Changes in HPV vaccine hesitancy and influencing factors among female university students in China: A national repeated study

HPV vaccine hesitancy remains a critical barrier to cervical cancer prevention in China despite a series of strategic policy initiatives. Our study conducted two large-scale online cross-sectional surveys in 2022 and 2025 among nationally representative samples of female university students, applying propensity score matching to enhance comparability. HPV vaccine hesitancy, assessed on a 0-10 scale (including graded hesitancy and refusal), increased significantly over time, with prevalence rising from 8.8% to 21.6%, and mean hesitancy scores also increasing. Although HPV knowledge improved and exposure to negative information declined, the perceived necessity of vaccination fell markedly, and trust eroded across several domains, including trust in health professionals' advice and in both domestic and imported vaccines. Multivariable analyses identified perceived necessity, healthcare professional recommendation, and trust in professionals and domestic vaccines as protective factors, while prior self-payment for other vaccines was also associated with lower hesitancy. These determinants remained stable over time, underscoring the need for targeted strategies to counter rising hesitancy.