HPV Vaccination and Awareness Programs at Maryland Colleges and Universities

Abstract

Context:

About half of adolescents aged 13 to 17 in United States are not fully vaccinated against human papillomavirus (HPV). As they age into young adulthood, colleges may be an excellent target population nexus for implementing interventions to improve HPV vaccination uptake.

Objectives:

Our study goal was to generate knowledge about HPV vaccine offerings and awareness programs at colleges to ascertain the extent of campus-facilitated access to HPV immunization and education in 1 state.

Design:

An electronic survey was designed and emailed to 32 of 47 Maryland colleges for which relevant campus contacts could be identified.

Settings:

The study took place at Johns Hopkins Bloomberg School of Public Health in consultation with the Maryland Cancer Collaborative and the Maryland Department of Health.

Participants:

Maryland colleges and universities

Main Outcome Measures:

HPV vaccine and awareness program offerings on college and university campuses.

Results:

Twenty Maryland colleges responded. Two colleges offer awareness programs only. Ten colleges offer HPV vaccine, covering about 39% of Maryland college students. Of these, 4 colleges schedule “periodic” campus health clinics or provide an immunization prescription, which is filled at nearby pharmacies. In all colleges, which offer HPV vaccine, immunization is offered to everyone (both men and women) at no out-of-pocket cost.

Conclusions:

In cooperation with the Maryland Cancer Collaborative, the implementation arm for the Maryland Cancer Control Plan, we showed that college campuses are an excellent target site for implementation of interventions to improve access of college age students to HPV vaccine and awareness programs. We lay the groundwork for recommendations, programs and policies that can improve HPV vaccine offerings among college students thus raising the HPV vaccination rate in young adults. Simple inexpensive alternatives to offering vaccine at college health centers may be periodic campus health clinics and arrangements with nearby pharmacies.

Human papillomavirus (HPV) is the most common sexually transmittable infection (STI) in the United States.1 More than 80% of sexually active Americans become infected with HPV virus in their lifetime.2

HPV is sexually transmitted by vaginal, anal, and oral sex among men and women. HPV causes almost all cervical cancers and the majority of anal (90%), vaginal (75%), vulvar (69%), oropharyngeal (70%), and penile (63%) cancers.3 Pre-cancerous lesions are most common among women in their 30s, while peak prevalence of cervical cancers is at ages 40 to 50.4-6 Thus, to prevent these cancers it is imperative to immunize before exposure or strategically at as young an age as possible.3,7

The current Gardasil-9 vaccine protects against 9 HPV types and reduces the incidence of infection and cervical cancer caused by those types by nearly 100%.8 Among men, HPV vaccine prevents more than 80% of oral and oropharyngeal HPV Infections and is expected to have similar efficacy against HPV-related oropharyngeal cancers.9,10 Centers for Disease Control and Prevention (CDC) has recommended routine HPV vaccination for everyone aged 11 through age 26 years. While the HPV vaccine is not routinely recommended at older ages, it is approved for use in adults aged 27 to 45, who may decide to be vaccinated after consultation with their physicians.7,11 Recommended administration of the vaccine is 2 doses, unless the first dose is administered after age 15 when a third dose is then recommended.7,11 The list price for every dose of the HPV vaccine Gardasil 9 is $295.12 The Affordable Care Act (c) requires most private insurance plans to cover the full cost for the HPV vaccine for age-recommended populations.13

Despite this policy-friendly vaccine profile of effectiveness, cost, efficiency, and accumulated scientific evidence, the US HPV vaccination uptake rate has not achieved the Healthy People 2020 target of 80% for full vaccination among adolescents aged 13 to 15 years.14,15 HPV vaccination coverage (≥1 dose) among adolescents was 65.5% and full coverage with ≥2 doses among those aged 17 years was only 51.4%.16 Policy is frequently made by each state, and as such HPV vaccine is currently required in only 4 states (Hawaii, Rhode Island, Virginia, and the District of Columbia, DC,17 while in other states it is recommended but not required.

HPV vaccine uptake at recommended vaccine ages 12 to 13 remains sub-optimal and thus by the time adolescents age into young adulthood, some are still unprotected against HPV at age 18 when individuals typically are making health decisions for themselves.18 A Study has shown state level characteristics such as religiosity, political ideology, and education policies are factors accounting for HPV vaccine completion among adolescents when parents are the decision makers.19 The National Academies has published a report about young adults (age 18-26) who are disproportionately affected by some medical conditions, and how this age group lacks awareness of effective health habits and interventions, as well as policies and programs tailored to their age group.20 College students comprise a large portion of young adults, who are still at risk for HPV-related disease.

Several studies have shown a low level of knowledge about HPV vaccine and low uptake among college students.21-23 A survey of college students in California reported that 65% of male and 52% of female respondents did not know that the HPV vaccine is recommended by CDC through 26 years of age. Another sizable portion, 47.6%, did not know they can receive the HPV vaccine at their college health center.24 Important predictors of immunization were ethnicity, family income, and the highest level of education in the family. Another survey of South Carolina college lead nurses showed that more than 91% support HPV vaccination, although only 41% envisioned active roles for themselves in promoting HPV vaccination among students.25

Additional studies have shown that offering vaccine at college combined with awareness raising sessions can significantly increase the rate of vaccination uptake by students, even in low-income settings.26,27 Interviews with college administrators revealed barriers to HPV vaccination at colleges to be costs and reliance on governmental and professional organization recommendations for implementation at colleges. Reported facilitators of vaccination included partnerships with health care providers, advocates, and community coalitions28 To date, college policies about HPV awareness raising and HPV vaccination offerings have not been well studied.

In Maryland, HPV vaccine is not required for middle or high school enrollment.17 Nevertheless, Maryland ranked 6th best among US states for HPV vaccination coverage in 2021.29 The estimated full HPV vaccination coverage for adolescents 13-17 years of age in Maryland was about 53% in 2017,30 and by 2020 the vaccination rate in the state of Maryland for the same age group rose to 70%.29 While this improvement is notable for successive adolescent cohorts, there remains a large proportion of young adults in Maryland who are eligible yet remain unvaccinated.

To learn the status of HPV vaccine availability and awareness programs at Maryland colleges and to inform developing relevant state and local policies and programs, we conducted a practice survey of Maryland colleges.

Methods

Forty-seven Maryland colleges (public, private, 2 year, 4 year, graduate level, and technical) were identified and retrieved from a Maryland government website and Wikipedia in September 2022 (Table 1).31,32 Data collection was completed in December 2022.

TABLE 1.

Characteristics of Maryland Colleges Who Did Not and Did Submit the HPV Vaccine Survey (“Non-Responding” and “Responding”) and by Whether They Do Not or Do Offer an HPV Vaccine Intervention (“Non-Intervention” and “Intervention”)

	All Colleges		Colleges by Response to the Survey					Colleges by HPV Vaccine Intervention
			Non-Responding		Responding			Non-Intervention		Intervention
	Number	%	Number	%	Number	%	Pearson Chi2 P Value	Number	%	Number	%	Pearson Chi2 P Value
Maryland region
National capital	9	19%	6	22%	3	15%		6	17%	3	25%
Western MD	5	11%	1	4%	4	20%		4	11%	1	8%
Eastern shore	6	13%	4	15%	2	10%		5	14%	1	8%
Southern MD	1	2%	0	0%	1	5%		1	3%	0	0%
Baltimore region	26	55%	16	59%	10	50%	.30	19	54%	7	58%	.91
Total	47	100%	27	100%	20	100%		35	100%	12	100%
College
2-year	17	36%	13	48%	4	20%		15	43%	2	17%
4-year	30	64%	14	52%	16	80%	.05	20	57%	10	83%	.10
Total	47	100%	27	100%	20	100%		35	100%	12	100%
Type
Public	18	38%	10	37%	8	40%		22	63%	7	42%
Private	29	62%	17	62%	12	60%	.84	13	37%	5	58%	.78
Total	47	100%	27	99%	20	100%		35	100%	12	100%
Level
Undergrad	19	40%	14	52%	5	25%		16	46%	3	25%
Grad/Undergrad	28	60%	13	48%	15	75%	.06	19	54%	9	75%	.21
Total	47	100%	27	100%	20	100%		35	100%	12	100%
Number of students
Range	305-40 709		305-21 917		446-40 709			305-21 917		446-40 709
Median	3060		2560		5070			2646		5422
Total	293 111		134 719	46%	158 392	54%		171 461	58%	121 650	42%

An electronic survey (Appendix 1, available at http://links.lww.com/JPHMP/B457), on the HPV Vaccine Availability and Awareness Survey among Maryland Colleges, 2022 was designed and implemented using REDCap (Queen Mary University, London). After being piloted with faculty and staff at Johns Hopkins University and Maryland Department of Health (MDH), the survey was distributed by email to colleges during October with follow-up emails in November, and December the same year.

To ascertain a contact person at each college, each college website was searched for a student health center, nurse office, or any source that offered physical health services to students. An email address was identified for staff working at a student health center whenever possible. When a health center was not found, a phone call to the college was placed (at least 2 call attempts) to reach the health center. When no health center or any reliable email address for health-related services could be found, a general inquiry email address was used. Six weeks after emailing the survey, non-responders were telephoned (at least 2 attempts) to request completion and return of the survey. Among 47 colleges identified, 32 were sent the survey and 20 completed it. As a final attempt to learn vaccine availability at all colleges, the website of these non-responders was checked for information about HPV vaccine and none was found.33

Characteristics of colleges were obtained from internet sources. Religious affiliation, level of college (undergraduate or graduate), type of college (4- or 2-year degrees), nature of the college (public or private), and number of students enrolled were identified at CollegeSimply or MyFuture websites.34,35 Historically Black Colleges and Universities (HBCUs) were identified at the website of the United Negro College Fund36 and verified at the college website.

Geographic location of colleges was coded into 5 Maryland regions based on MDH Vital Statistics designations and retrieved from the government website.37

Tabulations and significance testing were done using Excel (Microsoft Corporation 2018) and Stata (Stata Corp. 2021, release 17). In reporting outcomes, nonresponsive colleges which were mainly undergrad, 2-year colleges, were combined with those that did not provide the vaccine or awareness programs, because among the colleges of that type, those who responded often did not offer HPV vaccine programming (Table 1).

This study was determined to be exempt from IRB approval by the JHSPH IRB office (FWA #00000287).

Results

Thirty-two colleges or about two-thirds (32/47 = 68.1%) of all colleges could be contacted and were surveyed electronically. Among those 32 colleges, almost two-thirds responded (20/32 = 63%), representing 42.6% (20/47) of all Maryland colleges (Table 1).

The responding 20 colleges were similar to the 27 colleges, which did not respond or had no contact email to send the survey, with regard to public/private college status and Maryland region. However, responding colleges were significantly more likely than non-responders to be 4-year colleges (80% vs 52%, P = .047), and to offer graduate programs (75% vs 48%, P = .06; Table 1).

There were no differences between colleges which offered any awareness program or vaccinations and those which did not as a matter of program length (2 vs 4 years), level (degree offered), type (public vs private) and Maryland region (Table 1). Twelve colleges reported HPV vaccine intervention availability, representing 42% of all Maryland students. These schools were primarily 4-year degree schools (83%), compared to 57% of 35 colleges that did not have an HPV intervention (P = .10), though the difference was not statistically significant (Table 1).

Fifty percent of colleges (10/20) of respondents, 31% (10/32) of colleges that were sent the survey, and 21% (10/47) of all Maryland colleges identified for this study reported offering the HPV vaccine. There were 8 colleges, which offered awareness programs about HPV vaccine, representing 40% of respondents (8/20), 25% of colleges contacted (8/32), and 17% of all Maryland colleges identified (8/47). Six colleges offered both the HPV vaccine and an awareness program, 30% of respondents. Students at colleges known to offer an HPV vaccine intervention (the vaccine or awareness program), are estimated to serve 41.5% (121 650/293 111) of all Maryland college students (Table 2).

TABLE 2.

Results for HPV Vaccine Availability and Awareness Survey Among Maryland Colleges, 2022

	Survey Question	Answers	Response Distribution for Each Question [N(%)]	Response Distribution Among All Responding Colleges [N(%)]
1	Is HPV vaccine available (ie, do you administer HPV vaccine) for students at your campus health service centers?	No	10 (50)
		Yes, at college health center	6 (30)
		At vaccine clinics or nearby pharmacy	4 (20)
		Total	20 (100%)
1a	At your college student health center, who do you recommend HPV vaccination to?	Men only	0 (0)	0 (0)
		Women only	0 (0)	0 (0)
		All students	7 (100)	7 (35)
		Unsure	0 (0)	0 (0)
		Total	7 (100)	7 (35)
1b	At your college health center, at what type of visit do you recommend HPV vaccine? (Select all that apply.)	Never	0 (0)	0 (0)
		At arrival/orientation	0 (0)	0 (0)
		STI visits	5 (71)	5 (25)
		Sick visits	0 (0)	0 (0)
		Check up and wellness visit	4 (57)	4 (20)
		All clinic visits regardless of reason	2 (29)	2 (10)
		Total	7 (100)	7 (35)
1c	How often do providers at your health center recommend HPV vaccination?	Never	0 (0)	0 (0)
		Sometimes	2 (29)	2 (10)
		Often	4 (57)	4 (20)
		Always	1 (14)	1 (5)
		Provider dependent	1 (14)	1 (5)
		Total	7 (100)	7 (35)
1d	Are there any out of pocket costs for HPV vaccination for the students at the campus health service centers of your college? (Select all that apply.)	No	7 (100)	7 (35)
		Unsure	0 (0)	0 (0)
		Yes	0 (0)	0 (0)
		Total	7 (100)	7 (35)
1e	Is it required to have health insurance to get HPV vaccination at the student health clinic(s) at your college?	No	1 (14)	1 (5)
		Yes, must have college insurance	2 (29)	2 (10)
		Yes, can use any insurance	4 (57)	4 (20)
		Total	7 (100)	7 (35)
2	Does your college ask students about their HPV vaccination status before they come to campus?	No	11 (55)
		Unsure	0 (0)
		Yes	9 (45)
		Total	20 (100)
3	Is HPV vaccine covered by the health insurance that your college provides?	No	6 (30)
		Yes	9 (45)
		Unsure	5 (25)
		Total	20 (100)
4	At your college, are ALL students required to be covered by the health insurance your college provides?	No	3 (15)
		Yes	17 (85)
		Total	20 (100)
4.a.	If yes, do you know the approximate percentage of your college students that are covered by college provided health insurance?	No	6 (35)	6 (30)
		Unsure	7 (41)	7 (35)
		Yes	4 (24)	4 (20)
		Total	17 (100)	17 (85)
4.a.i.	What is the approximate percentage of students covered by college provided health insurance?	Total	4 (100)	4 (100)
			Mean: 20.6%
5	Is there any health insurance requirement at your college?	No	5 (29)	5 (25)
		Yes	12 (71)	12 (60)
		Total	17 (100)	17 (85)
6	Within the past 5 years has there been any HPV vaccine awareness program on your campus?	No	7 (35)	7 (35)
		Unsure	5 (25)	5 (25)
		Yes	8 (40)	8 (40)
		Total	20 (100)	20 (100)
6.a.	If Yes, what type? (Select all that apply)	Presentation for providers on campus	1 (13)	1 (5)
		Presentation for students on campus	4 (50)	4 (20)
		Visual material on campus	7 (88)	7 (35)
		Total	8 (100)	8 (40)

The following description of results is focused on responding colleges. Among the 20 colleges, which responded to the survey, 71% (5/17) have a health insurance requirement for enrollment (Question 5), and 86% (Question 1e, 6/7) require health insurance to get HPV vaccine and 45% (Question 2, 9/20) asked the HPV vaccination status of students upon arrival (Table 2).

Among the 10 colleges that offered HPV vaccine (Question 1), 60% (6/10) offer it at college health centers and 40% (4/10) offer it at health clinics or refer students to nearby pharmacies. Seventy percent of these 10 colleges reported that HPV vaccine was offered to everyone without out-of-pocket costs (Question 1d, 7/10). These 7 colleges reported at what visit types they offer HPV vaccine (Question 1b): 71% offered HPV vaccine at STI visits, 57% at checkup and wellness visits, and 29% offer the vaccine at any visit (29%). No schools offered vaccination at orientation or upon arrival of new students (Question 1b). Colleges that offered HPV vaccine at health centers (Question 1c) usually offered it often (4/7 = 57%), with sometimes (2/7 = 29%), always (1/7 = 14%), or provider dependent (1/7 = 14%) less often (Table 2).

Among the 8 colleges that had HPV vaccine awareness programs (Question 6/6a), 88% used visual material on campus, 50% used a presentation for students, and 13% used a presentation for providers (Table 2). Two colleges offered the HPV vaccine but not an awareness program. One of the 2 was a military institution, which had an opt out option for HPV vaccination. Two colleges, both in rural areas, had HPV vaccine awareness programs but did not offer the HPV vaccine.

Four HBCU colleges were included in this study. None offered the vaccine, but one offered an HPV awareness program. Three Catholic colleges and 2 Jewish, non-coed colleges completed the survey offered neither HPV vaccines nor awareness programs (Table 2).

Discussion

This study contributes to a limited literature about HPV vaccine availability and awareness programs on college campuses. Though only a small proportion (26%, N = 12) of Maryland colleges offered HPV vaccinations and vaccine awareness programs, schools with these programs included 42% of Maryland college students, and thus had a sizable reach. However, as more than half of Maryland students are at a college without any HPV vaccine program, this study highlights that there are clear opportunities for improved prevention, outreach and policy and program development especially among 2-year schools, those serving only undergraduates, and public institutions.

A previously published study of school nurses had suggested some barriers to HPV prevention offerings may be the high cost of vaccine for the colleges and/or students when insurance coverage is not available25; lack of storage space (personal communications, September-December 2022); or no mechanism for billing the health insurer for HPV vaccine (personal communications, September-December 2022). Using hospitals and local medical or public health clinics for offering HPV and other health services to students rather than the health center itself (personal communications, September-December 2022) may extend coverage to students enrolled at colleges not offering HPV vaccine on campus.

When HPV vaccination was offered at Maryland colleges, our survey showed it was offered to both men and women suggesting the benefit to men as well as women was known to these college health centers. Also, when offered, HPV vaccination did not have associated out-of-pocket costs and was offered often or always at student visits to the health center, strengthening uptake. The vaccine was never offered at orientation or upon arrival, thus mid-academic-year occasions of student body gatherings in addition to orientations and arrivals may present opportunities to improve HPV vaccine knowledge and access.

Two colleges offered HPV vaccine awareness programs without HPV vaccinations, suggesting when HPV vaccination is not available on campus in some instances. HPV awareness programs may at least be an option to inform students and connect them with local pharmacies, public health departments, or other community resources where they can be vaccinated. The types of awareness programs offered by the colleges and targeted toward the student population were low-cost. Visual presentations was the most common type of HPV awareness program at the surveyed colleges and was a cost-effective way of increasing HPV vaccine awareness and increasing student uptake of the HPV vaccination as reported by Kessler and Auwaerter.26

Some small Maryland colleges provided opportunities for HPV vaccination at periodic health, STI, vaccine clinics, or mobile clinics on campus.38 This suggests that HPV vaccination as a service could be piggybacked on other student health offerings to attain more greater vaccination completion among students.

This study highlighted several success stories among the colleges surveyed that provide insight for future program developments:

1. One college of about 1000 students gave prescriptions for HPV vaccine to students that could be filled at a pharmacy nearby campus, thus providing an achievable and efficient alternative to offering the vaccine at the college health center. Two colleges in rural areas with about 2000 students each, did not offer HPV vaccine but offered HPV awareness programs, making students cognizant of the possibility of getting the vaccine off campus.

2. A college with fewer than 500 students offered HPV vaccinations and an awareness program to students at the college health center demonstrating student body size does not always limit programming.

3. There were 3 colleges with fewer than 10 000 students each that have neither a health center nor a source for HPV vaccination. Instead, these colleges offered periodic health, STI, or special vaccine clinic opportunities on campus during which they offered the HPV vaccination. This suggests a feasible target population option when offering the vaccine more broadly was not possible.

4. A military college provided an opt out option for HPV vaccine, overriding the need for awareness program.

5. A university with about 30 000 students and a medical school offered the HPV vaccine with an awareness program across campus and at the college health center. The awareness program included campus signs, presentation for health center providers, and prompts recommending HPV vaccination to students. These efforts nearly doubled HPV vaccination prevalence among students (12.2% to 20.8% of students).26

These examples suggest an HPV vaccine intervention is feasible at nearly all colleges. Based on these examples, several recommendations are offered that may improve HPV vaccination among colleges of Maryland.

State and Local Health Departments: Administer a survey of HPV offerings at colleges and universities periodically to learn more about the non-responders. This would give more information about community college students and those in the Baltimore Region, for example. HPV vaccine surveillance would allow monitoring HPV vaccine intervention uptake among colleges where young adults spend a considerable amount of time and monitoring of higher education policies and programs that may follow this report.

Orienting campus providers about offering HPV vaccinations to students is an underutilized way of increasing awareness among college and university administrators about HPV vaccination of students and its importance to health.25,28 An informational handout or letter about HPV vaccine sent to all colleges would provide vaccine information to administrators and health staff.28

Two-Year Colleges: Partner with local health departments or pharmacies, which might afford periodic HPV vaccine clinics on campus or nearby. These colleges offered HPV vaccination less often than 4-year institutions. Their students tend to be parttime, older, more often working, living off campus, and seek various services off campus, which may dictate less time, in general, on campus.33,39

Four-Year Colleges: Facilitate advocacy for budgeting additional resources and designating or hiring staff if applicable.25

All Colleges: Increase student awareness by posting information about the health center on the college website or social media pages, including a brief description of services and contact information. A webpage will increase awareness among students about the health services offered and facilitate contact with health centers. Colleges may also opt to orient students about the health center upon arrival, systematically inquiring about vaccination status and offering the HPV vaccine in the future if students are not fully vaccinated upon arrival. Asking college health centers to report to college administration overall HPV vaccination rates at the time of enrollment may facilitate prioritizing and planning for any vaccination program.

Adults up to age 26 are covered by parent insurance policies, which provide evidence-based prevention tools at no cost under the ACA.13 A strategy that some colleges have used is including HPV vaccination as a requirement for enrollment (along with other common communicable disease vaccines.40) All colleges could adopt an opt-out strategy for HPV vaccine as is the case for some other communicable disease prevention measures prior to or at enrollment. An opt out strategy has the additional advantage of very good compliance using that alone.

Almost all colleges have student mental health or wellness centers as indicated by a review of their websites (data not shown). With training, these centers can render HPV vaccine awareness programs or referral to physical health services.41 To improve HPV vaccine awareness programs, offerings, and quality, colleges can provide educational material about HPV vaccination at popular campus locations and on college social media pages, though these interventions have had mixed effects.42 Simple signs about HPV availability were effective at least 1 institution.26

Historically or Religiously Defined Colleges: Among the 4 HBCU colleges included in this study, none offers HPV vaccination, and 1 offers an awareness program. Catholic- and Jewish-affiliated colleges did not provide HPV awareness or HPV vaccination programs to their students and in the case of HPV vaccine they may not be amenable to general public health guidance. There may be a need for tailored approaches to HPV vaccinations at these institutions that meet their institutional and student needs. Resources and discussions to help address concerns due to religious assumptions or expectations about sexual behaviors are needed.

Study Limitations

The main limitation of this study was its dependency on reaching out to colleges to complete and return the survey. Response rates were not optimal and limitations in time and personnel prevented individualized in-person outreach which might have increased responses.

Sending the electronic survey depended on having the email address or phone number of the college health center or contact information for a specific person in charge of providing health services to college students. Many colleges do not provide such information on their website. The general phone number of colleges was operated frequently by answering machines or operators who could not direct us to medical expertise on campus, thus our ability to achieve an improved response rate may be limited though we suspect these campuses have the smallest student bodies.

We may not have reached administrative entities that are largely virtual such as those with global students, and those for whom a single health center is not relevant though these were not systematically identified. Also, some colleges do not provide any specific information about health centers or services at their multiple campuses, so the survey answers may reflect their main campus only or the campuses that had separate health centers posted on their website.

Nevertheless, this study lays the groundwork for specifying HPV vaccine program implementation recommendations at colleges. This status report, repeated periodically, would improve statewide knowledge about HPV programs at colleges and their programs that address an unserved and vulnerable population group. Offering of HPV vaccine in Maryland colleges can substantially improve. Short of tracking testing and vaccination services for students, public health surveillance of colleges as one place where a target population for vaccine outreach may be found is feasible. To date, dissemination of current practices to colleges remains slow despite several examples of successful outreach that lie within available college resources.

Conclusions

Adolescents age 13 to 17 are not fully vaccinated against HPV and as they age into young adulthood, colleges are an excellent target population nexus for implementing interventions to improve HPV vaccination usage.

As potential public health policy and program partners, colleges are in a position to help close the gap in young adult HPV vaccination coverage that to date remains slowly disseminated.

Implications for Policy & Practice

• Offering HPV vaccine and awareness programs in Maryland colleges can improve substantially.

• College campuses are an excellent site for implementing interventions to improve access and awareness about HPV vaccine among college students.

• We identified alternatives for offering the vaccine on low resource campus.

• Developing policies and programs can provide funding and other resources for HPV vaccine interventions on college campuses.

• This is significant because about half of American pre-college age students are not fully vaccinated for HPV and are at high risk of HPV transmission, infection, and subsequent cancers.

• They comprise a needy subpopulation for HPV vaccination programs.