Limited discriminant validity of health belief and 3C models in high HPV vaccine coverage settings: the moderating role of hukou and structural barriers.
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BACKGROUND: Whether traditional health belief models (HBM) and 3C models can distinguish residual non-vaccinators in settings with >70% HPV vaccine coverage is unknown. The moderating role of China's household registration (hukou) on psychological factors and behavior has rarely been quantified. METHODS: From April 2025 to February 2026, we surveyed 1,257 women aged 18-65 from six Shenzhen communities. We collected demographics, HBM (15 items), 3C (12 items), social support, HPV vaccination intention (measured by a single item: willingness to receive the HPV vaccine within the next 6 months), self-reported vaccination history, reasons for non-vaccination, and information channel preferences. Analyses included t-tests (Cohen's d), observed-variable multi-group path analysis, and cross-sectional comparisons of vaccination proportions among women with high intention. RESULTS: HPV vaccination rate was 70.0% (880/1,257); cervical cancer screening rate 58.3%. Vaccinated and unvaccinated groups differed on only two of ten psychological constructs (trivial effect sizes: perceived susceptibility d = 0.13, self-efficacy d = 0.13). HPV vaccination intention did not differ significantly between vaccinated (M = 3.72, SD = 0.83) and unvaccinated women (M = 3.67, SD = 0.80), t = 0.81, p = 0.417. Main reasons for non-vaccination were high cost (42.3%) and safety concerns (33.8%). Observed-variable multi-group path analysis showed good fit (CFI = 0.968, RMSEA = 0.051). Perceived barriers were significantly negatively associated with HPV vaccination intention among non-Shenzhen hukou women (β = -0.247, p < 0.001), but not among Shenzhen hukou women (β = -0.102, p = 0.128). The formal test of hukou moderation was not statistically significant (Δχ2 = 2.358, Δdf = 8, p = 0.968). Most preferred information channels: WeChat official accounts (91.5%), face-to-face doctor consultations (85.1%), short video platforms (76.5%). CONCLUSION: At 70% coverage, HBM and 3C scales show limited discriminant validity between vaccinated and unvaccinated individuals. Residual non-vaccination is associated with cost and safety barriers. Hukou showed a suggestive but not statistically significant moderating effect on the perceived barriers-intention association. Interventions may need to target structural barriers and tailor information channels.