https://orcid.org/0000-0001-7678-1008
ABSTRACT
In the US, individuals between ages 18 and 26 have the highest incidence of new human papillomavirus (HPV) infections, the most common sexually transmitted infection worldwide. HPV infection can cause genital warts, and persistent infection with cancerous strains can develop into multiple types of cancers. In 2011, the Centers for Disease Control and Prevention recommended that both men and women receive the vaccine. However, young adult men, including college-aged men, have been slow to initiate and complete the vaccine series. Our cross-sectional study, guided by the Theory of Planned Behavior, explores college men’s vaccination uptake and series completion behaviors and their intentions to vaccinate. Using logistic regression, we examined how students’ attitudes, perceived behavioral control, and subjective norms impacted their HPV vaccine–related behaviors and intentions. Subjective norms, followed by perceived behavioral control to communicate with a provider about the HPV vaccine, had the largest impact on students’ HPV vaccine uptake and completion behaviors and intentions to vaccinate. Both subjective norms and positive attitudes about the vaccine impacted students’ intentions to vaccinate against HPV. Based on these findings, we make various recommendations including campus interventions and policies that could increase HPV vaccine uptake and completion behaviors among college men.
Introduction
Human papillomavirus (HPV) is the most common sexually transmitted infection (STI),Citation1 and incidence of new HPV infection is greatest among individuals between 18 and 26 years old.Citation2 Although HPV infection is often asymptomatic, infection with some HPV strains, namely Types 6 and 11, can cause noncancerous genital warts.Citation3 Persistent infection with cancerous strains, particularly Types 16 and 18, can cause various cancers. Although originally associated with cervical cancer in women, HPV also causes cancers (oropharyngeal, anal, penile) in men.Citation4,Citation5 In fact, in the US, HPV-related oropharyngeal cancer is now the most common cancer attributable to HPV and is five times more common in men than women.Citation5
In the US, vaccines that protect against the two most common cancerous HPV strains (Types 16 and 18) have been commercially available since 2006. In 2007, the Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices (ACIP) recommended that females between ages 11 and 12 be routinely vaccinated (with “catch-up vaccination” for women ages 13 to 26) with a 4-valent HPV (4vHPV) vaccine, Gardasil 4, which offers protection against Types 6, 11, 16, and 18.Citation6 At the time, the vaccine was marketed as a cervical cancer prevention resource. In 2011, ACIP began recommending 4vHPV vaccination to 11- and 12-year-old males and catch-up vaccination for all men between ages 13 to 21, primarily as a means to prevent genital warts.Citation7 Additionally, ACIP recommended that all gay and bisexual men up to age 26 vaccinate against HPV, given their increased risk for both genital warts and anal cancer.Citation7 In December 2016, ACIP changed the vaccine dosage so that all individuals between ages 9 and 14 only need two doses of the 9-valent HPV vaccine (Gardasil-9, which protects against Types 6 and 11 and seven cancerous strains, including Types 16 and 18). Everyone age 15 and older still needs three doses to complete the series.Citation8 In June 2020, the U.S. Food & Drug Administration approved the use of Gardasil-9 to prevent HPV-related oropharyngeal cancers, and this may impact future marketing of this vaccine, particularly for men.Citation9 The most recent HPV vaccine policies advise immunizing everyone up to age 26 and engaging in shared decision-making (between patient and provider) to vaccinate individuals up to age 45.Citation10 However, males, including college-aged males, lag behind females in HPV vaccine uptake and completion.Citation11
The “feminization” of HPV may explain males’ lower rates of HPV vaccine uptake.Citation12 Daley and colleagues attributed various factors to this phenomenon, which include the 10-year lag in published science that links the connection of HPV infection to cancer development in men, the marketing of the HPV vaccine to women as a resource to prevent cervical cancer, and the initial HPV vaccine cost-effectiveness analyses that included women’s HPV vaccine uptake data only, excluding men and assuming heteronormative behavior.Citation12 It is critical to debunk both the perceptions of HPV as exclusively a women’s health issue and of HPV vaccination for women only, since these stigmatizing beliefs may discourage men from receiving this vaccine.Citation13
Increasing HPV vaccination among college men is an important and feasible method of increasing HPV vaccination rates, especially among a population who can autonomously decide to receive the vaccine. The American College Health Association has acknowledged this disease prevention opportunity and aims for 80% of all college students to complete the HPV vaccine series.Citation14 Although many college and university health services offer this cancer prevention resource,Citation15 a recent survey found that, among college attendees, just 65% of women and 53% of men have received at least one dose of the HPV vaccine.Citation16
Previous HPV vaccine research studies have used the Theory of Planned BehaviorCitation17 (TPB) to predict vaccine uptake among college men and women.Citation18–20 The TPB is a health behavior theory positing that behavioral intentions largely drive behaviors. Further, behavioral intentions, the antecedents to behavior, are influenced by (1) attitudes toward the behavior (e.g., seeking the HPV vaccine); (2) subjective norms, or the expectation that people in one’s social group want them to enact a behavior; and (3) perceived behavioral control, or the confidence in one’s ability to enact a behavior.Citation17 One past research study found that the TPB predicted 39% of HPV vaccine behavior, outperforming another common theory, the Health Belief Model, in predicting vaccine uptake.Citation18 The current research study aims to assess college men’s HPV vaccine behaviors and intentions and assess how their attitudes, perceived behavioral control, and subjective norms impact their behaviors and intentions.
Materials and methods
Measures
Using previously validated survey items, we created a survey instrument comprising 25 questions that measured TPB psychosocial constructs.Citation18,Citation19,Citation21–24 We chose HPV vaccination uptake and completion,Citation19 previous communication with providers,Citation24 and intention to vaccinateCitation19 as our main outcome variables. We included two different types of perceived behavioral control measures: (1) perceived behavioral control to financially access the vaccine, since cost is a major barrier to receiving the vaccine,Citation25 and (2) questions related to students’ confidence in communicating with healthcare providers about the vaccine, since provider recommendation is the strongest predictor of HPV vaccine uptake.Citation26 Although not a construct of the TPB, we included an additional construct – stigma against HPV – because it has influenced HPV vaccine acceptability and uptake, with greater levels of stigma predicting greater acceptance of the vaccine.Citation27,Citation28 We therefore modified a previous survey that assessed stigma against HIVCitation29 and included five items that assessed stigma against HPV and receiving a diagnosis of HPV infection. See for all TPB and stigma-related questions and response options. We assessed participants’ knowledge and awareness of HPVCitation30,Citation31 and the HPV vaccine.Citation22 Additionally, we asked participants to provide the following demographic information (total of 14 questions): age, full- or part-time student status, year in school, race, ethnicity, sexual orientation,Citation21 health insurance status,Citation21 sexual history, prior diagnosis with genital warts or other sexually transmitted infections,Citation21 and current engagement with a primary care provider. The survey included a total of 54 questions.
Table 1. Survey questions which assessed participants’ behaviors, Theory of Planned Behavior psychosocial constructs, and HPV stigma (n = 574)
Participant recruitment
Upon receiving approval from the Arizona State University Institutional Review Board to conduct this study, we entered the survey questions into RedCAP, software for organizing databases and online survey responses. We generated a QR code and Tiny URL that linked to the survey.
To recruit participants, we announced the study on our university’s online platform. The announcement, posted from September to October 2019, included the following information: inclusion criteria, the study topic, information about incentives (25 random drawings for 10 USD e-gift cards), and the QR code/Tiny URL for the survey. When students followed the URL or scanned the QR code, they were immediately brought to an online short consent form. Students demonstrated consent by clicking on an “I agree” button after reading the consent language. After providing consent, students were asked to complete the survey, followed by an unlinked demographic form and an additional unlinked page where they could enter their contact information for the raffle.
Analyses
We analyzed all data in Stata/MP 16.0. We used descriptive statistics to summarize participants’ demographic information and responses to the theoretically informed survey items. It is important to note that all participants were over 18 years old. Based on their age, all participants were over 14 years old when ACIP updated the HPV vaccine dosage. Therefore, they would have needed three doses of the vaccine to complete the series.
We created indices or composite scores for all psychosocial constructs (e.g., intentions, attitudes, behavioral control, etc.). To assess the interrelationships between the multiple psychometric indices on vaccination/communication behaviors and intentions, we conducted multinomial logistic regression, estimated with heteroskedasticity-corrected standard errors. For the logistic regression, all coefficients were exponentiated in order be more easily interpreted as odds ratios. To better compare the strength of the statistical associations between these variables and the dependent variable, all index measures, used as independent variables in the logistic regressions, were standardized to a zero mean. Standard deviations were equal to one. In this way, the coefficient estimates describe the change in odds ratio associated with a one standard deviation increase in the corresponding index.
Results
Potentially, 36,865 male students (including undergraduate and graduate students) were exposed to the study announcement. A total of 654 students responded to the survey, of whom 574 completed 50% or more of the survey items and were, therefore, included in the study. describes participants’ demographics. The average age of participants was 21.3 years old. The majority (n = 353, 63.7%) of the respondents reported being white. Most students (n = 457, 79.6%) reported having a primary care provider and have health insurance (n = 512, 89.2%). Just over half (n = 295, 51.4%) reported being sexually active, with 207 (35.1%) reporting always using a condom during sex. Only 11 respondents (1.9%) reported ever having been diagnosed with genital warts, an indicator of previous HPV infection. Another 37 (6.4%) reported having had a different, undisclosed sexually transmitted infection.
Table 2. Sample demographics
lists participants’ survey responses. Approximately one-third (33.1%, n = 205) of students reported receiving at least one dose of the HPV vaccine, while 245 (39.6%) reported never having received a single dose. Among those vaccinated, 131 (63.9%) received all three doses, 47 (22.9%) received one or two doses, and 27 (13.2%) were unsure of how many doses they had received. illustrates that students’ age significantly impacted both HPV vaccine initiation and completion rates, with younger populations (18, 19 to 22 years old) having a greater likelihood of both initiating and completing the HPV vaccine series as compared to students over age 22. Other than age, Hispanic ethnicity was the only other demographic variable that was positively correlated with HPV vaccine uptake (Odds Ratio [OR] = 2.30, 1.04–5.11). Finally, students who were sexually active were 2.5 times more likely to have completed the vaccine series (OR = 2.50, 1.12–5.57).
Table 3. Impact of demographic factors on HPV vaccine uptake and completion
illustrates that, among the psychosocial influences assessed, subjective norms to vaccinate against HPV had the strongest influence on initiating (OR = 3.79, 2.40–5.98) and completing (OR = 2.83, 1.49–5.38) the vaccine series. Perceived behavioral control to communicate with a provider about the HPV vaccine also significantly impacted HPV vaccine initiation (OR = 2.06, 1.11–3.82). Perceived behavioral control to access the vaccine, despite the vaccine’s expense, had some impact (OR = 0.30, 0.11–0.79) on vaccine series completion.
Table 4. Psychosocial influences on HPV vaccine uptake and completion
Most (70.8%) students who had received at least one dose of the HPV vaccine intended to complete the series. Among students who had not initiated the vaccine series, 245 (75.1%) reported they had no intention to seek the vaccine. illustrates the “the impact of subjective norms [OR = 3.37, 2.22–5.13], followed by positive attitudes about the vaccine [OR = 1.60, 1.08–2.35], on students’ intentions to vaccinate against HPV. No other psychosocial construct was significantly associated with intentions.
Table 5. Impact of knowledge, awareness, attitudes, subjective norms, and perceived behavioral control on students’ intention to vaccinate against HPV
Discussion
Among study participants, 203 participants (33.1%) reported having received the vaccine, 244 (39.7%) reported never having received an HPV vaccine dose, and 167 (27.2%) were unsure whether they had been vaccinated against HPV. Students in our study had lower rates of HPV vaccine uptake and completion compared to the data in which 680 (5%) had initiated but not completed the vaccine series and 6634 (44%) had completed the vaccine series.Citation32 College-aged males are far below reaching the 80% HPV vaccine uptake goal. More efforts, such as directly targeting college males in social marketing campaigns, are needed to successfully encourage them to vaccinate against HPV.
Similar to past research with adult men between ages 18 to 26, younger college males were more likely to have vaccinated against HPV.Citation33 Older students may not realize that they are still age-eligible to receive the vaccine and that health insurance provides coverage up to age 26. In this study, as opposed to findings in past research studies,Citation34,Citation35 Hispanic ethnicity predicted HPV vaccine uptake. In this study, race did not significantly influence HPV vaccine–related behaviors.
Participants who reported being sexually active were more likely to have completed the HPV vaccine series. This may be due to increased perceived susceptibility to acquiring HPV and, in turn, demand for the vaccine. To increase college men’s intentions to vaccinate against HPV, particularly among sexually naïve or inactive men, it is important to emphasize that the HPV vaccine is most effective prior to sexual debut. Encouraging college freshmen to vaccinate against HPV may be an effective strategy to increase HPV vaccination,Citation20 particularly since sexual initiation and activity increases with age.Citation36 One potential policy-related strategy to increase HPV vaccination among all college students could include making the HPV vaccine series a requirement for college admission.Citation37 Currently, the HPV vaccine is a recommended, not required, vaccine.
Whereas past research states that provider recommendation to vaccinate is the strongest predictor of HPV vaccine uptake behaviors,Citation26,Citation38,Citation39 the majority of our participants reported never having spoken with a healthcare provider about getting the HPV vaccine. There are numerous possible reasons for this. First, participants may not remember the conversation with their providers, especially if the vaccine was offered to them in early adolescence and if they were accompanied by a parent who negotiated the health-related decision of whether to receive this vaccine. Second, this finding could also point to providers’ lack of communication (and therefore missed opportunities) with male patients about the HPV vaccine.Citation40 Past research described providers’ lack of perceived benefits of the HPV vaccine for male patients as a reason for not strongly recommending it to their male patients.Citation41 Additionally, due to the high cost and low reimbursement for the vaccine, some healthcare providers, especially those working in private practice, may not carry the vaccine,Citation42 thus impacting their HPV vaccine recommendations. Future research with college men could include specific questions related to whether a healthcare provider ever initiated a conversation about HPV and the HPV vaccine. Third, this lack of a conversation about the vaccine may perhaps also be attributed to males’ lack of primary care–seeking behaviors. Whereas college women more often receive the HPV vaccine on college campuses during wellness (including gynecological) visits,Citation34 college men are less likely to seek health care altogether, leading to missed opportunities to vaccinate against HPV.Citation35 College men have described the inconvenience of scheduling and attending a health care visit as barriers to receiving the HPV vaccine.Citation43 They have also described perceived lack of coverage for the vaccine series (by their insurance plans) and preference to avoid a vaccine-related or office-related copayment as barriers to vaccinating against HPV.Citation44 More information is needed to understand how best to motivate college men to seek primary care, which presents opportunities to receive the HPV vaccine. Additionally, increasing college males’ health insurance literacy to better understand how to use this resource may increase their access to and use of care.
Only 23.5% (n = 60) of students who stated that they had not vaccinated against HPV (n = 244, 39.7%) intended to initiate the HPV vaccine series within the next six months. Of the psychosocial variables assessed, subjective norms followed by positive attitudes about the vaccine impacted students’ intentions to vaccinate. Participants’ lack of subjective norms or perceived social expectation to vaccinate against HPV may have also impacted their lack of intention to vaccinate. In our study, students’ subjective norms varied (46.9–64.4%) in terms of the types of individuals (friends, significant other, family, healthcare provider) they believe think it important for them to vaccinate against HPV, with more participants believing that their healthcare providers would want them to receive the vaccine. Another study reported that college students’ beliefs that parents and healthcare providers expected them to vaccinate against HPV impacted their perceived behavioral control and, in turn, their intentions to vaccinate.Citation45 Future health education strategies could encourage male college students’ parents and campus healthcare providers to promote vaccinating against HPV to these college men, particularly as a resource to help prevent oropharyngeal cancers.Citation20,Citation43
Overall, college males in our study held positive attitudes about the HPV vaccine even though roughly one-third of participants (32%) reported never having heard about the HPV vaccine before taking this survey. One recent study with college students found that the majority (70%) of college male survey participants had not received a single dose of the HPV vaccine yet still reported favorable attitudes about it.Citation46 This may point to college males’ positive attitudes about vaccines in general and not necessarily positive attitudes about the HPV vaccine, specifically. Future qualitative research could further explore college males’ attitudes about vaccines in general and then ask specific questions about their perceptions of the HPV vaccine.
College men reported that they would have stigmatizing self-perceptions (“unclean,” “partially to blame,” “others would avoid me”) if they were diagnosed with HPV. Fewer reported believing that, more generally, people diagnosed with HPV were immoral or promiscuous. However, stigma was not associated with vaccine-related behaviors or intentions.
Limitations
A number of limitations exist for this study. We did not ask students to state when they initiated the initial dose of the HPV vaccine or whether their caregivers played a role in their HPV vaccination status. Based on their age when they were offered the vaccine, students’ caregivers may have played a larger role in deciding whether they received the vaccine, impacting students’ perceived behavioral control to vaccinate. Another limitation is that we did not include any questions related to the anticipated regret of not receiving the HPV vaccine. Past research has expanded the TPB to include anticipated regret of not receiving a vaccine as a unique influence on behavioral intentions,Citation47 particularly for HPV vaccination among men.Citation48 Future research assessing college males’ HPV vaccine behavior should consider including measures that assess anticipated regret. We also did not include measures to assess altruistic vaccination (vaccinating as a means to protect sexual partners from HPV), a predictor of HPV vaccine acceptability among men.Citation13 Sampling (selection) bias may have occurred, given that a convenience sample of students self-selected to participate in the study. Additionally, data were collected from male students at one large, southwestern university. Results may, therefore, have limited generalizability, given that students from only one institution participated in this study. Nevertheless, this is a large sample, with a number of respondents similar to other college health–related research.Citation37 Given the higher incidence of HPV-associated cancers among gay and bisexual men,Citation49 future studies of college students should oversample men who have sex with men. The large degree of item nonresponse in the survey appears to happen evenly across observational respondent characteristics, but there may be unobserved factors driving the item response that further distorts the representativeness of these findings. Finally, due to its cross-sectional design, this study cannot determine temporality or causality of students’ HPV vaccine behaviors.
Conclusion
College males have an increased risk for acquiring HPV. In order to be protected against cancer-causing and genital warts–causing strains of HPV, this population needs to complete the HPV vaccine series. Overall, college males in this study had positive attitudes about the HPV vaccine and perceived behavioral control to access it. However, they lacked intention to vaccinate, which may have been driven by a lack of subjective norms to be vaccinated against HPV. Normalizing and encouraging HPV vaccine initiation and completion among college men as a cancer prevention behavior may be strategies that lead to increased vaccination against HPV.
Disclosure of potential conflicts of interest
No potential conflicts of interest were disclosed.
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