Optimizing HPV Vaccine Introduction in Shanghai, China
Phase: NA
Conditions: Vaccine Refusal
Sponsor: University of Michigan

Optimizing vaccine introduction 
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Optimizing vaccine introduction 
 
Principal Investigator: 
 
Abram L. Wagner, PhD, MPH 
 
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Table of Contents 
 
List of Abbreviations 
3 
Protocol Summary 
4 
 
 
1    Key Roles 
5 
2    Background Information and Scientific Rationale 
7 
        2.1    Background Information 
7 
        2.2    Scientific Rationale 
7 
        2.3    Potential Risks and Benefits 
7 
3    Objectives 
8 
4    Study Design 
9 
5    Study Population 
10 
        5.1    Selection of the Study Population 
10 
        5.2    Inclusion and Exclusion Criteria 
10 
6    Data and Safety Monitoring Plan 
11 
        6.1    Study Procedures 
11 
        6.2    Expected Adverse Events 
11 
        6.3    Data analysis and management 
12 
7    Statistical Considerations 
14 
        7.1    Study Outcome Measures 
14 
        7.2    Sample Size Considerations 
14 
        7.3    Participant Enrollment and Follow-Up 
14 
        7.4    Analysis Plan 
14 
8    Subject Confidentiality 
15 
        8.1    Future Use of Stored Specimens 
15 
9    Informed Consent Process 
16 
10  Literature References 
17 
 
 
Supplements and Appendices 
19 
 
 
 
 
 
 
 

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List of Abbreviations 
 
CDC 
Centers for Disease Control and Prevention 
PI 
Principal Investigator 
WHO 
World Health Organization 
 
 
 

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Protocol Summary 
 
 
Title:  
Optimizing vaccine introduction 
 
Population: 
1,000 Parents of children or adolescents in Shanghai (objectives 1-
3) 
120 vaccination providers (objective 4) 
 
Number of Sites: 
40 immunization clinics 
Several elementary, middle, and high schools 
 
Study Duration: 
First wave (summer 2019): 3 months 
Second wave (summer 2022): 3 months 
 
Study Design: 
 
Experiment 
Objectives: 
 
 
Primary Objective: 
To determine how the framing of the HPV vaccination across 
several dimensions affects short-term willingness to receive it 
 
Secondary Objective: 
To determine how the framing of the HPV vaccination across 
several dimensions affects sustained willingness to receive it 
 
Tertiary Objective: 
To determine how the framing of the HPV vaccination across 
several dimensions affects actual uptake of vaccine 
 
Quaternary Objective:  
To understand what factors providers think are important when 
promoting the HPV vaccine 
 
 
 
 

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1    Key Roles 
 
Principal Investigator: 
 
Abram Wagner 
1415 Washington Heights, 5234 SPH II 
Ann Arbor, MI 48109-2029 
awag@umich.edu  
T: 1 (734) 763-2330 
 
Graduate Student Researchers: 
 
Mengdi Ji 
mengdiji@umich.edu  
 
Megan Laffoon 
laffoonm@umich.edu  
 
Leah Pinckney 
pinckney@umich.edu  
 
Co-investigators: 
 
Matthew L. Boulton, MD, MPH 
1415 Washington Heights, 5208 SPH II 
Ann Arbor, MI 48109-2029 
mboulton@umich.edu  
T: 1 (734) 647-1120  
 
 
Brian J. Zikmund-Fisher, PhD 
1415 Washington Heights, 3834 SPH I 
Ann Arbor, Michigan 48109-2029  
bzikmund@umich.edu  
T: 1 (734) 936-9179 
 
China site personnel: 
 
Department of Immunization Program (DIP) 
Shanghai Municipal Center for Diseases Control & Prevention 
NO. 1380, West Zhongshan Road, 200336, Shanghai, P.R.China 
T: 0086-21-62758710-1302 
 
SUN Xiaodong, PhD 
sunxiaodong@scdc.sh.cn  
 
HUANG Zhuoying, MPH 
huangzhuoying@scdc.sh.cn  

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REN Jia, BMed 
renjia@scdc.sh.cn  
 

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2    Background Information and Scientific Rationale 
 
 
2.1    Background Information 
 
Since 2000, the US has licensed ten new vaccines (Plotkin & Plotkin, 2013), but research on 
vaccine hesitancy has not kept pace with vaccine development. HPV’s faltering rollout in the US 
is a cautionary tale about how not to inform the public about a vaccine. Prior to vaccine 
introduction, awareness of HPV was low (Friedman & Shepeard, 2007). The Advisory 
Committee on Immunization Practices (ACIP) published its first set of recommendations in 2006 
(Markowitz et al., 2007, 2014); early reports focused on the relation between vaccination and 
sexual intercourse (Clark, 2007b, 2007a). The vaccine was not recommended for routine use in 
males until 2011. Parents have remained concerned about the HPV vaccine’s impact on their 
child’s sexual behaviors (Brewer & Fazekas, 2007), and uptake remains low—37% for girls and 
13% for boys in 2014 (Lancet, 2016). Programs that have attempted to promote HPV 
vaccination since its introduction in the US have met with mixed success (Walling et al., 2016). 
In contrast, the hepatitis B vaccine—which protects against an infection largely spread through 
injection drug use or sexual intercourse—has not had such a pushback from the public, likely 
because it was marketed as vaccine that protects against the development of chronic infection 
in young infants (Hardt et al., 2016). The scientific premise of this study is that the period when 
a vaccine is adopted into the national immunization program is the critical window for shaping 
public discourse about and uptake of the vaccine. As more vaccines are formulated, it is critical 
that we determine how to best promote these vaccines to the public. 
 
2.2    Scientific Rationale 
 
This grant proposal will be carried out in China so I can focus on changes in attitudes toward 
vaccines as new vaccines are added to the national immunization schedule. I will focus on 
HPV—a sexually transmitted disease that causes cancer. Only 14.5% of Chinese have heard of 
HPV (Li et al., 2009). This proposal represents a substantial contribution to the field by 
evaluating the best methods for introducing a new vaccine to market  These findings can help 
increase vaccine uptake and prevent disease. 
 
 
2.3    Potential Risks and Benefits  
 
The main risk associated with this study would be loss of confidentiality – where someone would 
be able to identify participants and discover how they responded.  
 
Participants will not directly benefit from study, although others might benefit. This is because 
we may be able to improve vaccination coverage rates in the future with our findings about what 
characteristics about vaccines are or are not important to emphasize.  
 
 

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3    Objectives  
 
Primary Objective 
To determine how the framing of the HPV vaccination across several dimensions affects short-
term willingness to receive it 
 
Primary Outcome Measures 
At the end of the survey, parents will respond to a series of statements about their willingness to 
get their child vaccinated (which will be assessed on a 5-point scale from “strongly willing” to 
“not at all willing”). In the analysis, this outcome can be analyzed either as a continuous/ordinal 
outcome or as a dichotomized outcome (agree vs disagree).  
 
Secondary Objective 
To determine how the framing of the HPV vaccination across several dimensions affects 
sustained willingness to receive it 
 
Secondary Outcome Measures 
Same as primary outcome measure (but asked 3 years after initial intervention). 
 
Tertiary Objective 
To determine how the framing of the HPV vaccination across several dimensions affects actual 
uptake of vaccine 
 
Tertiary Outcome Measures 
Uptake of HPV vaccination, as recorded in the electronic immunization registry (four years after 
initial intervention). 
 
Quaternary Objective 
To understand what factors providers think are important when promoting the HPV vaccine 
 
Quatenary Outcome Measures 
We will enroll vaccination providers from all clinics to complete a simple questionnaire about 
HPV vaccination. 
 
 
 
 

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4    Study Design 
 
 
Participants will be randomized into two groups to receive information about the HPV vaccine. 
This information will be depicted on a sheet of paper using graphs and words. For one group, 
they will receive information similar to how it was historically presented in the US (as a sexually 
transmitted disease). The other group will receive modified messaging that downplays both the 
“gendered” nature of the disease and the role of sexual transmission and emphasizes that HPV 
is a cancer. The exact messaging will be developed in consultation with a mentor, Dr. Zikmund-
Fisher, and after taking related coursework (as part of training goal 1). Although I believe this 
latter method will result in higher acceptance of HPV, the former method of presenting the 
information is still ethical because it will replicate materials from the WHO (World Health 
Organization, 2014). We will also collect demographic and socioeconomic data, along with 
measures of exposure to various information sources, including traditional media, social media, 
and messaging from hospitals and doctors. 
 
Parents will provide information at three different stages. For wave 1 (this protocol), they will 
spend 30 minutes at a clinic filling out a paper questionnaire. For wave 2 (a separate protocol to 
be developed in the future), they will be re-contacted by phone and asked if they want to come 
to the clinic again to participate in another study. The third stage of data collection involves us 
linking their questionnaire data to their child’s vaccination records; we notify them about this in 
the informed consent document, but since we will also collect their child’s vaccination record 
number at the time of wave 1, we will not need to recontact them in the future in order to access 
the electronic immunization registry. 
 

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5    Study Population 
 
 
5.1    Selection of the Study Population  
Participants may be sampled from several locations. There is a two-stage selection procedure. 
Townships have already been sampled (through a random selection procedure, stratified by 
district within the city) based on the population of their surrounding township according to the 
2010 Census.  
 
The primary location would be immunization clinics. Parents could be selected as a 
convenience sample (from parents already at the clinic for vaccination appointments), or they 
could be sampled randomly from population registers at the clinic. 
 
For the first wave of data collection, a convenience sample within each clinic will be taken of 
parents of children. On days of data collection, we (i.e., the PI or a master’s student) will go to 
the clinic in the morning and explain the study. As the vaccine providers vaccinate children 
throughout the day, they will direct parents of children into a private room, where we can explain 
the study more, ask for informed consent, and give the parent-participant a questionnaire. 
 
Another potential study location will be middle schools or high schools in Shanghai. We will 
attempt to go to schools within the townships that we have already selected, but the extent to 
which we use schools will be dependent on their availability. At schools, teachers will send 
questionnaires and informed consent forms to students, and students will bring these 
documents home to their parents to fill out. 
 
We will enroll 120 vaccination providers from all clinics (an average of 3 per clinic) to complete a 
simple questionnaire about HPV vaccination. 
 
5.2    Inclusion and Exclusion Criteria 
 
Participants can be included if they are parents of children 2-18 years old. 
 
All vaccination providers at a clinic which offers an HPV vaccine are eligible. 
 
 

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6    Data and Safety Monitoring Plan 
 
 
6.1    Study Procedures 
 
Oversight responsibilities 
Oversight of the trial is provided by the Principal Investigator (PI), Dr. Wagner and his mentors 
on the study: Drs. Matthew Boulton, Brian Zikmund-Fisher, and Xiaodong Sun. 
 
Monitoring procedures 
Dr. Wagner assures that informed consent is obtained prior to performing any research 
procedures, that all subjects meet eligibility criteria, and that the study is conducted according to 
the IRB-approved research plan. The research protocol will be reviewed by the University of 
Michigan IRB and the Shanghai CDC ethical review committee (collectively referred to as the 
“IRBs”).  
 
Study data are accessible at all times for the PI and mentors to review. The PI and mentors will 
review study protocol prior to each period of data collection, and will review study conduct, drop-
outs, and protocol deviations one month and two months after the beginning of each data 
collection period. The PI will review AEs and SAEs individually in real-time and aggregate on a 
weekly bases (see the “AE Management” and “Data analysis plans” sections below). The PI 
ensures all protocol deviations, AEs, and SAEs are reported to the NIH and IRBs according to 
the applicable regulatory requirements. 
 
6.2    Expected Adverse Events 
 
Expected AEs 
Because we are not testing any therapy, are not taking any biological samples, and are only 
engaging in an educational/behavioral intervention, we do not expect any “physical” AE to 
occur. However, we potentially could change someone’s attitude about the HPV vaccine for the 
worse. Because our goal in this study is to identify ways in which we can improve acceptance of 
HPV vaccination, if it turns out that we are in fact making people more vaccine hesitant, that 
would be a behavioral/attitudinal AE. 
 
Although no previous study in China has replicated exactly what we will plan to do, 
observational studies have found a variation in acceptability of HPV vaccine. One study in Hong 
Kong found “the prevalence of parental acceptability of HPV vaccination for the index son and 
daughter were: […] 51.6% and 63.0% (free vaccination)” (Wang et al., 2018). Another study 
from Jinan found that “female students were more willing to take the HPV vaccine than male 
students (76.7% vs 58.6%)” (Xue et al., 2017). 
 
If, from preliminary analyses (see below), we find that acceptability of the vaccine is less than 
40% (about 10% to 20% less than acceptability of what was found in previous studies – we are 
using a lower number to account for variability in the study population characteristics), we will 
stop data collection (enrollment of new participants), notify the IRBs, and identify ways to 
change the protocol prior to re-starting data collection. 
 
AE Management 
 

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If we found someone with a low attitude towards vaccines, we do not believe that it would be 
appropriate to try to change their attitude, since (1) further interaction with someone who had a 
negative experience with us is unlikely to make their experience more positive, and (2) we do 
not know for sure if this attitude was related to their participation in this study. However, we can 
provide materials from a neutral party (like pamphlets on HPV from the National CDC) to the 
study site locations, so that individuals can have a different perspective on the medical issue. 
 
Of course, if a participant participates some physical adverse event, we are unsure how it could 
be linked to our study, but all study procedures will occur at an immunization clinic (which are 
co-located with larger medical facilities), and so the individual should be able to receive timely 
and appropriate care. 
 
6.3    Data analysis and management 
 
Data analysis plans 
As data are being collected and entered into a database, we will tabulate our endpoint – vaccine 
acceptability, which we will dichotomize from a Likert scale – on a weekly basis. And if these 
numbers fall below a certain threshold, we will follow the procedures as outlined in the 
“Expected AEs” section above. 
 
Reporting of AEs 
All physical AEs will be reported according to the two IRBs’ AE reporting guidelines. In addition, 
aggregate statistics about behavioral/attitudinal AEs will be reported if they cross the threshold 
listed in this document. 
 
Plan for data management 
Compliance of regulatory documents and study data accuracy and completeness will be 
maintained through an internal study team quality assurance process.  
 
Confidentiality throughout the trial is maintained by keeping informed consent forms and 
questionnaires in separate locations, and destroying the questionnaires after they have been 
input into an electronic database. Informed consent forms will be kept for a period of time 
designated by the IRBs. The informed consent forms and questionnaires will be in a locked 
locker, in a locked room, at the Shanghai CDC, which is a complex of buildings with guards at 
each entrance.  
 
The data will initially be stored in a secure online platform – such as Box – which is HIPAA 
compliant and which the University of Michigan supports. While the data are being collected, 
and while some personally identifiable information may be present in the database, this folder 
will be password-locked and only available to study team members. 
 
We will also keep a record linking the participants’ ID number to their vaccination record 
number. This linkage file will be kept separate from the questionnaires, and it will be on the hard 
drive of a computer at the Shanghai CDC. The computer will be password-locked and will only 
be accessible to study team members. 
 
Data sharing 

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Reproducibility and replicability of studies are both extremely important. Therefore, we plan to 
upload a final dataset (along with code detailing my statistical analysis) to a public repository, 
such as figshare.com. This dataset will have personally identifiable information removed – and 
the clinic location will be coded by a number (not the name of the location) to prevent individuals 
being able to locate members of the study and identify them. 
 
 
 
 

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7    Statistical Considerations  
 
7.1    Study Outcome Measures 
 
At the end of the survey, parents will respond to the statement, “I am willing to vaccinate my 
child against HPV,” using a five-point Likert scale from “strongly willing” to “not at all willing”. In 
the analysis, this outcome can be analyzed either as a continuous/ordinal outcome or as a 
dichotomized outcome (agree vs disagree).  
 
7.2    Sample Size Considerations  
Based on previous results, we are powering to detect a difference between 70% and 80% in the 
outcome between the two groups (see explanation below). This would require a simple random 
sample of 588 or an effective sample size of 994 based on a design effect of 1.69. The 
enrollment of parents will be in immunization clinics. 
 
This sample size of providers is limited by the number of clinics (n=40), but because we are 
sampling few providers from each clinic, the design effect is negligible, and we should be able to 
provide an estimate of risk perception with a confidence interval of 8 percentage points 
(assuming an outcome proportion of 80%). The outcome is the proportion of individuals who 
respond “somewhat important” or “very important” to questions on a 5-point Likert scale. 
 
7.3    Participant Enrollment and Follow-Up 
 
I estimate the follow-up rate to be 80%, given figures in recently published studies from China: 
86.1% (Lau, Gross, Wu, Cheng, & Lau, 2017), 83% (Choi, Steward, Miège, Hudes, & Gregorich, 
2016), 80.3% (Xu, Byles, Shi, McElduff, & Hall, 2016), 79.8% (Guo et al., 2017).  
 
Participants from previous waves will be contacted by phone and asked to come to the 
immunization clinic for an additional survey. The person contacting past participants by phone 
would be me, a master’s student, or staff from the vaccination clinic.  
 
7.4    Analysis Plan 
 
We will use standard regression methods to compare this outcome between the main study 
arms. To account for the complex survey design, all models will use survey procedures, 
including weights, clustering, and Taylor series estimation of variance. 
 
 
 
 

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8    Subject Confidentiality 
 
Confidentiality throughout the trial is maintained by keeping informed consent forms and 
questionnaires in separate locations, and destroying the questionnaires after they have been 
input into an electronic database. Informed consent forms will be kept for a period of time 
designated by the IRBs. The informed consent forms and questionnaires will be in a locked 
locker, in a locked room, at the Shanghai CDC, which is a complex of buildings with guards at 
each entrance.  
 
The data will initially be stored in a secure online platform – such as Box – which is HIPAA 
compliant and which the University of Michigan supports. While the data are being collected, 
and while some personally identifiable information may be present in the database, this folder 
will be password-locked and only available to study team members. 
 
We will also keep a record linking the participants’ ID number to their vaccination record 
number. This linkage file will be kept separate from the questionnaires, and it will be on the hard 
drive of a computer at the Shanghai CDC. The computer will be password-locked and will only 
be accessible to study team members. 
 
8.1    Future Use of Stored Specimens 
 
This study does not include any biological specimens. 
 
Although participant information will be de-identified from the main dataset, a separate linkage 
file will show their name, their study ID, their vaccination record ID, and their contact 
information. We will use this information to contact them in the future and to obtain their 
vaccination records. 
 
 
 

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9    Informed Consent Process 
Many parents and children visit vaccination clinics every day in China to receive mandatory 
vaccines. They wait in line until they are called to visit with a nurse (“vaccination provider”), who 
discusses vaccination options with them, and then directs them to another nurse who will obtain 
the vaccines they need and administer the dose(s) required. Afterward, the parents and children 
are supposed to wait at clinics for 30 minutes after vaccination to see if there is any adverse 
reaction to the vaccine. A large age range of children come into the clinic, and so we will notify 
the vaccination providers what are required age range is (2-18 years), and parents of those 
children will then be told by the nurses about our study. The nurses will mention to parents 
whose children fall into the age category (2-18 years) that a study is taking place about their 
attitudes towards vaccination. Vaccination providers will then direct parents to come into a 
private room to learn more about the study. Of course, some parents may be uninterested at 
this point and we would never see them. At the end of our time at each clinic, we will ask the 
nurses how many parents did not come and see us (so we can tally up our response rate). 
 
Clinics have a few private rooms for conducting meetings which are out of the way from where 
other parents are waiting (before and after vaccinations). Within such a room we will ask 
parents the screening question (is their child between 2-18 years), and if they answer 
affirmatively, give the parents the informed consent form and ask if they want to voluntarily 
participate in this study. We will give them time to read through the document and sign and ask 
any questions to study staff. 
 
Similarly, for parents sampled at schools, the forms (questionnaire, enrollment log, and informed 
consent form) will be sent by the teacher to the child’s home. The teacher will be responsible for 
collecting these documents and handing them back to the study team.  
 
If they sign the informed consent, we will file it in a separate location from the questionnaires. 
This questionnaire is something that the parents can fill out themselves, and study staff will be 
available to answer any questions. 
 
Any follow-up survey (i.e., 3 years later) will involve the parents being re-consented. 
 
 
 

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10    Literature References 
 
 
Brewer, N. T., & Fazekas, K. I. (2007). Predictors of HPV vaccine acceptability: a theory-
informed, systematic review. Preventive Medicine, 45(2–3), 107–14. 
http://doi.org/10.1016/j.ypmed.2007.05.013 
Choi, K.-H., Steward, W. T., Miège, P., Hudes, E., & Gregorich, S. E. (2016). Sexual Stigma, 
Coping Styles, and Psychological Distress: A Longitudinal Study of Men Who Have Sex 
With Men in Beijing, China. Archives of Sexual Behavior, 45(6), 1483–1491. 
http://doi.org/10.1007/s10508-015-0640-z 
Clark, A. (2007a). Controversy Swirls Around HPV Vaccine. Retrieved March 27, 2017, from 
http://www.cbsnews.com/news/controversy-swirls-around-hpv-vaccine/ 
Clark, A. (2007b). Should HPV vaccination be mandatory? Retrieved March 27, 2017, from 
http://www.cbsnews.com/news/should-hpv-vaccine-be-mandatory/ 
Friedman, A. L., & Shepeard, H. (2007). Exploring the Knowledge, Attitudes, Beliefs, and 
Communication Preferences of the General Public Regarding HPV. Health Education & 
Behavior, 34(3), 471–485. http://doi.org/http://dx.doi.org/10.1177/1090198106292022 
Guo, Y., Liu, L. J., Tang, P., Lv, Y. Y., Feng, Y., Xu, L., & Jonas, J. B. (2017). Outdoor activity 
and myopia progression in 4-year follow-up of Chinese primary school children: The Beijing 
Children Eye Study. PLoS ONE, 12(4), 1–15. http://doi.org/10.1371/journal.pone.0175921 
Hardt, K., Bonanni, P., King, S., Santos, J. I., El-Hodhod, M., Zimet, G. D., & Preiss, S. (2016). 
Vaccine strategies: Optimising outcomes. Vaccine, 34(52), 6691–6699. 
http://doi.org/10.1016/j.vaccine.2016.10.078 
Lancet, T. (2016). HPV vaccination: a decade on. Lancet, 388(10043), 438. 
http://doi.org/10.1016/S0140-6736(16)31206-5 
Lau, J. T. F., Gross, D. L., Wu, A. M. S., Cheng, K., & Lau, M. M. C. (2017). Incidence and 
predictive factors of Internet addiction among Chinese secondary school students in Hong 
Kong: a longitudinal study. Social Psychiatry and Psychiatric Epidemiology, 52(6), 657–
667. http://doi.org/10.1007/s00127-017-1356-2 
Li, J., Li, L.-K., Ma, J.-F., Wei, L.-H., Niyazi, M., Li, C.-Q., … Qiao, Y.-L. (2009). Knowledge and 
attitudes about human papillomavirus (HPV) and HPV vaccines among women living in 
metropolitan and rural regions of China. Vaccine, 27(8), 1210–1215. 
http://doi.org/10.1016/j.vaccine.2008.12.020 
Markowitz, L. E., Dunne, E. F., Saraiya, M., Chesson, H. W., Curtis, C. R., Gee, J., … Unger, E. 
R. (2014). Human Papillomavirus Vaccination Recommendations of the Advisory 
Committee on Immunization Practices (ACIP). MMWR Recommendations and Reports, 
63(1), 1–30. 
Markowitz, L. E., Dunne, E. F., Saraiya, M., Lawson, H. W., Chesson, H., & Unger, E. R. (2007). 
Quadrivalent Human Papillomavirus Vaccine: Recommendations of the Advisory 
Committee on Immunization Practices (ACIP). Morbidity and Mortality Weekly Report, 
56(RR-2), 1–24. http://doi.org/10.1037/e601292007-001 
Plotkin, S. L., & Plotkin, S. A. (2013). A short history of vaccination. In S. A. Plotkin, W. A. 
Orenstein, & P. A. Offit (Eds.), Vaccines (6th ed., pp. 1–13). Elsevier. 
Walling, E. B., Benzoni, N., Dornfeld, J., Bhandari, R., Sisk, B. A., Garbutt, J., & Colditz, G. 
(2016). Interventions to Improve HPV Vaccine Uptake: A Systematic Review. Pediatrics, 
138(1), e20153863–e20153863. http://doi.org/10.1542/peds.2015-3863 
Wang, Z., Wang, J., Fang, Y., Gross, D. L., Wong, M. C. S., Wong, E. L. Y., & Lau, J. T. F. 
(2018). Parental acceptability of HPV vaccination for boys and girls aged 9–13 years in 
China – A population-based study. Vaccine, 36(19), 2657–2665. 

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http://doi.org/10.1016/j.vaccine.2018.03.057 
World Health Organization. (2014). Human papillomavirus vaccines: WHO position paper, 
October 2014. Weekly Epidemiological Record, 89(43), 465–492. 
http://doi.org/10.1186/1750-9378-2-15.Voir 
Xu, X., Byles, J., Shi, Z., McElduff, P., & Hall, J. (2016). Dietary pattern transitions, and the 
associations with BMI, waist circumference, weight and hypertension in a 7-year follow-up 
among the older Chinese population: A longitudinal study. BMC Public Health, 16(1), 1–12. 
http://doi.org/10.1186/s12889-016-3425-y 
Xue, L., Hu, W., Zhang, H., Xie, Z., Zhang, X., Zhao, F., … Ma, W. (2017). Awareness of and 
willingness to be vaccinated by human papillomavirus vaccine among junior middle school 
students in Jinan, China. Human Vaccines and Immunotherapeutics, 5515, 1–8. 
http://doi.org/10.1080/21645515.2017.1393132 
 
 

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Supplements and Appendices 
 
None