Discordant vaccine uptake and its determinants among adolescents in a context of high vaccination coverage and longtime immigration: a cross-sectional study in Umbria region, Italy

Discordant vaccine uptake and its determinants among adolescents in a context of high vaccination coverage and longtime immigration: a cross-sectional study in Umbria region, Italy | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Discordant vaccine uptake and its determinants among adolescents in a context of high vaccination coverage and longtime immigration: a cross-sectional study in Umbria region, Italy Vito Cerabona, Carlotta Bertola, Leonardo Bronzetti, Francesco Paciosi, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8956447/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 11 You are reading this latest preprint version Abstract Introduction Adolescent vaccination is a key public health strategy to ensure protection against vaccine-preventable diseases, including HPV. Although coverage for several adolescent vaccines in Italy is high, complete HPV uptake remains suboptimal, and evidence on overall adolescent vaccination and its determinants is limited. This study assessed full vaccination coverage in Umbria and explored socio-demographic, cultural, and psychosocial factors associated with uptake. Methods A cross-sectional study was conducted during the 2024/2025 school year among 12-year-old adolescents and their parents in Umbria, Italy, using a web-based questionnaire administered through lower secondary schools. Data were collected on vaccination status and key determinants, including health literacy, vaccine knowledge, attitudes, and cultural affiliation, using validated instruments. Adolescents were classified as fully vaccinated if they had received the diphtheria–tetanus–pertussis–polio booster, meningococcal vaccine, and at least one HPV dose. Associations with vaccination status were analyzed using chi-square tests. Results Among 277 adolescent–parent pairs (response rate: 3,9%), 79,9% (95% CI: 74,5%–84,3%) of adolescents were fully vaccinated. Coverage for DTaP-polio and meningococcal vaccines exceeded 86%, while HPV uptake was 69,7% (two doses). No significant associations were observed with socio-demographic characteristics. Vaccination status was significantly associated with cognitive and cultural determinants: higher parental HPV knowledge (p = 0.002) and adolescents’ correct awareness of HPV risks (p = 0.015) were linked to higher uptake, whereas greater general parental vaccine knowledge was paradoxically associated with lower uptake (p = 0.029). Adolescents with an active health orientation were more likely to be fully vaccinated (p = 0.018). Health literacy, vaccine attitudes, and cultural affiliation showed limited or no association. Conclusions A substantial proportion of adolescents remains incompletely vaccinated despite high coverage. Health orientation and HPV knowledge play a central role in uptake. Interventions strengthening health literacy and promoting accurate HPV knowledge may improve adherence to vaccination programs. Adolescent vaccination HPV vaccine Vaccine uptake Health literacy Vaccine hesitancy Figures Figure 1 Figure 2 Key Message What is already known on this topic Adolescent vaccination coverage in Italy is generally high, but HPV vaccine uptake remains suboptimal. Vaccine acceptance is influenced by socio-demographic, cognitive, and attitudinal factors, yet evidence focusing specifically on adolescents and their overall vaccination status is limited. What this study adds This study provides novel evidence on adolescents’ full vaccination status in Italy, showing that uptake is more strongly associated with HPV-specific knowledge and adolescents’ health orientation than with socio-demographic factors. It also highlights unexpected patterns in parental vaccine knowledge and acceptance. How this study might affect research, practice, or policy Findings support the development of targeted interventions aimed at strengthening adolescents’ health literacy and HPV-specific knowledge. Policies integrating adolescent-focused education and communication strategies may help improve vaccination coverage and reduce missed immunization opportunities. Introduction Vaccination during adolescence represents a crucial public health strategy, as it allows boosting immune systems and providing protection before the potential exposure to various infectious agents, such as Human Papilloma Virus (HPV). Several international health authorities, including the European Centre for Disease Prevention and Control (ECDC), emphasize the importance of adolescent immunization to ensure timely protection and long-term population health benefits ( 1 ). Within this framework, HPV vaccine plays a pivotal role in preventing HPV-related diseases. In Italy, HPV vaccination was introduced in 2007, and the National Immunization Prevention Plan (PNPV) 2017–2019 set a target of at least 95% coverage among 12-year-olds of both sexes. However, coverage for the complete HPV vaccination cycle remains below this goal, with substantial regional disparities ( 2 ). Coverage among males is even lower, ranging from 4.79% to 43.99%. The COVID-19 pandemic has further contributed to a decline in vaccination rates, particularly in the adolescent target group ( 3 ). The Italian National Immunization Programme (NIP) includes multiple vaccinations recommended during adolescence, namely those against diphtheria, tetanus, pertussis (DTaP), poliomyelitis, meningococcal diseases, and HPV. Although national vaccination coverage is regularly monitored, the available data are typically reported by individual vaccines rather than reflecting adolescents' overall immunization status. This approach limits the ability to assess the completeness of vaccination at the individual level and highlights the need for studies that evaluate the full vaccination status. We know that, in 2024, vaccination coverage for diphtheria, tetanus, pertussis, and poliomyelitis among 16-year-olds exceeded 92%, while coverage for meningococcal diseases surpassed 90%. These rates are markedly higher than coverage reported for the complete HPV vaccination cycle ( 4 ). The factors influencing vaccine uptake are diverse and multifaceted, and they have been categorized using various conceptual frameworks. One of the most widely adopted models is the matrix developed by the WHO Strategic Advisory Group of Experts (SAGE) on Immunization, which classifies determinants of vaccine acceptance into three broad domains: contextual influences (such as socioeconomic and political factors), individual and group influences (including personal beliefs, experiences, and social norms), and vaccine- or vaccination-specific issues (such as perceived risk, benefit, and accessibility) ( 5 ). Among the many reasons for low uptake, vaccine hesitancy—defined as a delay in acceptance or refusal of vaccination despite availability of vaccination services—plays a critical role ( 6 ). The determinants of vaccine hesitancy and uptake have been extensively studied in the general population and in childhood in Italy ( 7 ), yet research focusing specifically on adolescents remains limited. In the Italian literature, research on vaccination determinants addresses both contextual factors and individual and group influences on vaccination behavior. Among these individual determinants, socioeconomic factors such as financial hardship and education level have been identified as significant predictors of vaccine acceptance. Additionally, demographic characteristics—including racial background, parental age and marital status, and family size—have been shown to influence vaccination decisions. Cultural determinants, including religious beliefs, have also been identified as factors that may positively or negatively affect vaccine uptake ( 8 ). One key individual-group determinant that remains under-investigated is cultural affiliation, defined as the extent to which individuals attribute their everyday behaviours, attitudes, and values to the traditions and involvement with their self-identified cultural group ( 9 ). While cultural affiliation is generally considered to play a positive role in health behaviours, its specific impact on vaccine uptake, particularly among adolescents, has yet to be thoroughly examined ( 10 ). Furthermore, health literacy—understood as the combination of cognitive and social skills enabling individuals to access, understand, and use health information effectively ( 11 ) —has been acknowledged as an important determinant of health behaviour ( 12 ). Health literacy—the combination of cognitive and social skills enabling individuals to access, understand, and use health information effectively—has been recognized as an important determinant of vaccination behaviour, with several studies demonstrating its positive association with vaccine uptake in the general population, including adults. However, research focusing specifically on the role of health literacy in adolescent vaccination is still limited, especially in Italy, where data remain scarce ( 13 ). In this study, we specifically focus on the overall vaccination status of adolescents in Italy and on its individual and group determinants, with the aim to explore their association with adolescents’ adherence to vaccination programs. By investigating these factors, we aim to provide novel insights into the drivers of vaccine uptake in this critical age group, addressing areas that have received limited attention in previous research, thereby contributing to supporting the design of tailored interventions to increase vaccination coverage. Material and Methods Study design and population A cross-sectional observational study was conducted in Umbria, a Region of Central Italy with 852,000 inhabitants through the administration of a web questionnaire in the school year 2024/2025. The study source was represented by the lower secondary schools of the Umbria region who agreed to collaborate in the conduction of the study. The source population included 6,996 12-year-old adolescents attending the third year of the 77 Umbrian lower secondary schools (55 from the Province of Perugia (76%) and 20 (24%) from the Province of Terni) at the time of data collection, together with their parents. Inclusion criteria Participants were eligible for inclusion if their family met the following conditions: at least one family member had to be proficient in the Italian language, ensuring effective comprehension of the questionnaire. In addition, the family was required to have been residing or domiciled in the Umbria region for at least two years prior to the study. Finally, participation was contingent upon confirming voluntary agreement to take part in the research after reading the informed consent form. Participant recruitment Recruitment was carried through a two steps approach. First the principals of all the lower secondary schools in the Umbria region were reached out with the support of the Regional School Office to explore the willingness to let their schools participate in the project. After this step, a notice meant to be published in the electronic register and including the link to the survey and to informational materials was sent to the schools confirming their participation. Two reminder messages were sent in the following month. Collected variables: the questionnaire A questionnaire was developed to collect data on adolescents' vaccination status and a range of individual and groups determinants, including socio-economic, and cultural determinants. The questionnaire was created using SurveyMonkey, an online platform specialized in the design, administration, and analysis of surveys. The questionnaire was accompanied by a cover letter outlining the objectives of the study, procedures for data handling, and measures taken to ensure data protection. Both adolescents and their parents were invited to complete the questionnaire, which was divided into three main sections: individual socio-demographic characteristics, cultural individual determinants and cultural group determinants. Adolescents’ vaccination status was self-reported by parents and collected separately for all age-recommended vaccines. In respect to potential determinants the following information was collected: Individual socio-demographic characteristics : sex (of both the adolescent and the responding parent), residence (Perugia or Terni, the two provinces of Umbria region), parents’ educational attainment and employment status, responding parent’ citizenship, and religion. Cultural individual determinants, namely health literacy, as well as knowledge, attitudes, and behaviours toward vaccine-preventable diseases and vaccinations of both the adolescent and the responding parent. Cultural group determinants, namely cultural affiliation. To assess adolescents’ health literacy, the Measurement of Health Literacy Among Adolescents Questionnaire (MOHLAA-Q) was employed ( 14 ). Specifically designed for individuals aged 14 to 17, this instrument was translated from English into Italian and consists of 29 items grouped into four subdomains: (A) Difficulty in managing health-related information (cognitive and behavioural); (B) Health-related communication skills (behavioural-communicative); (C) Attitudes toward personal health and health information (self-awareness, self-control, motivation, and interest); (D) Health-related knowledge. Responses were measured using Likert scales. Parental health literacy was assessed using the Italian version of the Medical Term Recognition Test (IMETER) ( 15 ). This one-page instrument includes two columns: 40 commonly used medical terms and 30 non-medical or fictitious terms. An adjusted score was then calculated attributing 1 point to each correct recognitions but subtracting 1 for incorrect ones. To assess knowledge regarding vaccine-preventable diseases and vaccinations, different instruments were administered. Parents completed the "Vaccination & HPV Knowledge" (THinK) questionnaire ( 16 ), comprising 13 items on a 5-point Likert scale. Items addressed the general knowledge about vaccination, HPV, associated risks, and vaccine acceptability. Parents also answered 13 true/false/don’t know questions about HPV. Adolescents responded to six items assessing HPV knowledge using a 5-point agreement scale ( 17 ) with a different scoring system according to the type of questions. Certain items on the Likert scale were phrased negatively and were therefore reverse-coded to ensure consistency in the direction of scoring. Both adolescents and parents completed the Vaccine Attitudes Examination (VAX) Scale, consisting of 12 items across four subscales ( 18 ): 1. Mistrust of vaccine benefits; 2. Worries about unforeseen future effects; 3. Concerns about commercial profiteering; 4. Preference for natural immunity over vaccination-acquired immunity. Each item was rated on a 6-point Likert scale (1 = I definitely do not agree, 6 = I definitely agree). The 1st, 2nd, and 3rd items of the VAX SCALE are inversely scored. Cultural affiliation was measured using the Strength of Cultural Affiliation Scale (SCAS) developed by Mood ( 19 ). This 18-item instrument uses a 5-point Likert scale with total scores ranging from 0 to 72 (no cultural affiliation to 72 strongest cultural affiliation). Data management and statistical analysis Ahead of the statistical analysis, the following data reclassification was performed. As regards the socio-demographic variables, with reference to the educational attainment, the classification was as follows: “up to high school” for the answers "None", "Middle school" and "High school" and “degree or more” for the answers "Degree" and "Post-graduate". Citizenship was coded as Italy for Italian respondents and Not Italy for respondents with non-Italian citizenship. Adolescents’ health literacy was classified as follows. For the MOHLAA-Q scale A, mean scores were categorized as follows: 1–2.5, many difficulties; > 2.5–3, some difficulties; > 3–3.5, few difficulties; > 3.5–4, barely/no difficulties. For scale B the following classification was considered: 1–2.5, low communication/interaction skills; > 2.5–3, moderate skills; > 3–3.5: rather high skills; > 3.5–4: high skills. For scale C the following criteria were adopted: 1–3: passive attitudes; > 3–4: partially passive/active attitudes, > 4–5: active attitudes. For scale D a score from 0 to 3 was considered representing low health-related knowledge; 4–5, moderate knowledge; 6–8, high knowledge. Parental health literacy was considered low, marginal and functional if the adjusted score was 0–20, 21–34, and 35–40 respectively. Parental knowledge of vaccine-preventable disease and vaccinations was classified as low for THINK total scores ranging from 0 to 17, moderate for scores from 18 to 35 and high for scores higher than 25. Parental knowledge of HPV was classified low for score lower than 5, medium for scores from 5 to 18 and high for score higher than 8 at the 13-items questionnaire. Total VAX scores were categorized as follows: 12–31 - low negative attitude; 32–51 - moderate negative attitude; 52–72 - high negative attitude. Subcategories scores (each ranging from 3 to 18) were categorized as follows: 3–7 - low negative attitude; 8–12 - moderate negative attitude; 13–18 - high negative attitude. Cultural affiliation was classified as low, moderate or high for a total score less than 25, between 25 and 48 and higher than 48 respectively. Descriptive statistics summarized data across all questionnaire sections and subsections. Chi-square test was used to evaluate the association between individual and group determinants and the adolescents’ vaccination status. In respect to the latter, the study population was divided in two groups: fully vaccinated and not fully vaccinated. Fully vaccinated were adolescents who took the booster dose against diphtheria-pertussis-tetanus-polio and received the meningococcal vaccine and at least one dose of HPV vaccine. Adolescents whose parents did not remember the vaccination status were considered not vaccinated. Results Sociodemographic characteristics of the sample We received at least 1 response from 43 schools, 37 of these (86%) from the Province of Perugia and 6 (14%) from the Province of Terni. Out of the 6,996 potentially eligible participants, 277 adolescent-parent pairs completed the questionnaire, yielding an overall response rate of 3.9%. The general characteristics of the study population are presented in Table 1 . Regarding adolescents, the sample consists of 146 female participants (52.7%) and 131 male participants (47.3%). Responding parents consisted predominantly of mothers (91.7%). Most of them held a high school diploma (49.8%), followed by university degree (31.4%) and postgraduate degrees (11.2%). Only 7.6% reported an educational level below upper secondary school. Regarding the educational attainment of the spouse or cohabiting partner, a similar distribution was observed: high school (58.4%), university degree (17.3%), and middle school (18.1%), with postgraduate education reported in 3.6% of cases. In terms of employment, 48% of responding parents were employed full-time, 28.1% part-time, and 14.8% were freelancers or self-employed. The employment status of the spouse or cohabitant was predominantly full-time (64.3%), followed by self-employed (24.5%) and part-time (5.1%). Almost all participants were Italian citizens (96.7%), with small percentages from Romania (1.4%) and other European or Asian countries. As for religious affiliation, 84.5% identified as Catholic Christians, followed by atheists (9%), with a small proportion belonging to other religions or opting not to disclose their affiliation. Table 1 Sociodemographic Characteristics of the Sample Socio-demographic variable Frequency (N) Percentage (%) Adolescents Gender Female 146 52.7 Male 131 47.3 Province Perugia 238 85.9 Terni 39 14.1 Parents Parentage Mother 254 91.7 Father 23 8.3 Responder’s educational attainment Postgraduate 31 11.2 Degree 87 31.4 High school 138 49.8 Middle school 20 7.2 Nobody 1 0.4 Spouse/cohabitant’s educational attainment Postgraduate 10 3.6 Degree 48 17.3 High school 162 58.4 Middle school 50 18.1 Elementary school 2 0.7 Not applicable 4 1. 4 Nobody 1 0.4 Employment status Househusband 21 7.6 Full-time employee 133 48 Part-time employee 78 28.1 Unemployed 2 0.7 Job seekers 2 0.7 Freelancer/Self-employed 41 14.8 Spouse/cohabitant’s employment status Househusband 3 1.1 Full-time employee 178 64.3 Part-time employee 14 5.1 Unemployed 5 1.8 Freelancer/Self-employed 68 24.5 Not applicable 9 3.2 Responder’s citizenship Italy 268 96.7 Romania 4 1.4 Czech Republic 2 0.7 Albania 1 0.4 Filipino 1 0.4 Germany 1 0.4 Responder’s Religious affiliation Atheist 25 9 Catholic Christian 234 84.5 Orthodox Christian 2 0.7 Muslim 1 0.4 I prefer not to answer 15 5.4 Adolescents’ vaccination status and distribution of individual and group determinants 86.3% of parents reported that their children were administrated the diphtheria-pertussis-tetanus-polio booster, 90.6% the quadrivalent meningococcal vaccine, 69.7% two doses of the HPV vaccine, and 22.4% one dose only. Therefore, 79.9% (95%CI 74.5% – 84.3%) of the sample met the criteria for full vaccination status, while 20.2% (95%CI 15.6% – 25.4%) did not (Fig. 1 ). Health literacy among adolescents is shown in Table 2 . With regard to the management of health-related information, 16.6% of participants reported many difficulties, 53.8% some difficulties, 26.7% few difficulties, and only 2.9% reported no or negligible difficulties. Communication skills were generally adequate, with 32.5% of respondents scoring high, 32.1% quite high, 27.1% moderate, and 8.3% low. In terms of health attitudes, many adolescents exhibited an active orientation toward their health (51.3%), while 45.5% reported a mixed passive/active stance and only 3.2% demonstrated a predominantly passive attitude. Regarding general health knowledge, nearly half of the respondents (49.8%) showed a low level, 41.9% a moderate level, and only 8.3% a high level of knowledge. In the parent sample, the majority (59.6%) exhibited marginal literacy, 22.7% had low literacy, and only 17.7% demonstrated adequate functional literacy (Table 2 ). HPV-specific knowledge among adolescents highlighted several misconceptions (Table 2 ). A total of 20.6% of adolescents either agreed with or were uncertain about the statement that males cannot contract HPV, while 79.4% correctly disagreed. The majority (73.3%) acknowledged that vaccinated females should still undergo routine cervical cancer screening, and 81.6% correctly recognized HPV’s sexual transmission. However, 30.3% believed or were unsure whether HPV is very rare, and 24.9% did not identify HPV as a cause of cervical cancer. Notably, only 24.9% correctly understood that the HPV vaccine does not protect against all types of cervical cancer. Knowledge of vaccines and vaccine-preventable diseases among parents was predominantly low (76.9%), with 23.1% achieving a moderate level (Table 2 ). HPV-specific knowledge among parents was high in 41.6%, moderate in 48.8%, and low in 9.6% (Table 2 ). With respect to cultural affiliation, most parents reported a moderate influence of cultural beliefs on health-related decisions (66.4%), followed by low (24.5%) and high (9.1%) influence (Table 2 ). Table 2 Cultural individual and group determinants Frequency (N) Percentage (%) Adolescents Health literacy - MOHLAA-Q Subdomain A - Health Information Management Difficulty Level Many 46 16.6 Some 149 53.8 Few 74 26.7 Barely/No 8 2.9 Subdomain B – Health-related communication skills Low 23 8.3 Moderate 75 27.1 Quite high 89 32.1 High 90 32.5 Subdomain C - Attitude towards one's health and health information Passive 9 3.2 Partly passive – partly active 126 45.5 Active 142 51.3 Subdomain D - Level of knowledge related to health Low 138 49.8 Moderate 116 41.9 High 23 8.3 Adolescents’ HPV knowledge Males cannot contract HPV Agree - Strongly agree- Neither agree nor disagree 57 20.6 Strongly disagree – Disagree 220 79.4 Women vaccinated against HPV must have Pap smears (checks for cervical cancer) as they age Agree – Strongly agree 203 73.3 Neither agree nor disagree – Strongly disagree – Disagree 74 26.7 HPV can be contracted through sexual activity Agree –Strongly agree 226 81.6 Neither agree nor disagree – Strongly disagree – Disagree 51 18.4 HPV is very rare Agree - Strongly agree- Neither agree nor disagree 84 30.3 Strongly disagree – Disagree 193 69.7 HPV can cause cervical cancer Agree –Strongly agree 208 75.1 Neither agree nor disagree – Strongly disagree – Disagree 69 24.9 HPV vaccine protects against all types of cervical cancer Agree –Strongly agree 69 24.9 Neither agree nor disagree – Strongly disagree – Disagree 208 75.1 Parents Health literacy – IMETER Low literacy 63 22.7 Marginal literacy (limited) 165 59.6 Functional literacy (adequate) 49 17.7 Knowledge about vaccines and vaccine-preventable diseases - THINK (251) Low level 193 76.9 Moderate level 58 23.1 Parents' Knowledge of HPV (250) Low knowledge 24 9.6 Moderate knowledge 122 48.8 High knowledge 104 41.6 Influence of Cultural Affiliation - SCAS SCALE (253) Low influence 62 24.5 Moderate influence 168 66.4 High influence 23 9.1 Figure 2 reports vaccination attitudes among adolescents and parents. More than half of both adolescents and parents exhibited a moderate negative attitude toward vaccines, 54.7% and 55.3% respectively whereas 5.6% and 4.3% showed high negative attitudes. When analyzing the VAX Scale subcomponents, the following results emerged: Mistrust of vaccine benefit: Among parents, 49.4% exhibited a low negative attitude, 27.3% a moderate one, and 23.3% a high negative attitude. Among adolescents, a higher percentage, namely 58.3%, showed a low negative attitude, 23.6% a moderate one, and 18.1% a high negative attitude. Worries about unforeseen future effects: 17% of parents expressed a low negative attitude, 35.2% a moderate one, and 47.8% a high negative attitude. In adolescents, the distribution was similar: 13.1% low, 35.4% moderate, and 51.5% high negative attitude. Concerns about commercial profiteering: 58.9% of parents reported a low negative attitude, 31.2% a moderate one, and 9.9% a high negative attitude. Results were similar among adolescents, with 62.2% showing a low negative attitude, 30.5% a moderate one, and 6.9% a high negative attitude. Preference for natural immunity: 54.4% of parents expressed a low negative attitude, 34.5% a moderate one, and 11.1% a high negative attitude. Similarly, among adolescents, 44.9% showed a low negative attitude, 42.6% a moderate one, and 12.5% a high negative attitude. Associations between investigated determinants and vaccination status The analysis of the associations between investigated determinants and vaccination status did not reveal significant results in respect to socio-demographic characteristics (Table 3 ). Nevertheless, a higher proportion of fully vaccinated adolescents were observed among Italians, females, Catholic Christians and residing in the province of Terni, as well as in children of respondent parents with basic education and part-time employed. Table 3 Associations between socio-demographic determinants and adolescents’ vaccination status Potential determinants Fully vaccinated Not fully vaccinated P -value Adolescents (277) Gender Female 120 (82.2) 26 (17.8) 0.382 Male 102 (77.8) 29 (22.2) Province Perugia 189 (79.4) 49 (20.6) 0.704 Terni 32 (82.1) 7 (17.9) Parents (277) Mother 206 (81.1) 48 (18.9) 0.069 Father 15 (65.2) 8 (34.8) Responder’s educational qualification attainment Up to high school 130 (81.7) 29 (18.3) 0.341 University degree or over 91 (77.1) 27 (22.9) Spouse/cohabitant’s educational qualification attainment Up to high school 174 (79.4) 45 (20.6) 0.790 University degree or over 47 (81.1) 11 (18.9) Work Employment status Househusband 17 (80.9) 4 (19.1) 0.503 Full-time employee 103 (77.4) 30 (22.6) Part-time employee 67 (85.9) 11 (14.1) Unemployed 2 (100) 0 (0) Job seekers 1 (50) 1 (50) Freelancer 31 (75.6) 10 (24.4) Spouse/cohabitant’s employment status Househusband 1 (33.3) 2 (66.7) 0.119 Full-time employee 140 (78.6) 38 (21.4) Part-time employee 9 (64.3) 5 (35.7) Unemployed 4 (80) 1 ( 20 ) Freelancer 59 (86.8) 9 (13.2) Not applicable 8 (79.8) 1 (11.2) Responder’s Citizenship Italian 215 (80.2) 53 (19.8) 0.319 Not Italian 6 (66.7) 3 (33.3) Responder’s Religious affiliation Atheist 18 (71.9) 7 (28.1) 0.143 Catholic Christian 191 (81.6) 43 (19.4) Orthodox Christian 1 (50) 1 (50) Muslim 0 (0) 1 (100) I prefer not to answer 11 (73.3) 4 (26.7) On the contrary, significant associations were found in respect to specific cultural determinants. As shown in Table 4 , a significant association emerged for the THINK scale. Parents with lower knowledge showed a higher rate of fully vaccinated adolescents (84.9%) than those with moderate knowledge (72.4%; p = 0.029). Similarly, a strong association was found with parental knowledge about HPV. In this case, among parents with high knowledge, 88.4% reported to have children fully vaccinated, compared to 58.3% among those with low knowledge ( p = 0.002). Also, adolescents’ HPV knowledge revealed an association with vaccination status. Adolescents who incorrectly believed that the HPV vaccine protects against all types of cervical cancer had the highest uptake, 91.3% as compared to 75.8% among those who correctly denied this ( p = 0.006). Likewise, 83.2% of those who recognized that HPV could cause cervical cancer were fully vaccinated, versus 69.7% of those who did not ( p = 0.015). Awareness of the need for Pap testing in vaccinated women was also linked to higher uptake (82.3% vs. 72.9%), although this difference did not reach statistical significance ( p = 0.081). Parental health literacy was not found associated with vaccination status while, in respect to adolescents’ health literacy, a more active attitude toward health was significantly associated with a full vaccinated status. Among adolescents classified as "active", 78.9% were fully vaccinated, compared to only 44.4% of those with a passive stance ( p = 0.018). Eventually, cultural affiliation and both parents’ and adolescents’ VAX Scale scores, including their subcomponents (results not shown), were not significantly associated with vaccination status. Table 4 Associations between cultural determinants and adolescents’ vaccination status Potential determinants Fully vaccinated Not fully vaccinated p-value Adolescents (277) Health literacy - MOHLAA-Q Subdomain A - Health Information Management Difficulty Level Many 40 (86.9) 6 (13.1) 0.107 Some 117 (78.5) 32 (21.5) Few 60 (81.1) 14 (18.9) Barely/No 4 (50) 4 (50) Subdomain B – Health-related communication skills Low 17 (73.9) 6 (26.1) 0.136 Moderate 65 (86.7) 10 (13.3) Quite high 65 (73.1) 24 (27.9) High 74 (82.2) 16 (17.8) Subdomain C - Attitude towards one's health and health information Passive 4 (44.4) 5 (55.6) 0.018 Partly passive – partly active 105 (83.3) 21 (16.7) Active 112 (78.9) 30 (21.1) Subdomain D - Level of knowledge related to health Low 112 (81.2) 26 (18.8) 0.716 Moderate 92 (79.3) 24 (20.7) High 17 (73.9) 6 (26.1) Adolescents’ HPV knowledge Males cannot contract HPV Agree - Strongly agree- Neither agree nor disagree 45 (78.9) 12 (21.1) 0.860 Strongly disagree – Disagree 176 (80) 44 ( 20 ) Women vaccinated against HPV must have Pap smears (checks for cervical cancer) as they age Agree – Strongly agree 167 (82.3) 36 (17.7) 0.081 Neither agree nor disagree – Strongly disagree – Disagree 54 (72.9) 20 (27.1) HPV can be contracted through sexual activity Agree –Strongly agree 183 (80.9) 43 (19.1) 0.299 Neither agree nor disagree – Strongly disagree – Disagree 38 (74.5) 13 (25.5) HPV is very rare Aree - Strongly agree- Neither agree nor disagree 67 (79.8) 17 (20.2) 0.995 Strongly disagree – Disagree 154 (79.8) 39 (20.2) HPV can cause cervical cancer Agree –Strongly agree 173 (83.2) 35 (16.7) 0.015 Neither agree nor disagree – Strongly disagree – Disagree 48 (69.7) 21 (20.3) HPV vaccine protects against all types of cervical cancer Agree –Strongly agree 63 (91.3) 6 (8.7) 0.006 Neither agree nor disagree – Strongly disagree – Disagree 158 (75.9) 50 (24.1) Adolescents Vax Scale - General attitude towards vaccines Low negative attitude 96 (80.7) 23 (19.3) 0.930 Moderate negative attitude 115 (79.3) 30 (20.7) High negative attitude 10 (76.9) 3 (23.1) Parents (277) Parental Health literacy - IMETER Low literacy 45 (71.4) 18 (28.6) 0.170 Marginal literacy (limited) 136 (82.4) 29 (17.6) Functional literacy (adequate) 40 (81.6) 9 (18.4) Parental knowledge about vaccines and vaccine-preventable diseases - THINK (251) Low level 164 (84.9) 29 (15.1) 0.029 Moderate level 42 (72.4) 16 (27.6) Parental knowledge of HPV (250) Low knowledge 14 (58.3) 10 (41.7) 0.002 Moderate knowledge 99 (81.2) 23 (18.8) High knowledge 92 (88.4) 12 (11.6) Parental Vax Scale - General attitude towards vaccines (253) Low negative attitude 81 (81.8) 18 (18.2) 0.612 Moderate negative attitude 115 (82.1) 25 (17.9) High negative attitude 10 (71.4) 4 (28.6) Cultural Affiliation - SCAS SCALE (253) Low 53 (85.4) 9 (14.6) 0.295 Moderate 134 (79.8) 34 (20.2) High 21 (91.3) 2 (8.7) Discussion The present work shows that around one out of five adolescents enrolled in the study have not received all the vaccinations recommended by age. It is interesting to observe that this finding was not led by a lower HPV uptake as 92.1% of adolescents received at least one dose. This coverage is higher than the one reported in the official nationwide statistics for both the whole nation and the Umbria region at the end of 2024 and could be due to self-selection bias, namely the participation to the survey of people with better attitudes and behaviours to vaccination. Nevertheless, it should be noted that Umbria Region together with Lombardy consistently show higher coverage rates, for both the first dose and the full cycle ( 2 ). The study also issues new evidence on the individual cultural determinants of adolescents’ vaccination status, with findings that are not always aligned with the literature. In this respect, parents with higher levels of general knowledge about vaccines showed a lower likelihood of having fully vaccinated adolescents than those with lower knowledge. This is a departure from what has been highlighted in the literature, where greater knowledge is usually associated with greater vaccination acceptance ( 20 ). A possible explanation may lie in overexposure to sources of information that are not always reliable, which generates doubts even in subjects with apparent good knowledge, which may not reflect a true critical "vaccine literacy" ( 21 ). Indeed, it has been estimated that about two-thirds of the world population has access to internet; this opportunity, together with the growing distrust in health authorities, can foster the development and dissemination of alternative medicine theories and movements ( 22 ). Conversely, parental knowledge of HPV, in line with what has been reported in the literature ( 23 ), is associated with a higher probability of the uptake of recommended vaccination in adolescents. In addition, also adolescents’ specific knowledge about HPV is associated with vaccination status. In particular, the awareness that HPV can cause cervical cancer as well as the understanding that the vaccine does not protect against all types of cervical cancers are associated with a higher likelihood of being fully vaccinated. Studies conducted both in international contexts ( 24 , 25 ) and in Italy ( 26 – 28 ) confirm that accurate and realistic knowledge of infectious risks and vaccine benefits is an important predictor of vaccination among adolescents. A particularly interesting finding is the positive association between adolescents’ active attitude towards health and full vaccination status. This confirms the results of previous studies ( 29 ), according to which personal engagement in caring for one's own health is a powerful predictor of preventive behaviours ( 30 ), including vaccination. This result calls the attention on adolescents’ health literacy as a potential leverage for improving vaccinations uptake. Some caution needs to be put in interpreting the results of our study because of some limitations that need to be taken into account. First of all, the low response rate (3.9%) and the possible self-selection of the sample limit the generalizability of the results. It is indeed possible that adolescents and parents already sensitive to the issue of vaccination participated to the survey, reducing the variability of the sample. The low participation rate may also reflect practical and organizational constraints related to the study setting. The survey was administered through schools and involved a limited number of contact attempts, which may have reduced opportunities for participation. Schools generally aim to facilitate such surveys while minimizing the burden on parents, who are often reluctant to participate in research studies, and thus try to limit repeated solicitations. In addition, schools frequently receive numerous requests for survey-based research, making it challenging to implement multiple waves of data collection. More intensive recruitment strategies, such as additional contact waves, reminders addressed directly to adolescents and parents, or alternative modes of administration, might have increased response rates but were not feasible within the logistical and institutional constraints of the study context. Furthermore, information on reasons for non-participation was not available, preventing a direct assessment of non-response bias. It is possible that factors such as timing of data collection during the school year, family commitments, or limited engagement with school-mediated health initiatives contributed to non-response. Reporting these considerations may be informative for future studies aiming to assess adolescent vaccination status through school-based surveys. The possibility of self-selection bias cannot be ruled out, particularly given the high HPV vaccination coverage for the first dose detected in our sample compared with the overall Umbrian population. On the contrary the vaccination coverage for the full cycle detected in our study (69.7%), although higher than national estimates, was slightly lower than the one reported for Umbria Region in the last birth female and male cohorts in 2024 ( 2 ). This last finding could suggest that some adolescents did not have the chance to take their second dose only for the scheduling of doses (anticipatory children who started school earlier and turned 12 years old during the third year of the lower secondary school). Anyway, in order to avoid this potential problem, we decided to consider only the uptake of the first dose of HPV vaccine in identifying full vaccinated children. Overall, the findings of this study are likely to be most generalizable to adolescents living in the same regional context who belong to families with relatively higher awareness of vaccination-related issues and a greater propensity to participate in health surveys. The study population mainly consisted of adolescents and parents who voluntarily completed an online questionnaire, which may have favoured the participation of families with higher health literacy, more positive attitudes toward vaccinations, and greater engagement with preventive health services. Therefore, caution is warranted when extrapolating these results to adolescents from more disadvantaged backgrounds or with lower engagement in preventive healthcare. Another limit is linked to the potential misclassification of both the investigated determinants and the study endpoint that was not possible to verified through the vaccination records. However, in respect to the latter issue, previous studies have shown a generally good agreement between self-reported HPV vaccination status and medical records, suggesting that self-reported data can provide reasonably valid estimates of HPV vaccine uptake ( 31 – 33 ). Nevertheless, this misclassification is expected to be non-differential and could have contribute to a dilution of some associations. Eventually, found associations are not representing causal associations because of the nature of the study design. The study has also relevant strengths. To the best of our knowledge, it is the first study addressing the overall vaccination status of adolescents moving the attention from HPV only to all the vaccinations recommended by age providing new important insights and stimuli for future research also in the light of overcoming current challenges in the conduction of such kind of study. Furthermore, it encompasses a diversity of determinants, some of them often overlooked, through the adoption of validated tools and considering at the same time both parents and adolescents. Eventually, the study findings, albeit exploratory, set the foundation for further investigating the role of some specific determinants, such as health literacy, and for elaborating more on the role of attitudes towards vaccinations. Conclusions This study highlights that a relevant proportion of adolescents are not vaccinated against vaccine-preventable diseases for which they could be protected according to national recommendations. Beyond knowledge and attitudes, vaccination status is associated with adolescents’ health literacy, in particular with their attitude towards own’s health. This could play as new leverage to improve vaccination uptake in adolescents. Declarations Disclaimer: Merck Sharp & Dohme LLC provided financial support. The views expressed in this document are those of the authors and do not necessarily represent those of Merck Sharp & Dohme LLC. Funding declaration : This study was financially supported by Merck Sharp & Dohme LLC. The funder had no role in the design of the study; in the collection, analysis, or interpretation of data; in the writing of the manuscript; or in the decision to publish the results. Authors’ contributions: Conceptualization, CdW, M.C., G.P.; formal analysis, V.C.; investigation, V.C., C.B., L.B., F.P., data curation, V.C. and C.B.; writing—original draft preparation, V.C., C.B., L.B., F.P., G.P. and M.C. writing—review and editing, C.d.W.; supervision, C.d.W.; project administration, V.C., C.B. and CdW. All authors read and approved the final manuscript Ethics approval and consent to participate : The study protocol was approved by the Umbria Regional Ethics Committee (protocol n. 26538/22/OV of January 3rd, 2023). The study was conducted in accordance with the principles of the Declaration of Helsinki and with relevant national regulations, including EU Regulation 2016/679 (GDPR). Informed consent was obtained electronically from all participants prior to participation. Before accessing the questionnaire, participants were required to read the online informed consent form available via a dedicated link. Participants could proceed to the survey only after confirming that they had read the information sheet (“By proceeding, I declare that I have read the informed consent”). For underage participants, consent was obtained from parents or legal guardians through the same electronic procedure. Availability of data and materials : The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. Acknowledgements : The authors thank the Regional School Office for Umbria and the principals of participant schools for their support. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8956447","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":605063510,"identity":"ee086e89-7a98-4730-a423-651db338f9d0","order_by":0,"name":"Vito Cerabona","email":"","orcid":"","institution":"University of Perugia","correspondingAuthor":false,"prefix":"","firstName":"Vito","middleName":"","lastName":"Cerabona","suffix":""},{"id":605063511,"identity":"b4be429b-f28c-4ab1-8526-15d6027cc3a8","order_by":1,"name":"Carlotta 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adolescents\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-8956447/v1/14a4639a5759e224ebaed4c7.png"},{"id":104838082,"identity":"90e13772-9c1f-4a2c-b4c1-4d1b81325bf2","added_by":"auto","created_at":"2026-03-17 18:10:46","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":5713,"visible":true,"origin":"","legend":"\u003cp\u003eVaccination attitudes among parents and adolescents\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-8956447/v1/727ee1a1596c742f5250565f.png"},{"id":104838094,"identity":"1fd5c04e-1f80-4b77-b52c-94551410a7e3","added_by":"auto","created_at":"2026-03-17 18:10:55","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2401272,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8956447/v1/313faea6-63bc-4477-92a3-80d3ba0ba9bb.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eDiscordant vaccine uptake and its determinants among adolescents in a context of high vaccination coverage and longtime immigration: a cross-sectional study in Umbria region, Italy\u003c/p\u003e","fulltext":[{"header":"Key Message","content":"\u003cp\u003e\u003cstrong\u003eWhat is already known on this topic\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAdolescent vaccination coverage in Italy is generally high, but HPV vaccine uptake remains suboptimal. Vaccine acceptance is influenced by socio-demographic, cognitive, and attitudinal factors, yet evidence focusing specifically on adolescents and their overall vaccination status is limited.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eWhat this study adds\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study provides novel evidence on adolescents\u0026rsquo; full vaccination status in Italy, showing that uptake is more strongly associated with HPV-specific knowledge and adolescents\u0026rsquo; health orientation than with socio-demographic factors. It also highlights unexpected patterns in parental vaccine knowledge and acceptance.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHow this study might affect research, practice, or policy\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFindings support the development of targeted interventions aimed at strengthening adolescents\u0026rsquo; health literacy and HPV-specific knowledge. Policies integrating adolescent-focused education and communication strategies may help improve vaccination coverage and reduce missed immunization opportunities.\u003c/p\u003e"},{"header":"Introduction","content":"\u003cp\u003eVaccination during adolescence represents a crucial public health strategy, as it allows boosting immune systems and providing protection before the potential exposure to various infectious agents, such as Human Papilloma Virus (HPV). Several international health authorities, including the European Centre for Disease Prevention and Control (ECDC), emphasize the importance of adolescent immunization to ensure timely protection and long-term population health benefits (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Within this framework, HPV vaccine plays a pivotal role in preventing HPV-related diseases. In Italy, HPV vaccination was introduced in 2007, and the National Immunization Prevention Plan (PNPV) 2017\u0026ndash;2019 set a target of at least 95% coverage among 12-year-olds of both sexes. However, coverage for the complete HPV vaccination cycle remains below this goal, with substantial regional disparities (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Coverage among males is even lower, ranging from 4.79% to 43.99%. The COVID-19 pandemic has further contributed to a decline in vaccination rates, particularly in the adolescent target group (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). The Italian National Immunization Programme (NIP) includes multiple vaccinations recommended during adolescence, namely those against diphtheria, tetanus, pertussis (DTaP), poliomyelitis, meningococcal diseases, and HPV. Although national vaccination coverage is regularly monitored, the available data are typically reported by individual vaccines rather than reflecting adolescents' overall immunization status. This approach limits the ability to assess the completeness of vaccination at the individual level and highlights the need for studies that evaluate the full vaccination status. We know that, in 2024, vaccination coverage for diphtheria, tetanus, pertussis, and poliomyelitis among 16-year-olds exceeded 92%, while coverage for meningococcal diseases surpassed 90%. These rates are markedly higher than coverage reported for the complete HPV vaccination cycle (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). The factors influencing vaccine uptake are diverse and multifaceted, and they have been categorized using various conceptual frameworks. One of the most widely adopted models is the matrix developed by the WHO Strategic Advisory Group of Experts (SAGE) on Immunization, which classifies determinants of vaccine acceptance into three broad domains: contextual influences (such as socioeconomic and political factors), individual and group influences (including personal beliefs, experiences, and social norms), and vaccine- or vaccination-specific issues (such as perceived risk, benefit, and accessibility) (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). Among the many reasons for low uptake, vaccine hesitancy\u0026mdash;defined as a delay in acceptance or refusal of vaccination despite availability of vaccination services\u0026mdash;plays a critical role (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). The determinants of vaccine hesitancy and uptake have been extensively studied in the general population and in childhood in Italy (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e), yet research focusing specifically on adolescents remains limited. In the Italian literature, research on vaccination determinants addresses both contextual factors and individual and group influences on vaccination behavior. Among these individual determinants, socioeconomic factors such as financial hardship and education level have been identified as significant predictors of vaccine acceptance. Additionally, demographic characteristics\u0026mdash;including racial background, parental age and marital status, and family size\u0026mdash;have been shown to influence vaccination decisions. Cultural determinants, including religious beliefs, have also been identified as factors that may positively or negatively affect vaccine uptake (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). One key individual-group determinant that remains under-investigated is cultural affiliation, defined as the extent to which individuals attribute their everyday behaviours, attitudes, and values to the traditions and involvement with their self-identified cultural group (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). While cultural affiliation is generally considered to play a positive role in health behaviours, its specific impact on vaccine uptake, particularly among adolescents, has yet to be thoroughly examined (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). Furthermore, health literacy\u0026mdash;understood as the combination of cognitive and social skills enabling individuals to access, understand, and use health information effectively (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e) \u0026mdash;has been acknowledged as an important determinant of health behaviour (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). Health literacy\u0026mdash;the combination of cognitive and social skills enabling individuals to access, understand, and use health information effectively\u0026mdash;has been recognized as an important determinant of vaccination behaviour, with several studies demonstrating its positive association with vaccine uptake in the general population, including adults. However, research focusing specifically on the role of health literacy in adolescent vaccination is still limited, especially in Italy, where data remain scarce (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). In this study, we specifically focus on the overall vaccination status of adolescents in Italy and on its individual and group determinants, with the aim to explore their association with adolescents\u0026rsquo; adherence to vaccination programs. By investigating these factors, we aim to provide novel insights into the drivers of vaccine uptake in this critical age group, addressing areas that have received limited attention in previous research, thereby contributing to supporting the design of tailored interventions to increase vaccination coverage.\u003c/p\u003e"},{"header":"Material and Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design and population\u003c/h2\u003e \u003cp\u003eA cross-sectional observational study was conducted in Umbria, a Region of Central Italy with 852,000 inhabitants through the administration of a web questionnaire in the school year 2024/2025. The study source was represented by the lower secondary schools of the Umbria region who agreed to collaborate in the conduction of the study. The source population included 6,996 12-year-old adolescents attending the third year of the 77 Umbrian lower secondary schools (55 from the Province of Perugia (76%) and 20 (24%) from the Province of Terni) at the time of data collection, together with their parents.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eInclusion criteria\u003c/h3\u003e\n\u003cp\u003eParticipants were eligible for inclusion if their family met the following conditions: at least one family member had to be proficient in the Italian language, ensuring effective comprehension of the questionnaire. In addition, the family was required to have been residing or domiciled in the Umbria region for at least two years prior to the study. Finally, participation was contingent upon confirming voluntary agreement to take part in the research after reading the informed consent form.\u003c/p\u003e\n\u003ch3\u003eParticipant recruitment\u003c/h3\u003e\n\u003cp\u003eRecruitment was carried through a two steps approach. First the principals of all the lower secondary schools in the Umbria region were reached out with the support of the Regional School Office to explore the willingness to let their schools participate in the project. After this step, a notice meant to be published in the electronic register and including the link to the survey and to informational materials was sent to the schools confirming their participation. Two reminder messages were sent in the following month.\u003c/p\u003e\n\u003ch3\u003eCollected variables: the questionnaire\u003c/h3\u003e\n\u003cp\u003eA questionnaire was developed to collect data on adolescents' vaccination status and a range of individual and groups determinants, including socio-economic, and cultural determinants. The questionnaire was created using SurveyMonkey, an online platform specialized in the design, administration, and analysis of surveys. The questionnaire was accompanied by a cover letter outlining the objectives of the study, procedures for data handling, and measures taken to ensure data protection. Both adolescents and their parents were invited to complete the questionnaire, which was divided into three main sections: individual socio-demographic characteristics, cultural individual determinants and cultural group determinants. Adolescents\u0026rsquo; vaccination status was self-reported by parents and collected separately for all age-recommended vaccines.\u003c/p\u003e \u003cp\u003eIn respect to potential determinants the following information was collected:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003e \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eIndividual socio-demographic characteristics\u003c/span\u003e: sex (of both the adolescent and the responding parent), residence (Perugia or Terni, the two provinces of Umbria region), parents\u0026rsquo; educational attainment and employment status, responding parent\u0026rsquo; citizenship, and religion.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eCultural individual determinants, namely health literacy, as well as knowledge, attitudes, and behaviours toward vaccine-preventable diseases and vaccinations\u003c/span\u003e of both the adolescent and the responding parent.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eCultural group determinants, namely cultural affiliation.\u003c/span\u003e \u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eTo assess adolescents\u0026rsquo; health literacy, the Measurement of Health Literacy Among Adolescents Questionnaire (MOHLAA-Q) was employed (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). Specifically designed for individuals aged 14 to 17, this instrument was translated from English into Italian and consists of 29 items grouped into four subdomains: (A) Difficulty in managing health-related information (cognitive and behavioural); (B) Health-related communication skills (behavioural-communicative); (C) Attitudes toward personal health and health information (self-awareness, self-control, motivation, and interest); (D) Health-related knowledge. Responses were measured using Likert scales. Parental health literacy was assessed using the Italian version of the Medical Term Recognition Test (IMETER) (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). This one-page instrument includes two columns: 40 commonly used medical terms and 30 non-medical or fictitious terms. An adjusted score was then calculated attributing 1 point to each correct recognitions but subtracting 1 for incorrect ones. To assess knowledge regarding vaccine-preventable diseases and vaccinations, different instruments were administered. Parents completed the \"Vaccination \u0026amp; HPV Knowledge\" (THinK) questionnaire (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e), comprising 13 items on a 5-point Likert scale. Items addressed the general knowledge about vaccination, HPV, associated risks, and vaccine acceptability. Parents also answered 13 true/false/don\u0026rsquo;t know questions about HPV. Adolescents responded to six items assessing HPV knowledge using a 5-point agreement scale (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e) with a different scoring system according to the type of questions. Certain items on the Likert scale were phrased negatively and were therefore reverse-coded to ensure consistency in the direction of scoring. Both adolescents and parents completed the Vaccine Attitudes Examination (VAX) Scale, consisting of 12 items across four subscales (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e): 1. Mistrust of vaccine benefits; 2. Worries about unforeseen future effects; 3. Concerns about commercial profiteering; 4. Preference for natural immunity over vaccination-acquired immunity. Each item was rated on a 6-point Likert scale (1\u0026thinsp;=\u0026thinsp;I definitely do not agree, 6\u0026thinsp;=\u0026thinsp;I definitely agree). The 1st, 2nd, and 3rd items of the VAX SCALE are inversely scored. Cultural affiliation was measured using the Strength of Cultural Affiliation Scale (SCAS) developed by Mood (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). This 18-item instrument uses a 5-point Likert scale with total scores ranging from 0 to 72 (no cultural affiliation to 72 strongest cultural affiliation).\u003c/p\u003e\n\u003ch3\u003eData management and statistical analysis\u003c/h3\u003e\n\u003cp\u003eAhead of the statistical analysis, the following data reclassification was performed. As regards the socio-demographic variables, with reference to the educational attainment, the classification was as follows: \u0026ldquo;up to high school\u0026rdquo; for the answers \"None\", \"Middle school\" and \"High school\" and \u0026ldquo;degree or more\u0026rdquo; for the answers \"Degree\" and \"Post-graduate\". Citizenship was coded as Italy for Italian respondents and Not Italy for respondents with non-Italian citizenship. Adolescents\u0026rsquo; health literacy was classified as follows. For the MOHLAA-Q scale A, mean scores were categorized as follows: 1\u0026ndash;2.5, many difficulties; \u0026gt; 2.5\u0026ndash;3, some difficulties; \u0026gt; 3\u0026ndash;3.5, few difficulties; \u0026gt; 3.5\u0026ndash;4, barely/no difficulties. For scale B the following classification was considered: 1\u0026ndash;2.5, low communication/interaction skills; \u0026gt; 2.5\u0026ndash;3, moderate skills; \u0026gt; 3\u0026ndash;3.5: rather high skills; \u0026gt; 3.5\u0026ndash;4: high skills. For scale C the following criteria were adopted: 1\u0026ndash;3: passive attitudes; \u0026gt; 3\u0026ndash;4: partially passive/active attitudes, \u0026gt; 4\u0026ndash;5: active attitudes. For scale D a score from 0 to 3 was considered representing low health-related knowledge; 4\u0026ndash;5, moderate knowledge; 6\u0026ndash;8, high knowledge. Parental health literacy was considered low, marginal and functional if the adjusted score was 0\u0026ndash;20, 21\u0026ndash;34, and 35\u0026ndash;40 respectively. Parental knowledge of vaccine-preventable disease and vaccinations was classified as low for THINK total scores ranging from 0 to 17, moderate for scores from 18 to 35 and high for scores higher than 25. Parental knowledge of HPV was classified low for score lower than 5, medium for scores from 5 to 18 and high for score higher than 8 at the 13-items questionnaire. Total VAX scores were categorized as follows: 12\u0026ndash;31 - low negative attitude; 32\u0026ndash;51 - moderate negative attitude; 52\u0026ndash;72 - high negative attitude. Subcategories scores (each ranging from 3 to 18) were categorized as follows: 3\u0026ndash;7 - low negative attitude; 8\u0026ndash;12 - moderate negative attitude; 13\u0026ndash;18 - high negative attitude. Cultural affiliation was classified as low, moderate or high for a total score less than 25, between 25 and 48 and higher than 48 respectively. Descriptive statistics summarized data across all questionnaire sections and subsections. Chi-square test was used to evaluate the association between individual and group determinants and the adolescents\u0026rsquo; vaccination status. In respect to the latter, the study population was divided in two groups: fully vaccinated and not fully vaccinated. Fully vaccinated were adolescents who took the booster dose against diphtheria-pertussis-tetanus-polio and received the meningococcal vaccine and at least one dose of HPV vaccine. Adolescents whose parents did not remember the vaccination status were considered not vaccinated.\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eSociodemographic characteristics of the sample\u003c/h2\u003e \u003cp\u003eWe received at least 1 response from 43 schools, 37 of these (86%) from the Province of Perugia and 6 (14%) from the Province of Terni. Out of the 6,996 potentially eligible participants, 277 adolescent-parent pairs completed the questionnaire, yielding an overall response rate of 3.9%. The general characteristics of the study population are presented in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Regarding adolescents, the sample consists of 146 female participants (52.7%) and 131 male participants (47.3%). Responding parents consisted predominantly of mothers (91.7%). Most of them held a high school diploma (49.8%), followed by university degree (31.4%) and postgraduate degrees (11.2%). Only 7.6% reported an educational level below upper secondary school. Regarding the educational attainment of the spouse or cohabiting partner, a similar distribution was observed: high school (58.4%), university degree (17.3%), and middle school (18.1%), with postgraduate education reported in 3.6% of cases. In terms of employment, 48% of responding parents were employed full-time, 28.1% part-time, and 14.8% were freelancers or self-employed. The employment status of the spouse or cohabitant was predominantly full-time (64.3%), followed by self-employed (24.5%) and part-time (5.1%). Almost all participants were Italian citizens (96.7%), with small percentages from Romania (1.4%) and other European or Asian countries. As for religious affiliation, 84.5% identified as Catholic Christians, followed by atheists (9%), with a small proportion belonging to other religions or opting not to disclose their affiliation.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSociodemographic Characteristics of the Sample\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eSocio-demographic variable\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eFrequency (N)\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003ePercentage (%)\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eAdolescents\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eGender\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eFemale\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e146\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e52.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eMale\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e131\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e47.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eProvince\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003ePerugia\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e238\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e85.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eTerni\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eParents\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eParentage\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eMother\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e254\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e91.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eFather\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eResponder\u0026rsquo;s educational attainment\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003ePostgraduate\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eDegree\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e87\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e31.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eHigh school\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e138\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e49.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eMiddle school\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eNobody\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSpouse/cohabitant\u0026rsquo;s educational attainment\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003ePostgraduate\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eDegree\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eHigh school\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e162\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e58.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eMiddle school\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eElementary school\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eNot applicable\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1. 4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eNobody\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEmployment status\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eHousehusband\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eFull-time employee\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e133\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e48\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003ePart-time employee\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e78\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e28.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eUnemployed\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eJob seekers\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eFreelancer/Self-employed\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSpouse/cohabitant\u0026rsquo;s employment status\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eHousehusband\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eFull-time employee\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e178\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e64.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003ePart-time employee\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eUnemployed\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eFreelancer/Self-employed\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e68\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eNot applicable\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eResponder\u0026rsquo;s citizenship\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eItaly\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e268\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e96.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eRomania\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eCzech Republic\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eAlbania\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eFilipino\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eGermany\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eResponder\u0026rsquo;s Religious affiliation\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eAtheist\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eCatholic Christian\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e234\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e84.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eOrthodox Christian\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eMuslim\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eI prefer not to answer\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eAdolescents’ vaccination status and distribution of individual and group determinants\u003c/h3\u003e\n\u003cp\u003e 86.3% of parents reported that their children were administrated the diphtheria-pertussis-tetanus-polio booster, 90.6% the quadrivalent meningococcal vaccine, 69.7% two doses of the HPV vaccine, and 22.4% one dose only. Therefore, 79.9% (95%CI 74.5% \u0026ndash; 84.3%) of the sample met the criteria for full vaccination status, while 20.2% (95%CI 15.6% \u0026ndash; 25.4%) did not (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eHealth literacy among adolescents is shown in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. With regard to the management of health-related information, 16.6% of participants reported many difficulties, 53.8% some difficulties, 26.7% few difficulties, and only 2.9% reported no or negligible difficulties. Communication skills were generally adequate, with 32.5% of respondents scoring high, 32.1% quite high, 27.1% moderate, and 8.3% low. In terms of health attitudes, many adolescents exhibited an active orientation toward their health (51.3%), while 45.5% reported a mixed passive/active stance and only 3.2% demonstrated a predominantly passive attitude. Regarding general health knowledge, nearly half of the respondents (49.8%) showed a low level, 41.9% a moderate level, and only 8.3% a high level of knowledge. In the parent sample, the majority (59.6%) exhibited marginal literacy, 22.7% had low literacy, and only 17.7% demonstrated adequate functional literacy (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). HPV-specific knowledge among adolescents highlighted several misconceptions (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). A total of 20.6% of adolescents either agreed with or were uncertain about the statement that males cannot contract HPV, while 79.4% correctly disagreed. The majority (73.3%) acknowledged that vaccinated females should still undergo routine cervical cancer screening, and 81.6% correctly recognized HPV\u0026rsquo;s sexual transmission. However, 30.3% believed or were unsure whether HPV is very rare, and 24.9% did not identify HPV as a cause of cervical cancer. Notably, only 24.9% correctly understood that the HPV vaccine does not protect against all types of cervical cancer. Knowledge of vaccines and vaccine-preventable diseases among parents was predominantly low (76.9%), with 23.1% achieving a moderate level (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). HPV-specific knowledge among parents was high in 41.6%, moderate in 48.8%, and low in 9.6% (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). With respect to cultural affiliation, most parents reported a moderate influence of cultural beliefs on health-related decisions (66.4%), followed by low (24.5%) and high (9.1%) influence (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCultural individual and group determinants\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eFrequency (N)\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003ePercentage (%)\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cem\u003eAdolescents\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cem\u003eHealth literacy - MOHLAA-Q\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSubdomain A - Health Information Management Difficulty Level\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eMany\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eSome\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e149\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e53.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eFew\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e74\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eBarely/No\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSubdomain B \u0026ndash; Health-related communication skills\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eLow\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eModerate\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e27.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eQuite high\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e89\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e32.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eHigh\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e90\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e32.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSubdomain C - Attitude towards one's health and health information\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003ePassive\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003ePartly passive \u0026ndash; partly active\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e126\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e45.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eActive\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e142\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e51.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSubdomain D - Level of knowledge related to health\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eLow\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e138\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e49.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eModerate\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e116\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e41.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eHigh\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAdolescents\u0026rsquo; HPV knowledge\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMales cannot contract HPV\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eAgree - Strongly agree- Neither agree nor disagree\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eStrongly disagree \u0026ndash; Disagree\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e220\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e79.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eWomen vaccinated against HPV must have Pap smears (checks for cervical cancer) as they age\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eAgree \u0026ndash; Strongly agree\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e203\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e73.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eNeither agree nor disagree \u0026ndash; Strongly disagree \u0026ndash; Disagree\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e74\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHPV can be contracted through sexual activity\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eAgree \u0026ndash;Strongly agree\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e226\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e81.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eNeither agree nor disagree \u0026ndash; Strongly disagree \u0026ndash; Disagree\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHPV is very rare\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eAgree - Strongly agree- Neither agree nor disagree\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e84\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eStrongly disagree \u0026ndash; Disagree\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e193\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e69.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHPV can cause cervical cancer\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eAgree \u0026ndash;Strongly agree\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e208\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e75.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eNeither agree nor disagree \u0026ndash; Strongly disagree \u0026ndash; Disagree\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e69\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHPV vaccine protects against all types of cervical cancer\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eAgree \u0026ndash;Strongly agree\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e69\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eNeither agree nor disagree \u0026ndash; Strongly disagree \u0026ndash; Disagree\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e208\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e75.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eParents\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHealth literacy \u0026ndash; IMETER\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eLow literacy\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e63\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eMarginal literacy (limited)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e165\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e59.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eFunctional literacy (adequate)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eKnowledge about vaccines and vaccine-preventable diseases - THINK (251)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eLow level\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e193\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e76.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eModerate level\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e58\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eParents' Knowledge of HPV (250)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eLow knowledge\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eModerate knowledge\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e122\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e48.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eHigh knowledge\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e104\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e41.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eInfluence of Cultural Affiliation - SCAS SCALE (253)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eLow influence\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eModerate influence\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e168\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e66.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eHigh influence\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003cbr\u003e\u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003eFigure \u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e reports vaccination attitudes among adolescents and parents. More than half of both adolescents and parents exhibited a moderate negative attitude toward vaccines, 54.7% and 55.3% respectively whereas 5.6% and 4.3% showed high negative attitudes. When analyzing the VAX Scale subcomponents, the following results emerged:\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eMistrust of vaccine benefit: Among parents, 49.4% exhibited a low negative attitude, 27.3% a moderate one, and 23.3% a high negative attitude. Among adolescents, a higher percentage, namely 58.3%, showed a low negative attitude, 23.6% a moderate one, and 18.1% a high negative attitude.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eWorries about unforeseen future effects: 17% of parents expressed a low negative attitude, 35.2% a moderate one, and 47.8% a high negative attitude. In adolescents, the distribution was similar: 13.1% low, 35.4% moderate, and 51.5% high negative attitude.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eConcerns about commercial profiteering: 58.9% of parents reported a low negative attitude, 31.2% a moderate one, and 9.9% a high negative attitude. Results were similar among adolescents, with 62.2% showing a low negative attitude, 30.5% a moderate one, and 6.9% a high negative attitude.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003ePreference for natural immunity: 54.4% of parents expressed a low negative attitude, 34.5% a moderate one, and 11.1% a high negative attitude. Similarly, among adolescents, 44.9% showed a low negative attitude, 42.6% a moderate one, and 12.5% a high negative attitude.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eAssociations between investigated determinants and vaccination status\u003c/h2\u003e \u003cp\u003eThe analysis of the associations between investigated determinants and vaccination status did not reveal significant results in respect to socio-demographic characteristics (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Nevertheless, a higher proportion of fully vaccinated adolescents were observed among Italians, females, Catholic Christians and residing in the province of Terni, as well as in children of respondent parents with basic education and part-time employed.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eAssociations between socio-demographic determinants and adolescents\u0026rsquo; vaccination status\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003ePotential determinants\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eFully vaccinated\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003eNot fully vaccinated\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003eP -value\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eAdolescents (277)\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eGender\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eFemale\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e120 (82.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26 (17.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.382\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eMale\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e102 (77.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e29 (22.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eProvince\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003ePerugia\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e189 (79.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e49 (20.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.704\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eTerni\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e32 (82.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7 (17.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eParents (277)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eMother\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e206 (81.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e48 (18.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.069\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eFather\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15 (65.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8 (34.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eResponder\u0026rsquo;s educational qualification attainment\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eUp to high school\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e130 (81.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e29 (18.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.341\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eUniversity degree or over\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e91 (77.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e27 (22.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSpouse/cohabitant\u0026rsquo;s educational qualification attainment\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eUp to high school\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e174 (79.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e45 (20.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.790\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eUniversity degree or over\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e47 (81.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11 (18.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eWork Employment status\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eHousehusband\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17 (80.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (19.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"5\" rowspan=\"6\"\u003e \u003cp\u003e0.503\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eFull-time employee\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e103 (77.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30 (22.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003ePart-time employee\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e67 (85.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11 (14.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eUnemployed\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eJob seekers\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (50)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (50)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eFreelancer\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e31 (75.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10 (24.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSpouse/cohabitant\u0026rsquo;s employment status\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eHousehusband\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (33.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (66.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"5\" rowspan=\"6\"\u003e \u003cp\u003e0.119\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eFull-time employee\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e140 (78.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e38 (21.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003ePart-time employee\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9 (64.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (35.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eUnemployed\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (80)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eFreelancer\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e59 (86.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9 (13.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eNot applicable\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8 (79.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (11.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eResponder\u0026rsquo;s Citizenship\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eItalian\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e215 (80.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e53 (19.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.319\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eNot Italian\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (66.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (33.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eResponder\u0026rsquo;s Religious affiliation\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eAtheist\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18 (71.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7 (28.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003e0.143\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eCatholic Christian\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e191 (81.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e43 (19.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eOrthodox Christian\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (50)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (50)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eMuslim\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (100)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eI prefer not to answer\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11 (73.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (26.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eOn the contrary, significant associations were found in respect to specific cultural determinants. As shown in Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e, a significant association emerged for the THINK scale. Parents with lower knowledge showed a higher rate of fully vaccinated adolescents (84.9%) than those with moderate knowledge (72.4%; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.029). Similarly, a strong association was found with parental knowledge about HPV. In this case, among parents with high knowledge, 88.4% reported to have children fully vaccinated, compared to 58.3% among those with low knowledge (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.002). Also, adolescents\u0026rsquo; HPV knowledge revealed an association with vaccination status. Adolescents who incorrectly believed that the HPV vaccine protects against all types of cervical cancer had the highest uptake, 91.3% as compared to 75.8% among those who correctly denied this (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.006). Likewise, 83.2% of those who recognized that HPV could cause cervical cancer were fully vaccinated, versus 69.7% of those who did not (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.015). Awareness of the need for Pap testing in vaccinated women was also linked to higher uptake (82.3% vs. 72.9%), although this difference did not reach statistical significance (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.081). Parental health literacy was not found associated with vaccination status while, in respect to adolescents\u0026rsquo; health literacy, a more active attitude toward health was significantly associated with a full vaccinated status. Among adolescents classified as \"active\", 78.9% were fully vaccinated, compared to only 44.4% of those with a passive stance (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.018). Eventually, cultural affiliation and both parents\u0026rsquo; and adolescents\u0026rsquo; VAX Scale scores, including their subcomponents (results not shown), were not significantly associated with vaccination status.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eAssociations between cultural determinants and adolescents\u0026rsquo; vaccination status\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003ePotential determinants\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eFully vaccinated\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003eNot fully vaccinated\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003ep-value\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eAdolescents (277)\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eHealth literacy - MOHLAA-Q\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSubdomain A - Health Information Management Difficulty Level\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eMany\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e40 (86.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 (13.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e0.107\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eSome\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e117 (78.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e32 (21.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eFew\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e60 (81.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14 (18.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eBarely/No\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (50)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (50)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSubdomain B \u0026ndash; Health-related communication skills\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eLow\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17 (73.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 (26.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e0.136\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eModerate\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e65 (86.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10 (13.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eQuite high\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e65 (73.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24 (27.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eHigh\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e74 (82.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16 (17.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSubdomain C - Attitude towards one's health and health information\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003ePassive\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (44.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (55.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003e0.018\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003ePartly passive \u0026ndash; partly active\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e105 (83.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21 (16.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eActive\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e112 (78.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30 (21.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSubdomain D - Level of knowledge related to health\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eLow\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e112 (81.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26 (18.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e0.716\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eModerate\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e92 (79.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24 (20.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eHigh\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17 (73.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 (26.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAdolescents\u0026rsquo; HPV knowledge\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMales cannot contract HPV\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eAgree - Strongly agree- Neither agree nor disagree\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e45 (78.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12 (21.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.860\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eStrongly disagree \u0026ndash; Disagree\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e176 (80)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e44 (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eWomen vaccinated against HPV must have Pap smears (checks for cervical cancer) as they age\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eAgree \u0026ndash; Strongly agree\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e167 (82.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e36 (17.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.081\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eNeither agree nor disagree \u0026ndash; Strongly disagree \u0026ndash; Disagree\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e54 (72.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20 (27.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHPV can be contracted through sexual activity\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eAgree \u0026ndash;Strongly agree\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e183 (80.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e43 (19.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.299\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eNeither agree nor disagree \u0026ndash; Strongly disagree \u0026ndash; Disagree\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e38 (74.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13 (25.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHPV is very rare\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eAree - Strongly agree- Neither agree nor disagree\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e67 (79.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17 (20.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.995\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eStrongly disagree \u0026ndash; Disagree\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e154 (79.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e39 (20.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHPV can cause cervical cancer\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eAgree \u0026ndash;Strongly agree\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e173 (83.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e35 (16.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003e0.015\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eNeither agree nor disagree \u0026ndash; Strongly disagree \u0026ndash; Disagree\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e48 (69.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21 (20.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHPV vaccine protects against all types of cervical cancer\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eAgree \u0026ndash;Strongly agree\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e63 (91.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 (8.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003e0.006\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eNeither agree nor disagree \u0026ndash; Strongly disagree \u0026ndash; Disagree\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e158 (75.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e50 (24.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAdolescents Vax Scale - General attitude towards vaccines\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eLow negative attitude\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e96 (80.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23 (19.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e0.930\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eModerate negative attitude\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e115 (79.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30 (20.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eHigh negative attitude\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10 (76.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (23.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eParents (277)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eParental Health literacy - IMETER\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eLow literacy\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e45 (71.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18 (28.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e0.170\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eMarginal literacy (limited)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e136 (82.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e29 (17.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eFunctional literacy (adequate)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e40 (81.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9 (18.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eParental knowledge about vaccines and vaccine-preventable diseases - THINK (251)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eLow level\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e164 (84.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e29 (15.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003e0.029\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eModerate level\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e42 (72.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16 (27.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eParental knowledge of HPV (250)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eLow knowledge\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14 (58.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10 (41.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003e0.002\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eModerate knowledge\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e99 (81.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23 (18.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eHigh knowledge\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e92 (88.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12 (11.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eParental Vax Scale - General attitude towards vaccines (253)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eLow negative attitude\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e81 (81.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18 (18.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e0.612\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eModerate negative attitude\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e115 (82.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25 (17.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eHigh negative attitude\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10 (71.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (28.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCultural Affiliation - SCAS SCALE (253)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eLow\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e53 (85.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9 (14.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e0.295\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eModerate\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e134 (79.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e34 (20.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eHigh\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e21 (91.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (8.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe present work shows that around one out of five adolescents enrolled in the study have not received all the vaccinations recommended by age. It is interesting to observe that this finding was not led by a lower HPV uptake as 92.1% of adolescents received at least one dose. This coverage is higher than the one reported in the official nationwide statistics for both the whole nation and the Umbria region at the end of 2024 and could be due to self-selection bias, namely the participation to the survey of people with better attitudes and behaviours to vaccination. Nevertheless, it should be noted that Umbria Region together with Lombardy consistently show higher coverage rates, for both the first dose and the full cycle (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). The study also issues new evidence on the individual cultural determinants of adolescents\u0026rsquo; vaccination status, with findings that are not always aligned with the literature. In this respect, parents with higher levels of general knowledge about vaccines showed a lower likelihood of having fully vaccinated adolescents than those with lower knowledge. This is a departure from what has been highlighted in the literature, where greater knowledge is usually associated with greater vaccination acceptance (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). A possible explanation may lie in overexposure to sources of information that are not always reliable, which generates doubts even in subjects with apparent good knowledge, which may not reflect a true critical \"vaccine literacy\" (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). Indeed, it has been estimated that about two-thirds of the world population has access to internet; this opportunity, together with the growing distrust in health authorities, can foster the development and dissemination of alternative medicine theories and movements (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). Conversely, parental knowledge of HPV, in line with what has been reported in the literature (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e), is associated with a higher probability of the uptake of recommended vaccination in adolescents. In addition, also adolescents\u0026rsquo; specific knowledge about HPV is associated with vaccination status. In particular, the awareness that HPV can cause cervical cancer as well as the understanding that the vaccine does not protect against all types of cervical cancers are associated with a higher likelihood of being fully vaccinated. Studies conducted both in international contexts (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e) and in Italy (\u003cspan additionalcitationids=\"CR27\" citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e) confirm that accurate and realistic knowledge of infectious risks and vaccine benefits is an important predictor of vaccination among adolescents. A particularly interesting finding is the positive association between adolescents\u0026rsquo; active attitude towards health and full vaccination status. This confirms the results of previous studies (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e), according to which personal engagement in caring for one's own health is a powerful predictor of preventive behaviours (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e), including vaccination. This result calls the attention on adolescents\u0026rsquo; health literacy as a potential leverage for improving vaccinations uptake.\u003c/p\u003e \u003cp\u003eSome caution needs to be put in interpreting the results of our study because of some limitations that need to be taken into account. First of all, the low response rate (3.9%) and the possible self-selection of the sample limit the generalizability of the results. It is indeed possible that adolescents and parents already sensitive to the issue of vaccination participated to the survey, reducing the variability of the sample. The low participation rate may also reflect practical and organizational constraints related to the study setting. The survey was administered through schools and involved a limited number of contact attempts, which may have reduced opportunities for participation. Schools generally aim to facilitate such surveys while minimizing the burden on parents, who are often reluctant to participate in research studies, and thus try to limit repeated solicitations. In addition, schools frequently receive numerous requests for survey-based research, making it challenging to implement multiple waves of data collection. More intensive recruitment strategies, such as additional contact waves, reminders addressed directly to adolescents and parents, or alternative modes of administration, might have increased response rates but were not feasible within the logistical and institutional constraints of the study context. Furthermore, information on reasons for non-participation was not available, preventing a direct assessment of non-response bias. It is possible that factors such as timing of data collection during the school year, family commitments, or limited engagement with school-mediated health initiatives contributed to non-response. Reporting these considerations may be informative for future studies aiming to assess adolescent vaccination status through school-based surveys. The possibility of self-selection bias cannot be ruled out, particularly given the high HPV vaccination coverage for the first dose detected in our sample compared with the overall Umbrian population. On the contrary the vaccination coverage for the full cycle detected in our study (69.7%), although higher than national estimates, was slightly lower than the one reported for Umbria Region in the last birth female and male cohorts in 2024 (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). This last finding could suggest that some adolescents did not have the chance to take their second dose only for the scheduling of doses (anticipatory children who started school earlier and turned 12 years old during the third year of the lower secondary school). Anyway, in order to avoid this potential problem, we decided to consider only the uptake of the first dose of HPV vaccine in identifying full vaccinated children. Overall, the findings of this study are likely to be most generalizable to adolescents living in the same regional context who belong to families with relatively higher awareness of vaccination-related issues and a greater propensity to participate in health surveys. The study population mainly consisted of adolescents and parents who voluntarily completed an online questionnaire, which may have favoured the participation of families with higher health literacy, more positive attitudes toward vaccinations, and greater engagement with preventive health services. Therefore, caution is warranted when extrapolating these results to adolescents from more disadvantaged backgrounds or with lower engagement in preventive healthcare. Another limit is linked to the potential misclassification of both the investigated determinants and the study endpoint that was not possible to verified through the vaccination records. However, in respect to the latter issue, previous studies have shown a generally good agreement between self-reported HPV vaccination status and medical records, suggesting that self-reported data can provide reasonably valid estimates of HPV vaccine uptake (\u003cspan additionalcitationids=\"CR32\" citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e). Nevertheless, this misclassification is expected to be non-differential and could have contribute to a dilution of some associations. Eventually, found associations are not representing causal associations because of the nature of the study design. The study has also relevant strengths. To the best of our knowledge, it is the first study addressing the overall vaccination status of adolescents moving the attention from HPV only to all the vaccinations recommended by age providing new important insights and stimuli for future research also in the light of overcoming current challenges in the conduction of such kind of study. Furthermore, it encompasses a diversity of determinants, some of them often overlooked, through the adoption of validated tools and considering at the same time both parents and adolescents. Eventually, the study findings, albeit exploratory, set the foundation for further investigating the role of some specific determinants, such as health literacy, and for elaborating more on the role of attitudes towards vaccinations.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThis study highlights that a relevant proportion of adolescents are not vaccinated against vaccine-preventable diseases for which they could be protected according to national recommendations. Beyond knowledge and attitudes, vaccination status is associated with adolescents\u0026rsquo; health literacy, in particular with their attitude towards own\u0026rsquo;s health. This could play as new leverage to improve vaccination uptake in adolescents.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eDisclaimer:\u003c/strong\u003e Merck Sharp \u0026amp; Dohme LLC provided financial support. The views expressed in this document are those of the authors and do not necessarily represent those of Merck Sharp \u0026amp; Dohme LLC.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding declaration\u003c/strong\u003e: This study was financially supported by Merck Sharp \u0026amp; Dohme LLC. The funder had no role in the design of the study; in the collection, analysis, or interpretation of data; in the writing of the manuscript; or in the decision to publish the results.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions:\u003c/strong\u003e Conceptualization, CdW, M.C., G.P.; formal analysis, V.C.; investigation, V.C., C.B., L.B., F.P., data curation, V.C. and C.B.; writing\u0026mdash;original draft preparation, V.C., C.B., L.B., F.P., G.P. and M.C. writing\u0026mdash;review and editing, C.d.W.; supervision, C.d.W.; project administration, V.C., C.B. and CdW. All authors read and approved the final manuscript\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e: The study protocol was approved by the Umbria Regional Ethics Committee (protocol n. 26538/22/OV of January 3rd, 2023). The study was conducted in accordance with the principles of the Declaration of Helsinki and with relevant national regulations, including EU Regulation 2016/679 (GDPR). Informed consent was obtained electronically from all participants prior to participation. Before accessing the questionnaire, participants were required to read the online informed consent form available via a dedicated link. Participants could proceed to the survey only after confirming that they had read the information sheet (\u0026ldquo;By proceeding, I declare that I have read the informed consent\u0026rdquo;). For underage participants, consent was obtained from parents or legal guardians through the same electronic procedure.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e: The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e: The authors thank the Regional School Office for Umbria and the principals of participant schools for their support.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eEuropean Centre for Disease Prevention and Control (ECDC). Introduction of HPV vaccines in EU countries \u0026ndash; overview and recommendations. \u003cem\u003eECDC Technical Report\u003c/em\u003e, 2012. Available at: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.ecdc.europa.eu/en/publications-data/introduction-hpv-vaccines-eu-countries-overview-and-recommendations\u003c/span\u003e\u003cspan address=\"https://www.ecdc.europa.eu/en/publications-data/introduction-hpv-vaccines-eu-countries-overview-and-recommendations\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eItalian Ministry of Health. HPV vaccination at 31.12.2024. 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Ann Ig. 2017;29(3):171\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMatranga D, Lumia C, Guarneri R, et al. The vaccinaTion \u0026amp; Hpv Knowledge (THinK) questionnaire: a reliability and validity study on a sample of women living in Sicily (southern-Italy). PeerJ. 2019;7:e6254.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eForster AS, McBride KA, Davies C, et al. Development and validation of measures to evaluate adolescents' knowledge about human papillomavirus (HPV), involvement in HPV vaccine decision-making, self-efficacy to receive the vaccine and fear and anxiety. Public Health. 2017;147:77\u0026ndash;83.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMartin LR, Petrie KJ. Understanding the Dimensions of Anti-Vaccination Attitudes: the Vaccination Attitudes Examination (VAX) Scale. 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Influence of internet and social Media in the promotion of alternative oncology, cancer quackery, and the predatory publishing phenomenon. Cureus. 2018;12:c37.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMari A, Gianolio L, Edefonti V, et al. HPV Vaccination in Young Males: A Glimpse of Coverage, Parental Attitude and Need of Additional Information from Lombardy Region, Italy. Int J Environ Res Public Health. 2022;19(13):7763.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGalv\u0026atilde;o J, Mufato LF, Silva MM, et al. Knowledge and acceptability of HPV vaccine among vaccinated and unvaccinated adolescents at Western Amazon. Hum Vaccin Immunother. 2020;16(9):2117\u0026ndash;25.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWachira J, Busakhala A, Otieno G, et al. Knowledge of cervical cancer and acceptability of prevention strategies among HPV-vaccinated and unvaccinated adolescent women in Eldoret, Kenya. BioRes Open Access. 2019;8(1):134\u0026ndash;43.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDella Polla G, Pelullo CP, Di Giuseppe G, Pavia M. Knowledge, attitudes, and behaviors of adolescents regarding the human papillomavirus vaccine: an Italian cross-sectional study. Int J Environ Res Public Health. 2022;19(9):5265.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBerra E, Gualano MR, Unim B, Ricciardi W, Damiani G. HPV-related knowledge, attitude and behavior among adolescents and young women in Italy: a cross-sectional study. BMC Public Health. 2012;12:326.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBrunelli L, Valent F, Comar M, et al. Knowledge About HPV and the HPV Vaccine: Observational Study on a Convenience Sample of Adolescents from Select Schools in Three Regions in Italy. Vaccines (Basel). 2024;13(3):227.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLoer AM, Domanska OM, Stock C, Jordan S. 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Vaccine. 2013;31(37):3928\u0026ndash;35. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.vaccine.2013.06.041\u003c/span\u003e\u003cspan address=\"10.1016/j.vaccine.2013.06.041\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Epub 2013 Jun 24. PMID: 23806243; PMCID: PMC4689428.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eUlrich AK, McKearnan SB, Lammert S, Wolfson J, Pletcher J, Halloran ME, Basta NE. Validity of university students' self-reported vaccination status after a meningococcal B outbreak. J Am Coll Health. 2022;70(3):824\u0026ndash;9. Epub 2020 Jul 16. PMID: 32672510; PMCID: PMC7881838.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAntonsson A. Self-reported HPV vaccination and vaccination record linkage in the Australian Oral Diversity Study. Cancer Causes Control. 2023;34(9):785\u0026ndash;9. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s10552-023-01729-4\u003c/span\u003e\u003cspan address=\"10.1007/s10552-023-01729-4\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Epub 2023 May 31. PMID: 37256380.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Adolescent vaccination, HPV vaccine, Vaccine uptake, Health literacy, Vaccine hesitancy","lastPublishedDoi":"10.21203/rs.3.rs-8956447/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8956447/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eIntroduction\u003c/h2\u003e \u003cp\u003eAdolescent vaccination is a key public health strategy to ensure protection against vaccine-preventable diseases, including HPV. Although coverage for several adolescent vaccines in Italy is high, complete HPV uptake remains suboptimal, and evidence on overall adolescent vaccination and its determinants is limited. This study assessed full vaccination coverage in Umbria and explored socio-demographic, cultural, and psychosocial factors associated with uptake.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA cross-sectional study was conducted during the 2024/2025 school year among 12-year-old adolescents and their parents in Umbria, Italy, using a web-based questionnaire administered through lower secondary schools. Data were collected on vaccination status and key determinants, including health literacy, vaccine knowledge, attitudes, and cultural affiliation, using validated instruments. Adolescents were classified as fully vaccinated if they had received the diphtheria\u0026ndash;tetanus\u0026ndash;pertussis\u0026ndash;polio booster, meningococcal vaccine, and at least one HPV dose. Associations with vaccination status were analyzed using chi-square tests.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eAmong 277 adolescent\u0026ndash;parent pairs (response rate: 3,9%), 79,9% (95% CI: 74,5%\u0026ndash;84,3%) of adolescents were fully vaccinated. Coverage for DTaP-polio and meningococcal vaccines exceeded 86%, while HPV uptake was 69,7% (two doses). No significant associations were observed with socio-demographic characteristics. Vaccination status was significantly associated with cognitive and cultural determinants: higher parental HPV knowledge (p\u0026thinsp;=\u0026thinsp;0.002) and adolescents\u0026rsquo; correct awareness of HPV risks (p\u0026thinsp;=\u0026thinsp;0.015) were linked to higher uptake, whereas greater general parental vaccine knowledge was paradoxically associated with lower uptake (p\u0026thinsp;=\u0026thinsp;0.029). Adolescents with an active health orientation were more likely to be fully vaccinated (p\u0026thinsp;=\u0026thinsp;0.018). Health literacy, vaccine attitudes, and cultural affiliation showed limited or no association.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eA substantial proportion of adolescents remains incompletely vaccinated despite high coverage. Health orientation and HPV knowledge play a central role in uptake. Interventions strengthening health literacy and promoting accurate HPV knowledge may improve adherence to vaccination programs.\u003c/p\u003e","manuscriptTitle":"Discordant vaccine uptake and its determinants among adolescents in a context of high vaccination coverage and longtime immigration: a cross-sectional study in Umbria region, Italy","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-03-17 18:09:18","doi":"10.21203/rs.3.rs-8956447/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-04-06T11:05:32+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-27T18:17:21+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-26T10:34:50+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"142314450311882621229766955768021724902","date":"2026-03-25T12:40:17+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"96991065988998317640917736412049937495","date":"2026-03-24T15:11:16+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"275586264449364359243270091673134960682","date":"2026-03-17T07:55:15+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-03-10T00:10:04+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-02-27T07:05:30+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-02-26T03:37:15+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-02-26T03:36:48+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Public Health","date":"2026-02-24T10:39:36+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"80b4b0d3-5db1-45f1-a3e9-bd06f57c0cd2","owner":[],"postedDate":"March 17th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-04-21T02:38:59+00:00","versionOfRecord":[],"versionCreatedAt":"2026-03-17 18:09:18","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8956447","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8956447","identity":"rs-8956447","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}