Introduction

Background

Purpose

Methods

A cross-sectional study design was utilized for this exploratory analysis, in order to administer a self-report questionnaire to a relevant sample of 361 female college students from a large, public, state-supported Northeastern university in 2007. The university’s Institutional Review Board approved the study. Questionnaires were administered over a period of four weeks at different times and at several locations (e.g., University Health Services, Alpha Phi sorority, health class, aerobics class, and a choral rehearsal) on the university’s campus from the end of February through March 2007. Questionnaires were also distributed on campus to female college students enrolled at the university who were entering or departing scheduled classes and events. The anonymous surveys took an average of seven minutes to complete and were immediately collected from the participants upon completion. University Health Services administered surveys to female students as they waited for their appointments. Completed surveys were returned to the reception desk and were collected in a locked collection box.

All questionnaires had a cover letter attached that explained the purpose of the study and emphasized the anonymity and confidentiality of the results. Students were told to keep this letter for their records. There were no incentives for participating in this study. Additional open ended comments from the participants were recorded at the end of the survey.

The 23-item questionnaire was designed to determine demographic information, level, and source of self-reported knowledge about HPV and the HPV vaccine and attitudes, behaviors, and beliefs about the HPV vaccine. Revisions were made during the pilot testing phase of the questionnaire. Ambiguities associated with the survey content were not identified during test trials that were conducted prior to official questionnaire administration.

Respondents were asked if they knew what HPV was and if they had heard of the HPV vaccine, Gardasil ^® , prior to this survey (“Yes”/”No”/”Not sure” to both). In order to determine sources of information of the vaccine, respondents were asked to choose from the following sources: “Tell Someone” commercial, “One Less” commercial, talk show, news show, magazine advertisements, magazine articles, radio, newspaper articles, medical journals, Merck Pharmaceutical, Inc. web site, thehpvtest.com web site, general practitioner, nurse, other health professional, University Health Services, family, friends, and other. Respondents were instructed to circle all that applied to them.

Respondents were then asked if they would get the HPV vaccine if it were offered for free. Those who responded “No” or “Not sure” were asked a follow-up question to determine the reason for their response. There was also a question to determine what behavior changes have resulted from knowing about the HPV vaccine. Examples included: getting vaccinated against HPV; speaking with a healthcare professional about the HPV vaccine; sharing knowledge with family or friends; and engaging in further information gathering about the HPV vaccine and the link between cervical cancer and HPV.

Finally, information regarding the respondent’s attitude about the idea that HPV vaccination may lead to risky sexual behavior, a current controversial topic, was collected. Respondents were asked a series of questions to determine the degree to which they agree with statements about the HPV vaccine, such as should females between the ages of nine and 26 years of age get the HPV vaccine, and whether or not they were personally concerned about acquiring HPV. The questions were analyzed on a three-point scale, “Agree”/”Disagree”/”Not sure.”

All data were analyzed using the Statistical Package for Social Sciences (SPSS), Version 15.0 for Windows. Descriptive analyses were done for each of the following participant responses: specific college the participant was enrolled in at the university; age (age groups analyzed: 17-18, 19-21, 21-24, ≥25 years); race; if have had sexual intercourse; age at which first had sexual intercourse; number of sexual partners (the number of sexual partners analyzed: 0, 1, 2, 3-5, ≥6); condom use; relationship status; overall health status; if receive regular Pap screening tests; knowledge of HPV; heard of Gardasil ^® before survey; knowledge of the HPV vaccine; would get the HPV vaccine if it were offered for free; reasons for not getting the HPV vaccine if it were offered for free; behavior change(s) as a result of knowledge of the HPV vaccine; likelihood of recommending the HPV vaccine to others; agreement that females between the ages nine and 26 should get the HPV vaccine; belief that the HPV vaccine may encourage risky sexual behavior; and concern about possibly acquiring HPV.

Cross-tabulation analyses were done for the questions of interest and all demographic variables, as well as self-reported knowledge of HPV and the HPV vaccine. These questions included: would get the HPV vaccine if it were offered for free; likelihood of recommending the HPV vaccine to others; agreement that females between the ages nine and 26 should get the HPV vaccine; agreement that HPV vaccination against a sexually transmitted infection may encourage risky sexual behavior; and concern about possibly acquiring HPV. Pearson’s chi-square tests and two-tailed t-tests were done to assess relationships between two variables. For statistical tests, P-values less than 0.05 were considered to be statistically significant.

Results

The demographic and behavioral characteristics of female undergraduate respondents are shown in Table 1. Two hundred ninety-three of 361 surveys (81% response rate) were completed and returned by female college students enrolled at a large Northeastern State University. Female students, aged 18 to 34 years, voluntarily participated in the anonymous study. The mean age of the respondents was 20.4 years (standard deviation [SD] =0.125), and 93.5% of respondents were Caucasian. Based on a comparison to information compiled by the university’s Office of Institutional Research, the population demographics of our relevant sample are generalizable to the university’s undergraduate female population due to the relative similarities of the sample characteristics for gender and ethnicity to that of the university population. Non-traditional female students and female graduate students were underrepresented.

Figure 1

TABLE 1. Demographic and behavioral characteristics of female undergraduate respondents

The majority responded that they had previously had sex (90.4%), and t-test results found the average age of women who responded “Yes” to previously having sex to be 20.5 and “No” to be 19.9 (P<0.014). T-test results showed that the majority of respondents did get regular Pap tests (78.8%), and the mean age of those women who did get regular Pap tests (20.6) was statistically significant (P<0.001) from those who did not (19.5). Also, the mean number of sexual partners among women who got regular Pap tests (4.6) was statistically significant (P<0.001) from those women who did not get regular Pap tests (2.4).

The majority of respondents both knew what HPV was (85%) and had heard of the HPV vaccine, Gardasil ^® (85%), prior to completing this survey. The mean age of those who had heard of Gardasil ^® (20.4) was statistically different (P<0.022) from those who were not sure (18.7). The majority of respondents who knew what HPV was had also heard of Gardasil ^® (92%), but there was some inconsistency. For instance, of the participants who did not know what HPV was, 28.6% had heard of Gardasil ^® .

The most common sources of information about the HPV vaccine among respondents were the “Tell Someone” television commercial (64.9%) and the “One Less” television commercial (64.5%), both of which were developed by Merck Pharmaceuticals, Inc. Friends (41.8%) and family (31.9%) were the next most common sources of information regarding the HPV vaccine.

The majority of respondents would get the vaccine if it were offered for free (75.3%), and reasons for not getting the vaccine included “Need more information” (63.5%) and “Safety concerns” (39.4%). “Speaking to physician” (45.5%) and “Sharing your knowledge with others” (41.6%) were the most common behavior changes noted by respondents as a result of knowing about the HPV vaccine. There was a population of participants (16.2%) who answered that they had begun the HPV vaccination series. The mean age for those “early adopters” was 19.7 years. There was a statistically significant correlation (P<0.001) between those who had received the HPV vaccine and those who agreed that females between the ages of nine and 26 should get the HPV vaccine and were likely to recommend the vaccine to others.

We found several statistically significant associations between demographic variables and attitudes and behaviors with respect to the HPV vaccine. More than half of the respondents (52.9%) marked that “Yes,” they were concerned about possibly acquiring HPV. With cross-tabulation analysis, we found statistically significant associations between concern of acquiring HPV with each of the following variables: number of sexual partners (P<0.029); knowledge of HPV (P<0.002); if ever had sex (P<0.001); and current relationship status (P<0.001).

The majority of respondents (69.1%) were likely to recommend that others be vaccinated against HPV. The mean age for those respondents who were likely to recommend the HPV vaccine (20.4) was statistically different (P<0.025) from those who were not likely to recommend the HPV vaccine (19.6). Statistically significant associations were also found between the likelihood of recommending the HPV vaccine and the following variables: knowledge of HPV (P<0.001); knowledge of the HPV vaccine (P<0.001); if ever had sex (P<0.029); and if get regular Pap tests (P<0.002).

A high percentage of respondents (82.8%) agreed that females between the ages of nine and 26 should be vaccinated. Statistically significant associations with this statement were with knowledge of HPV (P<0.006) and current relationship status (P<0.022).

Finally, we addressed the controversial idea that vaccination against a sexually transmitted infection, specifically HPV, may encourage risky sexual behavior. The majority of respondents (65.3%) disagreed with this idea. The mean age of respondents who disagreed (20.6) was statistically different (P<0.03) from those who agreed (19.9). The most statistically significant correlations were found with this question and the following variables: knowledge of HPV (P<0.001); knowledge of the HPV vaccine (P<0.001); if ever had sex (P<0.001); number of sexual partners (P<0.021); age (P<0.04); and if get regular Pap tests (P<0.001) (Table 2).

Figure 2

TABLE 2. Characteristics of female undergraduate respondents and their belief that HPV vaccination may encourage risky sexual behavior

Discussion

The public health benefits of HPV vaccination would be expected to significantly reduce HPV-related morbidity, treatment, and overall U.S. economic burden, which is estimated at more than $5 billion annually. ²⁷ In addition, the HPV vaccine also has the potential to prevent cervical cancer cases that are currently undetected due to a lack of Pap test screening. ⁹ Although this population of female college students surveyed had heard of HPV and the HPV vaccine, the lack of knowledge was the predominant reason respondents would not get the HPV vaccine even if it were offered for free. In order to dispel a false sense of security among this at-risk population, our findings warrant integrated public health efforts among health educators on college campuses and in the private sector, among parents and community health professionals, to name a few resources, with respect to HPV infection and cervical cancer control via health behavior education. These coordinated public health education strategies should involve primary (e.g., HPV vaccination) and secondary (e.g., screening and early detection) prevention methods to significantly reduce the burden of these preventable illnesses among this vulnerable female population.

Previous studies have shown that college students have very little knowledge about HPV. ^28-30 In contrast, our results suggest that the majority (85%) of female college students in our study do know what HPV is and have previously heard of the HPV vaccine, Gardasil ^® . Interestingly, knowledge of HPV did not correlate directly to knowledge of the HPV vaccine. Conversely, 28.6% of women who did not know what HPV was, had heard of Gardasil ^® . The “Tell Someone” and “One Less” television commercials developed by Merck Pharmaceuticals, Inc., were the most common sources of information about the HPV vaccine. Continued use of the media will be important to incorporate into future public health education and awareness efforts. While informing the viewer, the commercials also stress the importance of sharing knowledge with others. Family and friends were the next most common source of information about the HPV vaccine, and sharing knowledge with others was a behavior change noted by the respondents.

Our study results indicate strong correlations of self-reported knowledge about HPV and the HPV vaccine with the following themes:

Decision to get the HPV vaccine if it were offered for free. Although the majority (75.3%) of women were likely to receive the HPV vaccine if it were offered for free, the remainder of women responded “No” or “Not sure.” The most common reason for this was “Need more information.” The respondents expressed that they do not feel they have enough information to decide to get the HPV vaccine, even if it were offered for free. The women also expressed concerns about safety of the HPV vaccine, which is understandable as Gardasil ^® is a new vaccine. Only 7% responded that they “Do not think the HPV vaccine is important.”

Likelihood of recommending the HPV vaccine to others and the belief that HPV vaccination will promote risky sexual behavior. Awareness of the HPV vaccine was another behavior that correlated significantly with the likelihood of recommending the vaccine to others and agreement that vaccination may encourage risky sexual behavior. Of those women who have heard of the HPV vaccine, 73.3% were likely to agree that others get the HPV vaccine. Of those women who had never heard of the HPV vaccine, 41.5% were likely to recommend it and 43.9% were not sure if they would recommend the HPV vaccine. In general, awareness of the HPV vaccine correlated with women being more likely to recommend the HPV vaccine and with disagreement that HPV vaccination may encourage risky sexual behavior. Interestingly, all of the women who were not sure what the HPV vaccine was were likely to recommend it and also agreed that HPV vaccination may encourage risky sexual behavior. This information suggests that these women may not view risky sexual behavior with a negative connotation since they are likely to recommend a vaccine that they think encourages risky sexual behavior. Furthermore, the age of the respondents significantly correlated with agreement that HPV vaccination may encourage risky sexual behavior with older respondents disagreeing with this belief. These findings highlight the need for health behavior education regarding risky sexual activity and how to prevent HPV infection.

Agreement that females between the ages of nine and 26 should get the HPV vaccine. Interestingly, 82.8% of respondents agreed that females between the ages of nine and 26 should be vaccinated, as compared to “likely” recommending that others receive the HPV vaccine. This may very well be due to women not feeling informed enough to responsibly recommend that others receive the vaccine. However, when asked whether to agree or disagree, women felt more comfortable agreeing that females between the ages nine and 26 should be vaccinated.

Relationship status. Current relationship status of the respondents was a characteristic that provided statistically significant correlations with concern about possibly acquiring HPV and agreement that females between the ages nine and 26 should receive the HPV vaccine. Of those women who were single or dating, the majority (56.1% and 58.8%, respectively) were concerned about acquiring HPV. Of those in monogamous relationships, 52.7% were concerned about acquiring HPV. Of those respondents who were married or living with a partner, more than half (54.5%) did not know or were not concerned about acquiring HPV. While women who are married or in a monogamous relationship may be at lesser risk for acquiring HPV, it is still a possibility. Therefore, this data emphasizes the importance of increased health educational awareness efforts, as women may be in high risk situations for acquiring HPV but not realize it. A majority of women, regardless of relationship status, agreed that females between the ages of nine and 26 should get the vaccine.

Sexual behavior and concern about possibly acquiring HPV. Of those women who previously had sexual intercourse, only slightly more than half (56.5%) were concerned about acquiring HPV. This low percentage leads us to believe that women may know what HPV is, but they are not aware of the infectivity and prevalence of HPV, especially among women of these vulnerable ages. Of those women who previously had sexual intercourse, 70.2% were likely to recommend that others receive the HPV vaccine, and 68.3% disagreed that HPV vaccination may encourage risky sexual behavior. Of those participants who had not had previous sexual intercourse, 60.7% were also likely to recommend that others receive the HPV vaccine, and 32.1% agreed that HPV vaccination may encourage risky sexual behavior. The data illustrates that sexual experience does significantly influence attitudes and behaviors toward the HPV vaccine.

Number of sexual partners. The number of sexual partners was another characteristic that provided statistically significant correlations. For example, with an increasing number of sexual partners from zero to more than six, there was an increase in the percentage of respondents who were concerned about acquiring HPV. A previous study found that HPV seropositivity increased with the number of sexual partners, from 10% with one partner, to 25% with two or three partners, and up to 53% with more than six partners. ³¹ Another study reported that each additional sexual partner added approximately 10% to the risk of acquiring HPV infection. ³² However, in our study, of those women who have had more than six sexual partners, 20% were not concerned about acquiring HPV. This is an alarming statistic that warrants the implementation of further public health HPV educational programs. It is possible that these women may feel comfortable with high-risk sexual activity if they believe they are protected from HPV infection by vaccination, hence a false sense of security. ³⁰ In addition, there is a concern that an effective HPV vaccine would cause sexually active women to significantly reduce their adherence to obtaining Pap screening tests, thus leading to a potential increase in cervical cancer cases. ³³ These findings, again, point to the need for vaccine availability to be accompanied by proper ancillary awareness education.

Risky behaviors. Furthermore, the age at which one first had sexual intercourse, condom use, description of health status, and race did not provide statistically significant correlations. However, the frequency distributions highlight risky behaviors among this vulnerable population. For example, 18.3% of the respondents “Hardly ever” or “Never” used condoms with their male partners. Condom use has been associated with decreased risk of acquiring HPV among newly sexually active women. ²¹ The practice of not using condoms potentially puts these respondents at a higher risk for acquiring HPV infection.

Limitations. Although the findings from this exploratory analysis provide valuable insight into female college student attitudes, behaviors, and beliefs about HPV and the HPV vaccine, several limitations to this study should be noted. The sampling bias associated with a non-probability sampling technique is similar to other HPV studies in college students and limits the generalizability of the findings from this study to female college students attending other universities. Yet, the sampling of female students in various classes and events provide enhanced representation. The sample characteristics were similar to the demographics of the university population and support the generalizability of findings for the sampled university. However, the findings cannot be applied to all female college students and may not be reflective of all young women. Future studies should use random samples from several universities to maximize the generalizability of the findings. Missing data occurred randomly across all surveys. In addition, the results were limited by the cross-sectional study design and compliance to the authenticity of self-reported information, such as HPV and HPV vaccine awareness. Despite these limitations, our findings have been appropriately qualified, and we propose that they provide valuable insight regarding selected correlates associated with sexual behavior and HPV vaccination. In addition, our findings warrant an educational intervention by health educators who may find this information useful when attempting to develop integrated public health education efforts that are targeted towards this at-risk population.

Acknowledgment