Vaccine: X 10 (2022) 100141

Contents lists available at ScienceDirect

Vaccine: X

journal homepage: www.elsevier.com/locate/jvacx

Human papillomavirus (HPV) infection and vaccination:

A cross-sectional study of college students’ knowledge, awareness, and
attitudes in Villanova, PA
Jennifer A. Goldfarb, Joseph D. Comber ⇑
Department of Biology, Villanova University, PA 19085, USA

a r t i c l e i n f o a b s t r a c t

Article history: Human papillomaviruses are major causative agents of multiple cancers including cervical, vulvar, penile,
Received 17 June 2021 anal, and oropharyngeal cancers. Almost all sexually active individuals are exposed to HPV in their life-
Received in revised form 2 January 2022 time and although not all HPV genotypes are capable of causing cancers, several high-risk subtypes
Accepted 11 January 2022
widely circulate. Several HPV vaccines have been developed and successfully utilized to limit the spread
Available online 17 January 2022
of these viruses and reduce rates of associated cancers. Despite their success, HPV vaccination rates in
the United States remain low. Studies estimate the highest prevalence of HPV in the United States is
Keywords:
among college students. This makes college students an important target for interventions that
Human papillomavirus (HPV)
promote HPV vaccination and prevention. To this end, we were interested in investigating the
Gardasil
relationship between low HPV vaccine uptake and attitudes and awareness about HPV vaccination
Vaccination
Vaccine hesitancy among college aged stu- dents. We designed a survey to assess knowledge and perception of HPV and
HPV vaccination that could help identify correlations between this knowledge and vaccination status.
Overall, the data suggest that factors beyond basic knowledge about HPV infections, such as vaccine
safety and social acceptance of vaccination, may have important impacts on vaccination rates. More
robust education in these areas, sup- plemented with education about the benefits of HPV vaccination
could be utilized to improve vaccination rates.
2022 The Author(s). Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND
license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

1. Introduction types have been licensed in the United States, although only one
of these vaccines is currently in use. Each of these HPV vaccines
Human papillomaviruses are non-enveloped double stranded contains virus like particles with the major capsid protein L1
DNA viruses in the Papillomaviridae family. There are over 170 assembling into HPV virions that lack DNA and that are unable to
human papillomaviruses and at least 40 are capable of infecting establish infection. [2]. Two of the earliest HPV vaccines were
the reproductive tract (among other tissues). High risk genotypes Cer- varix, a bivalent vaccine developed by GSK protecting against
of HPV are the most concerning since these are linked to cancer HPV 16 and 18, and Gardasil, a quadrivalent vaccine
development, causing upwards of five percent of all cancers glob- developed by Merck protecting against HPV 6, 11, 16, and 18 [2].
ally [1]. HPV is the cause of almost all cervical cancer (>99%) Although Cer- varix and Gardasil are successful at preventing
and causes most anal cancers (90%), vulvar cancers (70%), vaginal infections and are used globally [3], they are no longer
can- cers (70%), penile cancers (60%), and oropharyngeal cancers distributed in the United States. The current preferred vaccine in
(70%). In total, HPV is estimated to cause 570,000 cases of the US is Gardasil-9, a non- avalent vaccine developed by Merck
cancer in women and 60,000 cases of cancer in men worldwide that protects against nine dis- tinct HPV genotypes [4]. This
every year [1]. vaccine is estimated to prevent 32,000 of the 35,000 cancers
Vaccination is a highly effective intervention that protects caused by HPV per year [5].
against HPV infection and prevents the majority of cancers that Despite the importance of vaccination against HPV, HPV
these viruses cause. Three vaccines against high-risk HPV geno- vaccine uptake lags behind that of other vaccines
recommended to be administered around the same age. For
⇑ Corresponding author at: Department of Biology, Villanova University, 800 example, according to the 2019 National Immunization Survey
Lancaster Ave. Villanova, PA 19085, USA. (NIS-Teen), 90.2% of adoles- cents between 13 and 18 years of
E-mail address: [email protected] (J.D. Comber). age were vaccinated against teta- nus, diphtheria, and pertussis
(Tdap), 91.6% were vaccinated against HBV, and 88.9% were
vaccinated against meningococcus

https://doi.org/10.1016/j.jvacx.2022.100141
2590-1362/ 2022 The Author(s). Published by Elsevier Ltd.
This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
J.A. Goldfarb and J.D. Comber Vaccine: X 10 (2022) 100141

(MenACWY) [6]. In stark contrast, only 71.5% of adolescents in this Data were analyzed using chi-squared analyses to look for sig-
age group were vaccinated with at least one dose of HPV vaccine. nificant associations between: a) biological sex and response to
What’s more, only 54.2% of adolescents were up to date on their survey questions Q6 through Q32; b) awareness of the existence
HPV vaccine series, although coverage rates vary by state with of HPV and being vaccinated for HPV; c) perception of HPV vacci-
the lowest rate in Mississippi (30.5%) and the highest rate in Rhode nation as safe and being vaccinated for HPV; d) approval by fam-
Island (78.9%). In Pennsylvania, the site of the current study, the ily/friends of Gardasil 9 vaccination and being vaccinated for
numbers are similar to national levels, with 77% of adolescents HPV; e) correct response to knowledge section of the
being vaccinated with at least one dose of the HPV vaccine and questionnaire (Q11 through Q21) and being vaccinated for HPV; f)
only 60.1% being up to date in the vaccine series [6]. perceived risk for HPV infection (no risk, low risk, moderate risk,
Studies estimate the highest prevalence of HPV in the United high risk) and
States to be among women visiting STD clinics and college stu- being vaccinated for HPV. P-values < 0.05 were considered statisti-
dents [7]. This, combined with the lower vaccine uptake in adoles- cally significant in this study.
cence, makes college students an important target for
interventions that promote HPV vaccination and prevention. Sur-
veys among college students similar to the one we conducted have 3. Results
occurred throughout the United States including in Florida [8],
Southern California [9], South Carolina [10], Michigan [11], Missis- 3.1. General demographic information
sippi [12], Pennsylvania [13], and Utah [14]. Similar studies have
also been conducted outside of the United States in India [15,16], Table 1 summarizes the demographic characteristics of the
Turkey [17], and Vietnam [14]. study population. We collected responses from 217 participants
In an effort to boost HPV vaccination rates, it is necessary to (n = 217). Forty-nine individuals reported as male (22.59%), 167
investigate the relationship between low HPV vaccine uptake and individuals reported as female (76.95%), and 1 individual preferred
the public’s attitudes and awareness about HPV vaccination. This not to say (0.46%). Data from the respondent who preferred not to
is likely a multifaceted issue and there may be multiple reasons state biological sex were removed in an effort to maintain anonym-
why HPV vaccination rates are lower than those of other vaccines, ity of individual responses. Participants ranged in age from 18 to
for example the Td/Tdap and MenACWY vaccination rates recom- 25 + with the majority of students being between 18 and 22 years
mended for the same age group. Our survey focused on the college old (88.89%). Since the undergraduate population of Villanova is
much larger than the graduate population (6711 undergraduates
population to assess college students’ knowledge and awareness of
vs. 3823 graduate students at the time of the study), it was not sur-
HPV infection and HPV vaccination along with their HPV vaccina-
prising that most respondents were undergraduate students
tion status. We sought to identify possible correlations between
(92.59% vs. 6.48% graduate students and 0.92% of students who
knowledge, awareness, and/or perceptions of HPV infection and
preferred not to identify their year). Similarly, respondents were
HPV vaccination that may be linked to vaccination status. These
largely white and non-Hispanic (80.55%) which coincides with
results can be used to better educate individuals, dispel myths
the full-time student enrollment demographics for Villanova
and stigmas, and increase awareness surrounding HPV infection
University (White/Caucasian 75%). As expected since Villanova
and HPV vaccination. From this knowledge, we can also create ini-
University is a Catholic institution, most participants identified as
tiatives to promote HPV vaccination not only among college stu-
Christian (80.55%) [18].
dents, but possibly among the recommended HPV vaccination
age demographic (11–12) by considering what college students
stated as obstacles or aversions to vaccination. 3.2. Safe sex practices and routine screenings

Fig. 1 illustrates the respondents behavior surrounding safe sex

2. Materials and methods and routine STD screening. At the time of the survey, 69.5% of
females (n = 116) and 71.4% of males (n = 35) reported that they
In order to better understand the knowledge, awareness, and were currently sexually active or had been sexually active in the
attitudes of college-aged students towards the HPV vaccine, we past 12 months. Additionally, 31.5% of females (n = 51) and
conducted a cross-sectional study among university students at 30.6% of males (n = 15) reported having four or more sexual part-
Villanova University (Villanova, PA) between February 13th and ners in their lifetime. Although there was no significant statistical
March 9th, 2020. A convenience sampling method was used to difference between females and males with respect to sexual his-
recruit undergraduate and graduate students at least 18 years of tory, number of partners, or history of sexually transmitted dis-
age who were current students of Villanova at the time of survey ease/infection (STD/STI), females were more likely than males to
completion. The survey was distributed through email, promo- be routinely screened for STDs/STIs (p < 0.05). A remarkably low
tional flyers, and word-of-mouth and was hosted on a secure Goo- number of participants in this survey indicated that they are rou-
gle Forms account (G-Suite). All respondents provided informed tinely screened for these diseases (35.9% for females, 14.3% for
consent before completing the survey and survey responses were males). Only 1.7% (n = 6) of sexually active men reported being
collected in an anonymous manner. This study was approved by routinely screened for STDs.
the Villanova University Institutional Review Board (IRB-FY2020-
62). 3.3. Knowledge about HPV infection, vaccination, and vaccine safety
The survey consisted of 32 multiple choice questions and one
opened ended question, similar to previous studies [8–17]. Ques- The choice to be vaccinated is multifaceted, and factors that are
tions asked participants about demographic information, thought to play a role include knowledge about the vaccine and
general knowledge of HPV infection, perceived vulnerability of disease, health care provider recommendations, perceptions about
HPV infec- tion, general knowledge of HPV vaccines, perceptions the risks of diseases, perceptions about vaccination effectiveness,
about HPV vaccine effectiveness and safety, and a question about and socioeconomic status [19-21]. We were interested in under-
HPV vacci- nation status. The open-ended question asked standing more about these factors as they specifically relate to
students to identify any information that could be helpful to HPV vaccination status among college students. Therefore, we
convince them to get the vaccine. designed our survey to assess several potential factors that may
2
drive these decisions. One such factor was knowledge about HPV

2
J.A. Goldfarb and J.D. Comber Vaccine: X 10 (2022) 100141

Table 1
Demographic characteristics of participants. Q2 of the survey asked respondents to state their gender. This data is located in the column headings.

Question Number Demographic Variables Total, n (%) (n = 216) Female, n (%) (n = 167) Male, n (%) (n = 49)

Q1 Age
18 30 (13.9) 22 (13.2) 8 (16.3)
19 49 (22.7) 38 (22.8) 11 (22.4)
20 47 (21.8) 38 (22.8) 9 (18.4)
21 47 (21.8) 32 (19.2) 15 (30.6)
22 19 (8.8) 16 (9.6) 3 (6.1)
23 3 (1.4) 2 (1.2) 1 (2.0)
24 5 (2.3) 3 (1.8) 2 (4.1)
25+ 16 (7.4) 16 (9.6) 0 (0.0)

Q3 Ethnicity
White, non-Hispanic 174 (80.6) 135 (80.8) 39 (80.0)
Black, non-Hispanic 5 (2.3) 5 (3.0) 0 (0.0)
Hispanic or Latino 17 (7.9) 13 (7.8) 4 (8.2)
Other 20 (9.3) 14 (8.4) 6 (12.2)

Q4 Religion
Christian 174 (80.6) 135 (80.8) 39 (79.6)
Jewish 2 (0.9) 1 (0.6) 1 (2.0)
Not religious 34 (15.7) 26 (15.6) 8 (16.3)
Other 4 (1.9) 3 (1.8) 1 (2.0)
Prefer not to say 2 (0.9) 2 (1.2) 0 (0.0)

Q5 Academic Year
Freshman 52 (24.1) 36 (21.6) 16 (32.7)
Sophomore 52 (24.1) 45 (26.9) 7 (14.3)
Junior 35 (16.2) 25 (15.0) 10 (20.4)
Senior 61 (28.2) 48 (28.7) 13 (26.5)
Graduate student 14 (6.5) 11 (6.7) 3 (6.1)
Prefer not to say 2 (0.9) 2 (1.2) 0 (0.0)

Fig. 1. Females are more likely than males to be routinely screened for STDs/STIs. However, no other significant differences exist between males and females with respect
to sexual health. *p < 0.05.

infection itself, and to this end participants were surveyed on their Interestingly, participants (both
knowledge and awareness about HPV infection (Q11-16, Q19-20,
Fig. 2 and Table 2). The majority of participants correctly
identified that HPV affects both male and females (95.8%), is a
sexually trans- mitted disease (69.9%), and is capable of causing
cancer (76.9%). However, a much lower percentage of participants
understood that HPV can be spread by skin-to-skin contact with
only 29.6% of par- ticipants responding correctly to this question
(55.1% incorrectly) and 15.3% of participants unsure.

3
male and female) who responded correctly to all eight knowledge
questions were not significantly more likely to be vaccinated for
HPV (with at least one dose; p = 0.12).

3.4. Perception on HPV vaccination safety

We were also interested in understanding how participants

viewed the HPV vaccine itself in terms of safety and protection
from infection (Table 2). Females were more likely than males to

3
 Fig. 2. Knowledge about HPV does not play a significant role in influencing vaccination status. The correct response choices to these questions are listed in .

be aware of the existence of a vaccine for HPV (p < 0.05). However, to be sexually active (16.3% of males vs. 4.8% of females). Despite
there was no significant difference between female and male the high proportion of both females and males who believe that
response with respect to the knowledge that the newest HPV vac- vaccination would not impact their sexual activity, females were
cine, Gardasil-9, approved age range for administration has been more likely to believe that the vaccine would not make them
expanded. This might not be surprising since this approval is some- inclined to be more sexually active (p < 0.05). This result is also
what recent but nevertheless highlights the need to make this in line with other data indicating that HPV vaccine does not
information more widespread. Importantly however, participants
increase sexual promiscuity in recipients [23-26].
(both female and male) who responded that they were aware of
the existence of an HPV vaccination were more likely to be vacci-
3.6. Approval by family/friends and being vaccinated for HPV
nated with at least one dose (responding ‘‘yes” to Q23; p < 0.05).
Females were more likely than males to believe that an individ-
Because HPV is spread, in part, by sexual encounters, some have
ual cannot get HPV from receiving an HPV vaccine (p < 0.05).
argued that the vaccine suffers from being sexualized [22] which
61.1% of females (n = 102) and only 36.7% of males (n = 18)
suggests that vaccine uptake may be linked to approval from fam-
responded that an individual cannot get HPV from vaccination.
ily and friends. We were interested if this kind of ‘approval’, may
Interestingly, there was no significant difference between
play a role in the decision to get the HPV vaccine. Interestingly,
biological sex and per- ception about HPV vaccine safety and side
participants (both male and female) who believed their family/
effects. Greater than 50% of both females and males believed HPV
friends would disapprove of the vaccination (responding ‘‘yes” to
vaccination is safe (Q27) and does not have significant side
Q30) were less likely to be vaccinated for HPV with at least one
effects (Q26). Importantly, par- ticipants (both male and female)
dose (responding ‘‘no” to Q23), whereas individuals who did not
who believed vaccination is safe, effective, without significant side
believe their family/friends would disapprove (responding ‘‘no”
effects, and cannot result in HPV infection were more likely to be
to Q30) were more likely to be vaccinated (responding ‘‘yes” to
vaccinated with at least one dose (p < 0.05).
Q23; p < 0.05) (Fig. 3).

3.5. Knowledge about HPV vaccination and sexual activity

4. Discussion

HPV vaccines are usually administered to adolescents between

HPV vaccine uptake remains remarkably low in the United
11 and 12 years old. At this stage of their lives, it is likely that the
States, with only 71.5% of adolescents being vaccinated with at
decision to vaccinate is made by parents or guardians. One major
least one dose and only 54.2% of adolescents being up to date
objection voiced by these parents or guardians is the belief that a
with the HPV vaccine schedule [6]. Although these rates are
vaccine for an STD would make their child more sexually active
comparable to most other developed nations, they are
and/or promiscuous [22]. We were interested in determining if
significantly lower than Australia, where a strong nationalized,
col- lege aged students shared those beliefs about the HPV
school-based HPV vaccina- tion program has resulted in >75% of
vaccine (Table 2). 85.0% of females (n = 142) and 75.5% of males
adolescents up to date with the HPV vaccine schedule [27]. As
(n = 37) responded that they would not be more inclined to be
college students have the high- est prevalence of HPV in the
sexually active after getting the HPV vaccine. A higher
United States [7], we set out to inves- tigate the factors that may
proportion of male participants were unsure if the vaccination
influence the decision to be vaccinated in a college aged cohort of
would incline them
4
students at Villanova University (located

4
J.A. Goldfarb and J.D. Comber Vaccine: X 10 (2022) 100141

Table 2
Total, female, and male responses to study questions. *p < 0.05 **What was deemed to be the correct response if there was one.

Question Questions Pertaining to Sexual Health Total, n (%) Female, n (%) Male, n (%)
Number (n = 216) (n = 167) (n = 49)

Q6 Are you currently sexually active or have you been sexually active in the past 12 months?
Yes 151 (70.0) 116 (69.5) 35 (71.4)
No 64 (29.6) 50 (29.9) 14 (28.6)
Prefer not to say 1 (0.5) 1 (0.6) 0 (0.0)

Q7 Do you commonly use safe sex practices (i.e. condoms, contraceptives)?

Yes 143 (66.2) 111 (66.5) 32 (65.3)
No 18 (8.3) 12 (7.2) 6 (12.2)
This does not apply to me 55 (25.35) 44 (26.3) 11 (22.4)

Q8 Have you had four or more sexual partners in your lifetime so far?
Yes 66 (30.6) 51 (30.5) 15 (30.6)
No 148 (68.5) 114 (68.3) 34 (69.4)
Prefer not to say 1 (0.5) 1 (0.6) 0 (0.0)
Left question unanswered 1 (0.5) 1 (0.6) 0 (0.0)

Q9 Are you routinely (around once per year) screened for sexually transmitted diseases or
infections?*
Yes 67 (31.0) 60 (35.9) 7 (14.3)
No 146 (67.6) 104 (62.3) 42 (85.7)
Prefer not to say 1 (0.5) 1 (0.6) 0 (0.0)
Left question unanswered 2 (0.9) 2 (1.2) 0 (0.0)

Q10 Have you ever been diagnosed with a sexually transmitted disease or infection?
Yes 23 (10.6) 20 (12.0) 3 (6.1)
No 192 (88.9) 146 (87.4) 46 (93.9)
Prefer not to say 0 (0.0) 0 (0.0) 0 (0.0)
Left question unanswered 1 (0.5) 1 (0.6) 0 (0.0)

Questions Pertaining to Knowledge/Awareness of HPV infection Total, n (%) Female, n (%) Male, n (%)
(n = 217) (n = 168) (n = 49)

Q11 ‘‘HPV is a sexually transmitted infection”

True** 151 (69.9) 116 (69.5) 35 (71.4)
False 64 (29.6) 50 (29.9) 14 (28.6)
I don’t know 1 (0.5) 1 (0.6) 0 (0.0)

Q12 Can a person get HPV from skin to skin contact with a person infected with HPV?
Yes** 64 (29.6) 48 (28.7) 16 (32.7)
No 119 (55.1) 96 (57.5) 23 (46.9)
I don’t know 33 (15.3) 23 (13.8) 10 (20.4)

Q13 Can HPV cause cancer?

Yes** 166 (76.9) 134 (80.2) 32 (65.3)
No 10 (4.6) 6 (3.6) 4 (8.2)
I don’t know 40 (18.5) 27 (16.1) 13 (26.5)

Q14 Does HPV affect both women and men?

Yes** 207 (95.8) 160 (95.8) 47 (96.0)
No 2 (0.9) 0 (0.0) 2 (4.1)
I don’t know 6 (2.8) 6 (3.6) 0 (0.0)
Left question unanswered 1 (0.5) 1 (0.6) 0 (0.0)

Q15 Does HPV cause cancer only in women?

Yes 23 (10.6) 20 (12.0) 3 (6.1)
No** 139 (64.4) 108 (64.7) 31 (63.3)
I don’t know 53 (24.5) 39 (23.4) 14 (28.6)
Left question unanswered 1 (0.5) 0 (0.0) 1 (2.0)

Q16 Can condoms ensure you will not get HPV?*

Yes 29 (13.4) 26 (15.6) 3 (6.1)
No** 154 (71.3) 121 (72.5) 33 (67.3)
I don’t know 33 (15.3) 20 (12.0) 13 (26.5)

Q17 In which category do you believe your risk falls for getting HPV?
High risk 10 (4.6) 8 (4.8) 2 (4.1)
Moderate Risk 37 (17.1) 32 (19.2) 5 (10.2)
Low risk 139 (64.4) 103 (61.8) 36 (73.5)
No risk 30 (13.9) 24 (14.4) 6 (12.2)

Q18 Which statement do you identify with the strongest?

Having HPV would significantly affect my health in a negative way 137 (63.4) 106 (63.5) 31 (63.3)
Having HPV would slightly affect my health in a negative way 77 (35.6) 59 (35.3) 18 (36.7)
Having HPV would not affect my health 1 (0.5) 1 (0.6) 0 (0.0)
Having HPV would improve my health 0 (0.0) 0 (0.0) 0 (0.0)
Left question unanswered 1 (0.5) 1 (0.6) 0 (0.0)

(continued on next

5
J.A. Goldfarb and J.D. Comber Vaccine: X 10 (2022) 100141

Table 2 (continued)

Question Questions Pertaining to Sexual Health Total, n (%) Female, n (%) Male, n (%)
Number (n = 216) (n = 167) (n = 49)

Q19 Is there a cure for HPV?

Yes 16 (7.4) 12 (7.2) 4 (8.2)
No** 119 (55.1) 96 (57.5) 23 (46.9)
I don’t know 81 (37.5) 59 (35.3) 22 (44.9)

Q20 Can HPV infection be prevented?

Yes** 198 (91.7) 153 (91.6) 45 (91.8)
No 4 (1.9) 4 (2.4) 0 (0.0)
I don’t know 14 (6.5) 10 (6.0) 4 (8.2)

Questions Pertaining to HPV Vaccination Total, n (%) Female, n (%) Male, n (%)
(n = 217) (n = 168) (n = 49)

Q21 Did you know there is a vaccine for HPV?*

Yes 190 (88.0) 152 (91.0) 38 (77.6)
No 24 (11.1) 13 (7.8) 11 (22.4)
Left question unanswered 2 (0.9) 2 (1.2) 0 (0.0)

Q22 If you were aware that there is a vaccine for HPV, did you know it can be given until age
40?
Yes 79 (36.6) 65 (38.9) 14 (28.6)
No 137 (63.4) 102 (61.1) 35 (71.4)

Q23 Are you vaccinated against HPV (at least one dose)?
Yes 168 (77.8) 134 (80.2) 34 (69.4)
No 47 (21.8) 32 (19.2) 15 (30.6)
Left question unanswered 1 (0.5) 1 (0.6) 0 (0.0)

Q24 If you are vaccinated against HPV who recommended this vaccination to you?
Pediatrician or other healthcare provider 146 (67.6) 116 (69.5) 30 (61.2)
Parent or guardian 22 (10.2) 17 (10.2) 5 (10.2)
Friend 1 (0.5) 1 (0.6) 0 (0.0)
Teacher 0 (0.0) 0 (0.0) 0 (0.0)
Other 2 (0.9) 2 (1.2) 0 (0.0)
This does not apply to me because I am not vaccinated for HPV 44 (20.4) 30 (18.0) 14 (28.6)
Left question unanswered 1 (0.5) 1 (0.6) 0 (0.0)

Q25 The HPV vaccination is only needed if you have multiple sexual partners?*
Yes 3 (1.4) 2 (1.2) 1 (2.0)
No** 194 (89.8) 158 (94.6) 36 (73.5)
I don’t know 19 (8.8) 7 (4.2) 12 (24.5)

Q26 ‘‘The HPV vaccine has significant side effects”

True 10 (4.6) 6 (3.6) 4 (8.2)
False** 147 (68.1) 120 (71.9) 27 (55.1)
I don’t know 59 (27.3) 41 (24.6) 18 (36.7)

Q27 ‘‘The HPV vaccine is safe”

True** 178 (82.4) 140 (83.8) 38 (77.6)
False 4 (1.9) 3 (1.8) 1 (2.0)
I don’t know 34 (15.7) 24 (14.4) 10 (20.4)

Q28 Can you get HPV from receiving the HPV vaccination?*
Yes 4 (1.9) 2 (1.2) 2 (4.1)
No** 120 (55.6) 102 (61.1) 18 (36.7)
Almost never 66 (30.6) 47 (28.1) 19 (38.8)
I don’t know 26 (12.0) 16 (9.6) 10 (20.4)

Q29 The HPV vaccine (specifically Gardasil 9) is effective at preventing HPV infection?
Yes** 175 (81.0) 140 (83.8) 35 (71.4)
No 4 (1.9) 4 (2.4) 0 (0.0)
I don’t know 37 (17.1) 23 (13.8) 14 (28.6)

Q30 Do you agree with this statement? ‘‘My family and/or friends would disapprove if they
knew I was vaccinated for HPV”
Yes 12 (5.6) 8 (4.8) 4 (8.2)
No 194 (89.8) 154 (92.2) 40 (81.6)
I don’t know 10 (4.6) 5 (3.0) 5 (10.2)

Q31 If someone is vaccinated for HPV are safe sex practices (i.e. condoms, contraception) still
needed?*
Yes** 209 (96.8) 164 (98.2) 45 (91.8)
No 3 (1.4) 1 (0.6) 2 (4.1)
I don’t know 3 (1.4) 1 (0.6) 2 (4.1)
Left question unanswered 1 (0.5) 1 (0.6) 0 (0.0)

Q32 Do you think by getting the HPV vaccine you will be more inclined to be sexually active?*
Yes 21 (9.7) 17 (10.2) 4 (8.2)
No 179 (82.9) 142 (85.0) 37 (75.5)
I don’t know 16 (7.4) 8 (4.8) 8 (16.3)

6
J.A. Goldfarb and J.D. Comber Vaccine: X 10 (2022) 100141

Fig. 3. Individuals who feel their family and friends would approve of HPV vaccination are more likely to be vaccinated for HPV. *p < 0.05.

in Villanova, PA). We designed a survey to assess knowledge, commonly transmitted STI in the United States and a significant
atti- tudes, and awareness surrounding HPV infection and HPV proportion of sexually active men and women will be infected by
vaccina- tion along with self-reported HPV vaccination rates. Our some genotype of HPV in their lifetime [29], the majority of
findings indicate that lower vaccination rates for HPV are not respondents in our study feel they are at low risk for contracting
explained by overall knowledge about HPV and infection, but the virus. Although a conclusive statement cannot be made about
more likely involve concerns about vaccine safety and social the true risk of our study population, the majority of participants
stigmas associ- ated with HPV vaccination. reported being currently sexually active, including participants
Participants (both male and female) who responded correctly to who have had multiple sexual partners, as well as those who have
all eight knowledge questions were not more likely to be vacci- not practiced safe sex. Therefore, it is likely that individuals are at
nated for HPV. This does not preclude the possibility that knowl- greater risk for contracting HPV than they perceive. In support of
edge is an important factor in the decision to become vaccinated, this data, Holman et al. cite a low perceived risk of HPV infection
but our data suggest that factors beyond basic knowledge of HPV to be a potential barrier among parents getting their children vac-
may play more important roles in this decision. For example, cinated [30]. This highlights the importance of educating children,
although there were no significant differences between males adults, and parents alike about the widespread prevalence of HPV
and females with respect to knowledge about HPV, there was a and the likelihood of contracting some type of HPV in a person’s
general lack of knowledge about transmission and treatments. lifetime.
Only a small percentage of participants correctly responded that Individuals who believed HPV vaccination is safe, effective,
HPV can be spread by skin-to-skin contact. Although skin to skin without significant side effects, and cannot result in HPV infection
contact is not the most common route of transmission of HPV were significantly more likely to be vaccinated in at least one dose
infection, it is a possible route for transmission and more than half than participants who believed vaccination is unsafe. Scientific
of the study population is misinformed about it. Small subsets of data prove the safety and efficacy of HPV vaccines [4,31,32], but
participants also believed that there is a cure for HPV and/or were a divide exists between these facts and the public’s understanding
unsure if HPV causes cancer in only women. Despite being small of them.
subsets, the responses identify a population of individuals in need There is a perception held by some parents that getting their
of better education about HPV which may directly impact their child vaccinated for HPV will incline the child to become
decision to vaccinate. Overall, the data suggest that factors beyond sexually active. This is commonly linked to a feeling that
knowledge of the infectious disease play more significant roles in vaccination encourages sexual behavior [33]. Our findings add
the decision to vaccinate, in line with what has previously been evidence to dis- pel this notion. We found that the majority of
reported for HPV vaccination [20]. respondents indi- cated that they would not be more inclined to
Several factors may play significant roles in these decisions be sexually active after getting the HPV vaccine. This
including risk awareness, vaccine safety, and vaccine disapproval unsupported perception has the potential to be a detriment to
by parents, family, and friends. The majority of participants (both the health of the child through not vaccinating him or her
male and female) responded that they were at a low-risk for being against HPV or waiting until an older age to vaccinate which is
infected with HPV and only a small percentage felt that they were inadvisable. What’s more, the data indi- cate that individuals who
high-risk for infection. Therefore, although HPV is the most believe their family or friends would dis- approve of the HPV
vaccination were significantly less likely to be
7
J.A. Goldfarb and J.D. Comber Vaccine: X 10 (2022) 100141

vaccinated. It is imperative that repeated educational conversa- also like to thank Dr. Carol Weingarten, Dr. John Olson, the Vil-
tions occur between parents, children, and healthcare providers lanova Honors Department, and the Office of Health Professions
about HPV vaccination to eradicate its stigma with sexual promis- Advising for help in disseminating the survey. This work received
cuity or inclination. A physician’s recommendation for the HPV funding from Villanova University’s Falvey Memorial Library
vaccine has been shown to promote uptake and acceptance of Scholarship Open Access Reserve (SOAR) Fund.
HPV vaccination [30]. Therefore, physicians can be an important
target to promote HPV vaccination and alleviate concerns about
its link to sexual activity which is widely disproven [23–26]. References
There are several limitations to our study that highlight the
need for further investigation. First, although the total population [1] de Martel C, Plummer M, Vignat J, Franceschi S. Worldwide burden of cancer
attributable to HPV by site, country and HPV type. Int J Cancer 2017;141
of Villanova is over 8000 students, only 217 students responded.
(4):664–70. https://doi.org/10.1002/ijc.30716 .
Although these numbers are similar to response rates in other [2] Schiller JT, Castellsagué X, Garland SM. A review of clinical trials of human
studies [9,11], a larger sampling population may have been more papillomavirus prophylactic vaccines. Vaccine 2012;30(Suppl 5):F123–38.
https://doi.org/10.1016/j.vaccine.2012.04.108 .
informative and may eliminate bias in students who respond to
[3] Haghshenas Mohammad Reza, Mousavi T, Kheradmand M, Afshari M,
the survey (i.e., respondents who are science majors vs. non- Moosazadeh M. Efficacy of Human Papillomavirus L1 Protein Vaccines
science majors; vaccinated vs. non-vaccinated etc.) Secondly, we (Cervarix and Gardasil) in Reducing the Risk of Cervical Intraepithelial
Neoplasia: A Meta-analysis. Int J Prev Med 2017;8(1):44. https://doi.org/
did not stratify our responses based on age over 25 years old
10.4103/ijpvm.IJPVM_413_16 .
and it is possible that expanding the age stratification would [4] Joura EA, Giuliano AR, Iversen O-E, Bouchard C, Mao C, Mehlsen J, et al. A 9-
provide more information about knowledge and vaccination valent HPV vaccine against infection and intraepithelial neoplasia in women. N
Engl J Med 2015;372(8):711–23. https://doi.org/10.1056/NEJMoa1405044 .
rate that was not captured in this current study. Finally, we did
[5] CDC. Six Reasons to Get Vaccinated Against HPV. Cent Dis Control Prev; 2020.
not investi- gate economic impact of HPV vaccination- namely https://www.cdc.gov/hpv/parents/vaccine/six-reasons.html (accessed June 3,
cost to the student- and it is possible that vaccination status is 2021)..
impacted by health care plan and out of pocket expenses [6] Elam-Evans LD, Yankey D, Singleton JA, Sterrett N, Markowitz LE, Williams CL,
et al. National, Regional, State, and Selected Local Area Vaccination Coverage
related to obtaining the vaccine. Among Adolescents Aged 13–17 Years — United States, 2019. MMWR Morb
Taken together, the data presented in this study indicate that Mortal Wkly Rep 2020;69(33):1109–16. https://doi.org/10.15585/mmwr.
factors beyond basic knowledge of the infectious disease play mm6933a1.
[7] Revzina NV, DiClemente RJ. Prevalence and incidence of human papillomavirus
more significant roles in the decision to vaccinate, in line with infection in women in the USA: a systematic review. Int J STD AIDS 2005;16
what has previously been reported for HPV vaccination [20]. (8):528–37. https://doi.org/10.1258/0956462054679214 .
Since the rec- ommended age range for HPV vaccination is 11– [8] D’Urso J, Thompson-Robinson M, Chandler S. HPV knowledge and behaviors of
black college students at a historically black university. J Am Coll Health
12 years of age, clinicians should discuss the virus and vaccine 2007;56(2):159–63. https://doi.org/10.3200/JACH.56.2.159-164 .
with both parents and children and, if possible, dispel the myths [9] Kellogg C, Shu J, Arroyo A, Dinh NT, Wade N, Sanchez E, et al. A significant
that surround HPV vaccination. With the wide availability of HPV portion of college students are not aware of HPV disease and HPV vaccine
recommendations. Hum Vaccines Immunother 2019;15(7-8):1760–6. https://
vaccines in the US including at physicians’ offices, urgent care doi.org/10.1080/21645515.2019.1627819 .
clinics, and pharmacies, education about the vaccine must include [10] Kasymova S, Harrison SE, Pascal C. Knowledge and Awareness of Human
ways to obtain the vac- cine safely and with reasonable cost to Papillomavirus Among College Students in South Carolina. Infect Dis Res Treat
2019;12. https://doi.org/10.1177/1178633718825077 .
the individual. As individu- als move through the health care [11] Patel DA, Zochowski M, Peterman S, Dempsey AF, Ernst S, Dalton VK. Human
system, particularly into early adulthood, there continues to be Papillomavirus Vaccine Intent and Uptake among Female College Students. J
opportunities to educate about the benefits of HPV vaccination. Am Coll Health 2012;60(2):151–61. https://doi.org/10.1080/
07448481.2011.580028 .
[12] Barnard M, George P, Perryman ML, Wolff LA, De Groot AS. Human
papillomavirus (HPV) vaccine knowledge, attitudes, and uptake in college
Data Statement
students: Implications from the Precaution Adoption Process Model. PLoS ONE
2017;12(8):e0182266. https://doi.org/10.1371/journal.pone.0182266 .
Due to the sensitive nature of the questions and the perception [13] Lefkowitz ES, Kelly KM, Vasilenko SA, Maggs JL. Correlates of human
by students that their responses may be used to identify them, it papillomavirus vaccination among female university students. Women
Health 2014;54(6):487–501. https://doi.org/10.1080/03630242.2014.903552 .
was agreed between the authors and the IRB of Villanova Univer- [14] Kamimura A, Trinh HN, Weaver S, Chernenko A, Wright L, Stoddard M, et al.
sity that any raw data will not be published or shared. Knowledge and beliefs about HPV among college students in Vietnam and the
United States. J Infect Public Health 2018;11(1):120–5. https://doi.org/
10.1016/j.jiph.2017.06.006 .
CRediT authorship contribution statement [15] Singh J, Roy B, Yadav A, Siddiqui S, Setia A, Ramesh R, et al. Cervical cancer
awareness and HPV vaccine acceptability among females in Delhi: A cross-
sectional study. Indian J Cancer 2018;55(3):233. https://doi.org/10.4103/ijc.
Jennifer A. Goldfarb: Conceptualization, Methodology, Formal IJC_28_18.
analysis, Data curation, Writing – original draft, Writing – review [16] Rashid S, Labani S, Das BC, Natarajaseenivasan K. Knowledge, Awareness and
& editing, Visualization. Joseph D. Comber: Conceptualization, Attitude on HPV, HPV Vaccine and Cervical Cancer among the College Students
in India. PLoS ONE 2016;11(11):e0166713. https://doi.org/10.1371/journal.
Writing – review & editing, Funding acquisition, Supervision. pone.0166713 .
[17] Aynaci G, Guksu Z. Awareness of HPV and HPV vaccination in undergraduate
Declaration of Competing Interest students in the North West region of Turkey: Near future outlook. J Infect Dev
Ctries 2019;13:516–25. https://doi.org/10.3855/jidc.11405 .
[18] Villanova University Diversity: Racial Demographics & Other Stats n.d. https://
The authors declare that they have no known competing finan- www.collegefactual.com/colleges/villanova-university/student-life/diversity/
(accessed June 3, 2021)..
cial interests or personal relationships that could have appeared
[19] Dubé E, Laberge C, Guay M, Bramadat P, Roy R, Bettinger JA. Vaccine hesitancy:
to influence the work reported in this paper. an overview. Hum Vaccines Immunother 2013;9(8):1763–73. https://doi.org/
10.4161/hv.24657 .
Acknowledgements [20] Rodriguez SA, Mullen PD, Lopez DM, Savas LS, Fernández ME. Factors
associated with adolescent HPV vaccination in the U.S.: A systematic review
of reviews and multilevel framework to inform intervention development.
We would like to thank Dr. Carol Weingarten for her guidance Prev Med 2020;131:105968. https://doi.org/10.1016/j.ypmed.2019.105968 .
[21] Harmsen IA, Ruiter RAC, Paulussen TGW, Mollema L, Kok G, de Melker HE.
and suggestions during and after the data collection process, and
Factors that influence vaccination decision-making by parents who visit an
Dr. Carla NavarezDiaz for helpful comments and discussion anthroposophical child welfare center: a focus group study. Adv Prev Med
about the statistical tests used to analyze the collected data. We 2012;2012:1–7. https://doi.org/10.1155/2012/175694 .
would
8
J.A. Goldfarb and J.D. Comber Vaccine: X 10 (2022) 100141

[22] Grimes RM, Benjamins LJ, Williams KL. Counseling about the HPV Vaccine: [29] Satterwhite CL, Torrone E, Meites E, Dunne EF, Mahajan R, Ocfemia MCB, et al.
Desexualize, Educate, and Advocate. J Pediatr Adolesc Gynecol 2013;26 Sexually transmitted infections among US women and men: prevalence and
(4):243–8. https://doi.org/10.1016/j.jpag.2013.04.002 . incidence estimates, 2008. Sex Transm Dis 2013;40(3):187–93. https://doi.
[23] Bednarczyk RA, Davis R, Ault K, Orenstein W, Omer SB. Sexual activity-related org/10.1097/OLQ.0b013e318286bb53 .
outcomes after human papillomavirus vaccination of 11- to 12-year-olds. [30] Holman DM, Benard V, Roland KB, Watson M, Liddon N, Stokley S. Barriers to
Pediatrics 2012;130:798–805. https://doi.org/10.1542/peds.2012-1516 . human papillomavirus vaccination among US adolescents: a systematic
[24] Liddon NC, Leichliter JS, Markowitz LE. Human papillomavirus vaccine and review of the literature. JAMA Pediatr 2014;168(1):76. https://doi.org/
sexual behavior among adolescent and young women. Am J Prev Med 2012;42 10.1001/jamapediatrics.2013.2752 .
(1):44–52. https://doi.org/10.1016/j.amepre.2011.09.024 . [31] Angioli R, Lopez S, Aloisi A, Terranova C, De Cicco C, Scaletta G, et al. Ten years
[25] Mayhew A, Mullins TLK, Ding L, Rosenthal SL, Zimet GD, Morrow C, et al. Risk of HPV vaccines: State of art and controversies. Crit Rev Oncol Hematol
perceptions and subsequent sexual behaviors after HPV vaccination in 2016;102:65–72. https://doi.org/10.1016/j.critrevonc.2016.03.020 .
adolescents. Pediatrics 2014;133(3):404–11. https://doi.org/10.1542/ [32] Garland SM, Kjaer SK, Muñoz N, Block SL, Brown DR, DiNubile MJ, et al. Impact
peds.2013-2822 . and Effectiveness of the Quadrivalent Human Papillomavirus Vaccine: A
[26] Brouwer AF, Delinger RL, Eisenberg MC, Campredon LP, Walline HM, Carey TE, Systematic Review of 10 Years of Real-world Experience. Clin Infect Dis Off
et al. HPV vaccination has not increased sexual activity or accelerated sexual Publ Infect Dis Soc Am 2016;63(4):519–27. https://doi.org/10.1093/cid/
debut in a college-aged cohort of men and women. BMC Public Health 2019;19 ciw354.
(1). https://doi.org/10.1186/s12889-019-7134-1 . [33] Beavis A, Krakow M, Levinson K, Rositch AF. Reasons for Lack of HPV Vaccine
[27] Hall MT, Simms KT, Lew J-B, Smith MA, Brotherton JML, Saville M, et al. The Initiation in NIS-Teen Over Time: Shifting the Focus From Gender and
projected timeframe until cervical cancer elimination in Australia: a modelling Sexuality to Necessity and Safety. J Adolesc Health 2018;63(5):652–6.
study. Lancet Public Health 2019;4(1):e19–27. https://doi.org/10.1016/S2468- https://doi.org/10.1016/j.jadohealth.2018.06.024 .
2667(18)30183-X .