and the indirect effect of the path with perceived benefit as the mediating variable between social media use and HPV vaccination intention was 0.081 (95% CI: [0.065, 0.098]). Thus, health beliefs, including perceived susceptibility, perceived severity, and perceived benefits all play mediating roles between social media use and HPV vaccination intention. Thus, H3 is supported.
The results showed that the indirect effect of the path with information credibility as the mediating variable between social media use and HPV vaccination intention was 0.044 (95% CI: [0.029, 0.060]). Thus, information credibility plays a mediating role between social media use and HPV vaccination intention. Thus, H5a is supported.
The results showed that the indirect effect of the path with information satisfaction as the mediating variable between social media use and HPV vaccination intention was 0.102 (95% CI: [0.083, 0.122]). Thus, information satisfaction plays a mediating role between social media use and HPV vaccination intention. Thus, H5b is supported.
Then, the SPSS process (Model 6) which is based on the bias-corrected percentile bootstrap CI method, was applied to test the separate mediating roles of information credibility, information satisfaction, and three dimensions of health beliefs [94]. the bootstrap test was conducted with a sample size of 5000 at a 95% confidence interval recommended by Cheung and Lau [95].
The results showed that the chain mediating effect of the path with information credibility and perceived severity was 0.020 (95% CI: [0.015, 0.025]), the chain mediating effect of the path with information credibility and perceived susceptibility was 0.021 (95% CI: [0.016, 0.026]), and the chain mediating effect of the path with information credibility and perceived benefit was 0.025 (95% CI: [0.019, 0.031]). Thus, social media use has a positive effect on HPV vaccination intention through the chain mediating effect of information credibility and health beliefs. Thus, H6 is supported.
The results showed that the chain mediating effect of the path with information satisfaction and perceived severity was 0.019 (95% CI: [0.014, 0.025]), the chain mediating effect of the path with information satisfaction and perceived susceptibility was 0.024 (95% CI: [0.019, 0.031]), and the chain mediating effect of the path with information satisfaction and perceived benefit was 0.029 (95% CI: [0.022, 0.037]). Thus, social media use has a positive effect on HPV vaccination intention through the chain mediating effects of information satisfaction and health beliefs. Thus, H7 is supported.
The summary of the mediation effect analysis is shown in Table 4.
| Hypothesis | Path | Effect | SE | LLCI | ULCI |
|---|---|---|---|---|---|
| H2 | SMU ⟶ PSa ⟶ VI | 0.071 | 0.008 | 0.057 | 0.088 |
| SMU ⟶ PSb ⟶ VI | 0.077 | 0.008 | 0.062 | 0.094 | |
| SMU ⟶ PB ⟶ VI | 0.081 | 0.008 | 0.065 | 0.098 | |
| H3 | SMU ⟶ IC ⟶ VI | 0.044 | 0.008 | 0.029 | 0.060 |
| H4 | SMU ⟶ IS ⟶ VI | 0.102 | 0.010 | 0.083 | 0.122 |
| H5 | SMU ⟶ IC ⟶ PSa ⟶ VI | 0.020 | 0.003 | 0.015 | 0.025 |
| SMU ⟶ IC ⟶ PSb ⟶ VI | 0.021 | 0.003 | 0.016 | 0.026 | |
| SMU ⟶ IC ⟶ PB ⟶ VI | 0.025 | 0.003 | 0.019 | 0.031 | |
| H6 | SMU ⟶ IS ⟶ PSa ⟶ VI | 0.019 | 0.003 | 0.014 | 0.025 |
| SMU ⟶ IS ⟶ PSb ⟶ VI | 0.024 | 0.003 | 0.019 | 0.031 | |
| SMU ⟶ IS ⟶ PB ⟶ VI | 0.029 | 0.004 | 0.022 | 0.037 | |
- Abbreviations: IC, information credibility; IS, information satisfaction; PB, perceived benefit; PSa, perceived severity; PSb, perceived susceptibility; SMU, social media use; VI, vaccination intention.
4.3. Moderation Analysis (H8 and H9)
The SPSS process (Model 1) was utilized to test the moderation effects. First, taking information credibility as a dependent variable, the results show that there is a significant interaction effect between social media use and subjective norm (β = 0.49, p = 0.002, R2 = 0.158). As shown in Figure 2(a), the simple slope analysis reveals that the high subjective norm group (means + 1SD) had a significant positive effect on the relationship between social media use and information credibility (β = 0.308, p < 0.001, 95% CI: [0.253, 0.363]). For the low subjective norm group (means -1SD), the positive effect of social media use on information credibility was still significant but weakened (β = 0.195, p < 0.001, 95% CI: [0.144, 0.245]). Thus, H8 was supported.
Then, taking information satisfaction as a dependent variable, the results show that there is a significant interaction effect between social media use and health literacy (β = 0.044, p = 0.013, R2 = 0.216). As shown in Figure 2(b), the simple slope analysis reveals that the high health literacy group (means + 1SD) had a significant positive effect on the relationship between social media use and information satisfaction (β = 0.326, p < 0.001, 95% CI: [0.272, 0.380]. For the low health literacy group (means-1SD), the positive effect of social media on information satisfaction was still significant but weakened (β = 0.235, p < 0.001, 95% CI: [0.185, 0.285]. Thus, H9 was supported.
5. Discussion
This study was designed to assess the relationships between social media use and HPV vaccination intention with testing of several moderating (health literacy/subjective norms) and mediating effects (information satisfaction/information credibility/health beliefs). First, we found that participants who used social media more frequently were more dependent and were more likely to report higher HPV vaccination intention, and the effect was significant. This result is in line with previous studies that exposure to HPV information promoted vaccination intentions [96], especially in a setting with scarce availability of the vaccine in China. We also found evidence that information satisfaction, information credibility, and health beliefs are important factors influencing vaccination intention. The results are consistent with the findings that attitudes toward information [61, 70–73] and health beliefs [27, 34, 41, 42] contribute to the establishment of health-related attitudes, which are frequently utilized to forecast users’ health behaviors. Specifically, we found that individuals with higher social media usage had higher levels of information satisfaction, information credibility, and health beliefs, which led to higher HPV vaccination intention. The public is more willing to vaccinate when they trust the health information they obtained and are satisfied with the content. Social media provides an efficient and free platform for sharing information.
It is well-known that it is meaningful to study users’ varying health beliefs and attitudes through social media [12–16, 67, 68]. Addressing misinformation can also be beneficial, and strategies such as including fact-checking techniques should be considered. To ensure coherence of the effect, future work must also consider industry-level content manipulation; that is, there is a need to examine the underlying logic and algorithmic decisions that are used by social media platforms to keep users’ emotional and interpersonal engagement with content. This results in the creation of echo chambers which limits exposure to a wider range of different views.
We found that health literacy played a moderating role in the relationship between social media use and HPV vaccine information satisfaction. High health literacy groups can distinguish high-quality information and are more satisfied with the content. In contrast, people with low health literacy are more likely to be confused by inaccurate information. Likewise, subjective norms also moderated the relationship between social media use and information credibility.
Since HPV is a virus that is mainly transmitted through sexual transmission, people prefer to discuss related topics with close relationships (such as family and friends) and with healthcare professionals. External support, especially from important others, can increase their awareness and credibility of HPV vaccination. Therefore, to further ensure communication effectiveness, we can use a potential strategy of developing salient and relevant messages about HPV vaccines on social media for different audiences and those around them, which is a representation of the type of people created to focus on the demographics, concerns, and motivations of the targeted group.
In terms of the influence of demographic factors, social media use appears to have a more significant influence on HPV vaccination intentions among females compared to males. This suggests that social media may serve as a more effective platform for reaching and engaging female audiences regarding HPV vaccination information. Age also plays a crucial role in vaccination willingness. Individuals aged 16–45 are more inclined to accept HPV vaccination compared to those above 45. This could be attributed to more frequent social media usage and greater awareness and acceptance of preventative health measures among younger adults, as well as potentially higher levels of health literacy and proactive health behaviors within this age group. Income levels further impact vaccination intentions, with those earning below 5000 RMB demonstrating a lower likelihood of receiving the HPV vaccine compared to those with incomes above 10,000 RMB. This disparity highlights the role of socioeconomic factors in health decision-making, where lower income may limit access to healthcare resources or create additional barriers to vaccination. Educational attainment also correlates with vaccination willingness. Individuals with a bachelor’s degree or higher are more willing to receive the HPV vaccine compared to those with less education. This suggests that higher education levels are associated with better health knowledge and a greater acceptance of preventative health measures.
Overall, we used several key variables from behavior theories [34], integrating with information-related attitudes, to explain the factors and their mechanism related to social media use in affecting users’ intention of HPV vaccination, which helps better understand the internal and external factors influencing HPV vaccination intention.
Specifically, these findings shed light on the complex mechanisms through which social media influences HPV vaccination intention, emphasizing the importance of external factors of information processing, internal factors of health beliefs, and individual characteristics (such as subjective norms and health literacy). This provides theoretical foundations for designing intervention measures and information dissemination strategies aimed at improving public acceptance and understanding of HPV vaccination.
However, there are several limitations of this study. First, although we examined social media use, the information quality was not considered. Content quality characteristics, such as true and false information that are involved in social media, may result in such differences. Future studies are therefore needed to investigate the information quality that may play a pivotal role in HPV vaccination intention. Second, we used a cross-sectional survey to collect vaccine-related data, so there may be response bias in the sampling process. Respondents may provide untrue or inaccurate answers due to subjective factors or social expectations, resulting in biased results. Future studies could introduce the price into the influential paths of vaccination intention to explore the comprehensive effects of the price and other external factors in affecting Chinese females in accepting the HPV vaccines.
Conflicts of Interest
The authors declare no conflicts of interest.
Funding
This research was funded by the “Qinglan Project” of Universities in Jiangsu Province of China, and the Interdisciplinary Research Team Project of Young Scholars in Humanities and Social Sciences of Soochow University “Reflexive Regulation of Algorithmic Marketing Governance of Platforms” (Project no. 5033720423).
Acknowledgments
We would like to extend our sincere gratitude to associate professor Jing Wang and master students Liwen Jiang and Yifan Zhou from the School of Communication at Soochow University for their invaluable contributions and support throughout this research.
Open Research
Data Availability Statement
The data that support the findings of this study are available from the first author, Ke Zhang, upon reasonable request.
