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. Author manuscript; available in PMC: 2022 Jan 2.
Published in final edited form as: J Natl Med Assoc. 2020 Jul 12;112(6):639–649. doi: 10.1016/j.jnma.2020.06.005

HPVs Vaccination among Racial/Ethnic Minority College Students: Current Status and Future Direction

Dalnim Cho 1, Lois Ramondetta 2, Luz Garcini 3, Qian Lu 4
PMCID: PMC8720488  NIHMSID: NIHMS1767617  PMID: 32665067

Abstract

Objectives:

College is an important period for catch-up vaccination for Human Papillomaviruses (HPVs), but HPVs vaccination rates are low among college students. Given that racial/ethnic minorities are disproportionately affected by HPVs-related cancers, the aim of the present study is to conduct a scoping review about HPVs and HPVs vaccination conducted among racial/ethnic minority college students. Specifically, we examined: 1) the prevalence of HPVs vaccination among racial/ethnic minority college students in the US and 2) the correlates of HPVs vaccination or vaccination intention/interest.

Methods:

We searched three database (PubMed, PsycINFO, and CINAHL) for relevant articles. Of 58 articles initially identified, 23 articles met all inclusion/exclusion criteria.

Results:

Racial/ethnic minority college women (especially Black and Asian/Pacific Islander) were less likely to be vaccinated compared to their non-Hispanic white counterparts. Racial/ethnic minority college men reported lower knowledge of HPVs and HPVs vaccination compared with their women counterparts. However, overall, a majority of racial/ethnic minority college students appeared to have high knowledge about HPVs and intention to vaccinate. Age, doctor recommendation, and psychosocial and cultural factors (e.g., HPVs/HPVs vaccine knowledge, perceived benefits of vaccination, social norms and values, mistrust of health care providers, and cultural norms) were associated with vaccination and individuals’ intention to be vaccinated.

Discussion:

Significant racial/ethnic disparities in HPVs vaccination exist among both college men and women. Interventions to increase vaccine awareness, access, and uptake among racial/ethnic minority college students are lacking and warranted. Interventions targeting only knowledge and/or intention might not be sufficient. Theory-based studies that examine unique factors involved in vaccine uptake during college across multiple levels of influence including psychosocial, provider, health care, and culture are needed.

Keywords: Human papillomavirus, HPVs, Vaccination, College, University, Minority

INTRODUCTION

High-risk Human Papillomaviruses (HPVs) cause cancers in both men and women including cervical, anal, oropharyngeal, vaginal, vulvar, and penile cancers.1 Incidence and mortality rates of these HPVs-related cancers are disproportionately higher among racial/ethnic minorities. For example, cervical cancer is more likely to be diagnosed in Hispanics and Blacks compared to non-Hispanic Whites (NHWs) and Hispanic and Black women are more likely to die from cervical cancer compared with NHW women.2 Furthermore, compared to NHWs, vaginal and penile cancer incidence rates are higher in Blacks and Hispanic men also have a higher penile cancer incidence rate.3 Although overall incidence rates for cervical cancer are lower among American Asian/Pacific Islanders (APIs) than NHWs,2,3 Cambodians and Vietnamese have higher cervical cancer incidence rates (50% and 40% higher, respectively, than NHWs).4

HPVs vaccination is an effective prevention strategy against many HPVs-associated cancers such that it can prevent more than 90% of cervical cancers and majority of vaginal/vulvar cancers.5 Prevention rates for anal cancer and anogentical warts range from 75 to 99%.5 Routine HPVs vaccination is recommended for boys and girls at age 11 or 12 years, but it can begin as early as 9 years old.6 Catch-up vaccination is recommended through age 26.6 Although increasing, current catch-up vaccination rates are not optimal: in 2017, 65.5% of US adolescents aged 13–17 years received at least 1 dose of HPVs vaccine (62.6% of boys; 68.6% of girls).7

Previous HPVs vaccination studies have primarily focused on children and young adolescents. Although early vaccination is preferred, catch-up vaccination is also critical. For those who were not vaccinated during childhood and adolescence, young adulthood (18–26 years of age) is still a viable time to be vaccinated. Young adults can make important health-related decisions by themselves and do not need parents’ permission for vaccination. Efforts to increase the catch-up vaccination during young adulthood seem to be timely more than ever, given that rates of sexually transmitted diseases (STDs) such as chlamydia, gonorrhea, and syphilis are highest among 20–24 years old US men or women compared to any other age groups.8 It is of note that racial/ethnic minorities (except for Asians) report higher rates of STDs than NHWs: in particular, Blacks reported the highest rates of STDs among all racial/ethnic groups.8 Young adulthood is also a vulnerable period for HPVs infection.9,10 For example, the prevalence of high-risk HPVs infection among 20–24 years and 25–29 years men in the US was 25.0% and 29.6%, respectively.9 The prevalence of high-risk HPVs infection among 20–24 years and 25–29 years women in the US was 47.3% and 38.0%, respectively.10 There have been improvements in HPVs vaccine uptake among young adults aged 18–26;11 data from the 2013–2018 National Health Interview Survey showed that the percentage who ever received one or more doses of HPVs vaccine increased from 22.1% in 2013 to 39.9% in 2018. However, data also found racial/ethnic disparities in vaccination in that in 2018, NHW young adults were more likely than Hispanics to have ever received one or more doses of HPVs vaccine.11

College students comprise of a sizable chunk of young adults who are eligible for the catch-up vaccination; in the US, more than 42% of aged 18–24 years old men and women enrolled in postsecondary institutions.12 College campus may be an effective place to promote HPVs vaccination through educational campaigns and easy access to vaccines from student health center. It is important to improve vaccination rates for all eligible individuals but given the above-mentioned racial/ethnic health disparities in HPVs-related cancers and rates of STDs infection, racial/ethnic minority college students are still a population to target for tailored interventions.

This paper aimed to conduct a scoping review regarding the current status of HPVs vaccination among racial/ethnic minority college students in the US. We examined: 1) the prevalence of HPVs vaccination among racial/ethnic minority college students and 2) the correlates of HPVs-related outcomes including HPVs/HPVs vaccine knowledge, vaccination intention/interest, or vaccination.

MATERIALS AND METHODS

Literature search

We searched for studies conducted among college or university students in the US regarding HPVs and HPVs vaccination without using a specific date range from three databases: PubMed, PsycINFO, and CINAHL. Studies investigating racial/ethnic differences in HPVs vaccination and those examining correlates of HPVs vaccination (or vaccination intention/interest) among racial/ethnic minorities were our focus. Search terms were combinations of the following words: HPV*, college students, Hispanics, African Americans, Black, Asian Americans, and minorities. In addition, we manually searched the titles of relevant studies from the reference lists of the papers initially identified by the database searches to find additional relevant papers. The literature search was conducted between April and June 2018.

Inclusion/exclusion criteria

Articles were included if they: 1) investigated HPVs and HPVs vaccination (e.g., the prevalence of HPVs vaccination, HPVs or HPVs vaccine knowledge, and vaccination intention/interest) among racial/ethnic minority college students in the US; 2) were peer-reviewed; 3) were available as full-texts; and 4) were written in English. We excluded studies conducted among children and adolescents, and also parents or young adults who were not college students. Finally, we included both qualitative and quantitative studies (either observational or intervention and either cross-sectional or longitudinal, prospective).

We identified 58 articles and excluded 35 articles due to the following reasons: duplicate articles (n = 17), studies not about HPVs (n = 7), not conducted among college students (n = 8), and did not examine racial/ethnic differences in HPVs vaccination or correlates of HPVs vaccination/vaccination intention among racial/ethnic minorities (n = 3). Thus, a total of 23 articles were reviewed in the study.

RESULTS AND DISCUSSION

Prevalence of HPVs vaccination among racial/ethnic minority college students

We defined vaccination as receiving at least one dose of the recommended vaccination series and vaccination completion as completing all three doses. The prevalence of vaccine uptake by race/ethnicity among racial/ethnic minority college students is presented in Table 1. We found nine studies that investigated racial/ethnic differences in HPVs vaccination and/or vaccination completion. Of the nine studies, six were conducted among college women.13–18 Of the remaining three, one was conducted among college men19 and the other two included both genders,20,21 although more than 70% of the sample were women.

Table 1.

HPVs vaccination prevalence among racial/ethnic minority college students in the referenced studies.

First author Demographics HPVs vaccinationa Race/Ethnic difference
Daley13 N = 256 women, aged ≤26
Race: NHW (73.0%), Hispanic (17.5%), Black (7.7%)		 Hispanics (39%) vs. NHW (44%), none-Whites (38%) vs. NHW (45%) No difference
Lee14 N = 2270 women, aged 18–25 years
Race: API (15%), NHW (85%)		 HPV vaccination completion: 57.3%; 60.7% (NHW) and 38.6% (API) API < NHW
Lefkowitz15 N = 313 women, aged ≤ 20
Race: Black (26%), API (26%), NHW (42%), Hispanic (28%)		 18% (Black), 25% (API), and 33% (Hispanic/Latino) Black < non-Black
Licht16 N = 406 women, aged 18–26
Race: NHW (78.8%), Black (4.7%), Asian (8.6%), Hispanic (5.2%)		 47.2% (NWH), 26.3% (Black), 28.6% (Asian), and 33.3% (Hispanic/Latino) Black < NHW
Asian < NHW
Nuno17 N = 284 women, aged 18–26
Race: NHW (56%), Hispanic (25%), Black (4%), AI/AN (2%), API (9%)		 only 18% of the young women reported that they had received at least one HPV vaccine 71% (AI/AN), 68% (Hispanic), 58% (Black), 51% (NWH), 31% (API) NHW < Hispanic
Okafor18 N = 835 women, aged 18–26
Race: NHW (51%), Black (16.5%), Hispanic (13.8%), Asian (8.3%)		 Vaccination initiation: 57% (Hispanic), 57% (NHW), 42% (Black), and 51% (Asian)
Vaccination completion: 78% (NHW), 45% (Black), 66% (Hispanic), and 65% (Asian)		 For initiation:
Black < NHW
For completion:
Black < NHW
Ratanasiripong19 N = 189 men, aged 18–26
Race: NHW (12%), Black (11%), Hispanic (53.2%), Asian (15.6%)		 25.8%. Of those, 60.4% were Latino, 16.7% were Black, 8.3% were Asian, and 6.3% were NHW No difference
Thompson20 N = 107,716 (71.1% women), aged 18–26
Race: Most were NHWs (67.4% women, 65.2% men)		 For women: NHW (46.88 → 70.58%; Δ23.75%), Black (49.22 → 61.99%; Δ12.8%), Hispanic (48.52 → 67.06%; Δ 18.54%), API (27.95 → 61.86%; Δ33.9%) from 2009 to 2013
For men: NHW (15.23 → 43.27%: Δ28.1%), Black (36.66 → 40.64%; Δ6.9%), Hispanic (26.21%→42.80%; Δ16.59%), API (15.97%→41.41%; Δ25.44%) from 2009 to 2013		 For women:
API < NHW Black < NHW
For men:
No difference
Thompson21 N = 18,919 (73.5% women), aged 18–26
Race: NHW (68.5%), Black (4.2%), Hispanic/Latino (7.4%), API (7.7%), AI/AN, or NH (0.3%)		 % of vaccination for each race/ethnicity was not provided. For women: All minorities (Black, Hispanic, API, AI/AN, or NH) < NHW
For men: NHW < Black
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Note. NHW, Non-Hispanic White; API, Asian American and Pacific Islander; AI/AN, American Indian/American Native; NH, Native Hawaiian.

a

Vaccination indicates having at least 1 dose.

Based on the study, the prevalence of HPVs vaccination among college women varied across and within racial/ethnic groups: 44.0–70.5% among NHW, 18–62.0% among Black, 33.0–68.0% among Hispanic/Latino, and 25.0–51.0% among API. These wide variety of vaccination rates may be related to differences in size and representativeness of the samples. Due to lack of studies, the prevalence of HPVs vaccination among college men is difficult to conclude. Seven out of nine studies found significant racial/ethnic differences in vaccination. Of these seven studies, four reported NHW students were more likely to be vaccinated compared with racial/ethnic minority students. More specifically, API14,16 and Black women reported lower HPVs vaccination rates.15,18 Of the remaining three studies that found significant racial/ethnic differences, one reported that Hispanic women were more likely to be vaccinated than NHW women.17 The other two reported mixed results: one showed that all minority students (Black, Hispanic/Latino, API, American Indian/American Native or Native Hawaiian) were less likely to be vaccinated than NHW women, although Black college men were more likely to be vaccinated than NHW men.21 The other investigation was a nationwide study using The National College Health Assessment-II (Fall 2009–2013) conducted among US college students which showed that API and Black female students were less likely to be vaccinated than NHW college women but found no difference among college men: the vaccination prevalence rates in 2013 were 70.6 (NHW), 62.0 (Black), 67.1 (Hispanic), and 61.9% (API) among women and 43.3 (NHW), 40.6 (Black), 42.8 (Hispanic), and 41.4% (API) among men.20 In addition, Asian college women reported the highest rate of increase (33.9%) from 2009 to 2013, whereas Black college women reported the lowest (12.8%). NHW college men reported the highest rate of increase at 28.1% within the same time period (from 15.2% to 43.3%), whereas Black college men reported the lowest rate of increase (6.9%; from 33.7% to 40.6%).

Taken together, racial/ethnic minority college women (especially Black and API) were less likely to be vaccinated compared to their NHW counterparts. As the studies did not report time since vaccination, the prevalence of vaccination initiated during college among racial/ethnic minority students is unclear. Due to lack of published research, racial/ethnic differences in HPVs vaccination among college men are not conclusive. However, given that a longitudinal nationwide study showing that Black men and women reported the lowest rate of increase in vaccination from 2009 to 2013, more efforts are needed to promote vaccination for Black college students.

Vaccine knowledge and vaccination intention among racial/ethnic minority college students

With regard to vaccine literacy, a majority of racial/ethnic minority college students were aware of HPVs and HPVs vaccines (see Table 2).14,22–24 However, the reported level of HPVs knowledge is inconsistent: some studies reported that students have high knowledge of HPVs and HPVs vaccines,25,26 whereas others did not.14,27 One study reported a racial/ethnic difference in HPVs knowledge: NHW college women were more knowledgeable about HPVs than API college women.14 Also, there was a gender difference: racial/ethnic college women were more likely to have heard of HPVs and the HPVs vaccine22,25 and reported higher HPVs knowledge25,27 than their men peers. Overall, students reported high vaccination intention.22,24 Thus, while education with regard to susceptibility to HPVs infection and HPVs vaccine availability for racial/ethnic minority college men is important, more efforts than education seem to be required given the discrepancy between high vaccination knowledge/intention and vaccine uptake.

Table 2.

Correlates of HPVs vaccine uptake identified in the referenced studies.

First author Design Demographics Conceptual Model HPVs vaccination % Results
Bynum22 Observation, Cross-sectional N = 575 Black (68% women), aged 18–26 HBM 16% 75% heard of HPV; males (vs. females) were less likely to have heard of HPV, reported lower HPV knowledge, lower perceived severity of HPV, lower perceived benefit of HPV vaccination and cues to action for HPV vaccination, and higher perceived barriers to HPV vaccination. No significant gender difference in perceived susceptibility to HPV infection.
71% heard of the HPV vaccine; males were less likely to have heard of the HPV vaccine.
Of unvaccinated, about 76% indicated interest in vaccination; no gender difference was found regarding interest in vaccination.
Cohen28 Observation, Cross-sectional N = 4718 Hispanic women, aged 18–26 – 46.2% Younger age [+], health insurance [+], obesity [−], gynecological examinations [+], influenza vaccination [+] were associated with HPV vaccine initiation. Receipt of STD information was not significantly associated with HPV vaccine initiation [≠].
Crosby37 Observation, Cross-sectional N = 150 men, aged 18–24
Race: 53% (Black), 21% (API), 19% (White)		 Protection
Motivation
Theory		 – Oral sex behavior (yes/no) and oral sex behaviors with more than 2 partners were associated with vaccine acceptance [+]. The association between oral sex behavior and vaccine acceptance was reported by only non-Black students.
D’Urso27 Observation, Cross-sectional N = 351 Black students (69% women) aged 18–35+ – – 64% had never heard of HPV. Of those who had heard of HPV, 52% reported knowing what HPV was. Of the 66 respondents who reported knowing what HPV was, only 16% knew HPV could be asymptomatic; 94% thought condom use could prevent the spread of HPV.
Women were more likely to have accurate knowledge of HPV than were men.
Gerend25 Observation, Cross-sectional N = 124 (52% women), aged 18–26
Race: 57% (Black), 32% (NHW), 5% (biracial), 3% (Asian), 3% (Latino/Latina).		 – 52% 78% had heard of HPV; female students (94%) were more likely to have heard of HPV than male students (62%).
Most were quite knowledgeable about HPV; women scored higher on the HPV knowledge scale than did men. However, 56% disagreed that they were at risk for HPV infection.
64% were interested in learning more about HPV. Black students reported greater interest in HPV education (marginally significant).
Of the 60 women who were not vaccinated for HPV, 65% (n = 39) were interested in HPV vaccination. Dating status [+] and sexual activity ([+]; marginally sig) were associated with HPV vaccine interest.
Kolar32 Observation, Cross-sectional N = 711 women, <18 to 27+ years
Race: 46% (Hispanic), 27% (Black), 12% (Asian), and 5% (NHW)		 HBM and SCT – Mistrust [−]: Black and Asian who had not received the HPV vaccine had higher mistrust scores than vaccinated women. Higher mistrust scores were observed among women who believed that HPV vaccine is not safe and HPV vaccine costs a lot of money.
Lee14 Observation, Cross-sectional N = 341 API women, aged 18–25 Behavioral model of Health Services Utilization Completion: 38.6% NHW > API (Literacy of HPV); 73.6% of API heard of HPV (vs. 90.6% of NHW) and 72.7% of API heard of HPV vaccine (vs. 90.0% of NHW). NHW were more knowledgeable about HPV vaccine.
Younger age [+], HPV literacy [+], OBGYN visit [+], and having someone with cancer history [+] were associated with HPV vaccine completion. Birth of origin [≠], father's level of education [≠], and education about HPV [≠] were not associated with vaccine completion.
Lopez26 Observation, Cross-sectional N = 100 men, M age = 19.53 years (SD = 1.5)
Race: NHW (29.0%), Hispanic (28.0%), API (27.0%), Black (3.0%), Middle-Eastern (3.0%), other (10.0%)		 HBM – 33.7% of the participants never heard of HPV. 77% obtained 7+ questions correct on the 13 item scale.
High perceived severity of (74%) and susceptibility to (88.9%) HPV infection were reported.
Marchand23 Observation, Cross-sectional N = 178 women, aged 18–26
Race: Latina (59%), Black (32%), Asian (2.2%), NHW (1.1%)		 Health
Behavior
Framework		 25% had initiated the vaccine. Of these, 43% had completed all 3 doses. 80% had heard of HPV and 70% had heard of a vaccine for HPV.
Younger age [+], having a regular doctor [+], doctor's recommendation [+], having a health-related major [+], belief about vaccine safety [+], perceived social approval for HPV vaccination [+], and perceived HPV severity [−] were associated with vaccination. Race/ethnicity [≠], relationship status [≠], health insurance [≠], and sexual intercourse [≠] were not significantly associated with vaccination.
Schiffner33 Qualitative N = 16 Hispanic women aged 18–24 – – Participants had lack of knowledge regarding HPV and cervical cancer. Cultural norms (e.g., silence about sexual topics) prevent them learning about sexual issues.
Schiffner38 Qualitative N = 6 Hispanic men aged 18–24 – – Lack of knowledge regarding HPV and sexual health misconceptions were reported. Participants wanted to be more informed about sexual health issues. The most useful information about sexual health came from peers, older men, uncles, and siblings.
Schmotzer31 Observation, Cross-sectional N = 100 Hispanic (83.2% women), aged 18–54 – – Those who were vaccinated or intended to vaccinate report more correct HPV knowledge than those who were not vaccinated or not intend to vaccinate.
Sledge24 Observation, Cross-sectional N = 68 Black men aged −26 18 HBM 85% of the participants heard of HPV. 38.2% knew there was an HPV vaccine for women and 13.2% knew there was an HPV vaccine for men.
There was an association between knowledge and HPV vaccination intention [+].
Multiple regression analysis showed that perceived benefits [+] was associated with vaccination intention, whereas perceived severity [≠], perceived susceptibility [≠], perceived barriers [≠], and self-efficacy [≠] were not.
Staples36 Single-arm intervention N = 57 Black women – – Intervention improved knowledge about HPV/HPV vaccine and 87% of unvaccinated participants indicated plans to get the HPV vaccine.
Thomas29 Observation, Cross-sectional N = 116 Hispanic men – – About 24% of the participants agreed that HPV vaccine could prevent future problems for them. About 53% of the participants disagreed that they would be vaccinated with the HPV vaccination. About 24% of the participants responded that cost is a barrier to HPV vaccination.
Factors associated with HPV vaccination intention were benefits of vaccination [+], social norm [+], vaccination requirement (if the vaccine is required, I’ll be vaccinated) [+], cost [−], and doctor's recommendation [+].
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Note. HBM, Health Belief Model; SCT, Social Cognitive Model; +, positive association; −, negative association; ≠, null association; NHW, Non-Hispanic White; API, Asian American and Pacific Islander; AI/AN, American Indian/American Native; NH, Native Hawaiian.

Correlates of HPVs vaccine uptake or vaccination intention/interest among racial/ethnic minority college students

Nine observational, cross-sectional studies in which vaccination was retrospectively assessed examined correlates of HPVs vaccine uptake or vaccination intention/interest (see Table 2). One of the most consistently reported correlates of HPVs vaccination was age: younger individuals were more likely to be vaccinated.14,23,28 However, because studies did not report time since vaccination, this result may reflect a birth cohort effect: younger people were more likely to be vaccinated and probably were vaccinated before they entered college. Besides age, healthcare providers were shown to play an important role in vaccine uptake: OBGYN visits (or having a regular doctor) was positively associated with vaccination or vaccination intention.14,23,28,29

Several studies investigated psychosocial factors including knowledge, social norms, and the Health Belief Model (HBM)30 constructs (e.g., perceived severity of HPVs infection, susceptibility to HPVs infection, and benefits of and barriers to vaccination) and their association with HPVs vaccination or vaccination intention/interest. Three studies reported that correct knowledge about HPVs was associated with either HPVs vaccination14,31 or vaccination intention/interest.24,31 Positive social norm (social approval/acceptance of HPVs vaccine by valued others such as family, friends, and healthcare providers) was also associated with vaccination23 or vaccination intention.29 Note that less than half of the studies (7 of 15) stated their theoretical basis, but the most frequently cited theory was the HBM: three studies were solely based on the HBM22 and one study was based on both the HBM and the Social Cognitive Theory.32 Among HBM constructs, two studies reported that perceived benefits of vaccination was associated with vaccination intention.24,29 However, as other studies reported that cultural factors were especially relevant to racial/ethnic minorities, these typical behavioral theories might need to be tailored to specific populations. For example, a qualitative study conducted among Hispanic college students reported that cultural norms (e.g., silence about sexual topics) appear to hinder learning about sexual issues.33 Another study reported that non-vaccinated Black and Asian female college students had higher medical mistrust, whereas the association was not found among Hispanic, NHW, or other women.32

Previous studies reported that insurance and vaccine costs influence vaccination among college students.21,34 We found mixed results between two studies that investigated the effect of health insurance as a correlate of vaccination among racial/ethnic minority college students; one study found a positive association,28 whereas the other did not.23 However, in a study conducted among Black college men, the top two barriers to HPVs vaccination were cost-related: 1) “Insurance would not cover the vaccine” and 2) “They would have to pay a lot for the vaccine”.24 Likewise, in a study conducted among Hispanic college men, cost was negatively associated with HPVs vaccination intention.29 However, since the Affordable Care Act (ACA) has been implemented, cost should be no longer a major barrier to HPVs vaccination. Although not specifically conducted among racial/ethnic minority college students, after the ACA was implemented, HPVs vaccine initiation rates indeed increased more than 3 times and completion rates increased nearly 6 times.35 Thus, it will be important to examine whether racial/ethnic minority students are aware of the availability of this free-of-charge vaccination and to impart this opportunity as widely as possible.

Intervention studies conducted among racial/ethnic minority college students

We could not find intervention studies conducted among racial/ethnic minority college students with HPVs vaccine uptake as an outcome of interest. However, one intervention study, which assessed HPVs and HPVs vaccination knowledge at pre- and post-intervention among Black college women at four historically Black colleges, showed promising results.36 In this single-arm intervention study, the post-intervention survey was conducted right after the 1-h educational intervention was implemented. Results showed that the intervention improved knowledge and 87% of unvaccinated participants reported plans to get the vaccine.

CONCLUSIONS

Results from our scoping review showed that racial/ethnic minority college students reported lower HPVs vaccination rates than their NHW peers in most studies. Overall, racial/ethnic disparities in HPVs vaccination exist among both college men and women and, racial/ethnic minority college students reported lower HPVs and HPVs vaccine knowledge than their NHW counterparts, yet a majority of them appeared to have sufficient knowledge and high intention to vaccinate. Thus, interventions targeting only knowledge and/or intention might not be sufficient. Given that age, doctor recommendation, and psychosocial and cultural factors (e.g., knowledge about HPVs and HPVs vaccine, perceived benefit of vaccination, social norms, medical mistrust, and cultural norms) were associated with vaccination and vaccination intention, successful promotion of HPVs vaccine uptake in minority populations will likely require a multilevel approach that may address individual, peer, healthcare provider, healthcare system, and cultural factors on HPVs vaccination.

The disparities found among racial/ethnic minority college students are inconsistent with the fact that racial/ethnic minority adolescents aged 13–17 years report higher HPVs vaccination rates than NHW counterparts in the US7: specifically, in 2017, HPVs vaccination rate (≥1 dose) was 60.0% in NHW adolescents, but it was 70.0% in Black, 74.5% in Hispanic, and 70.4% in Asian US adolescents. The reason for this discrepancy is not clear, but it may be partly owing to the fact that the current review includes data collected from long time ago, whereas the data about adolescents are up-to-date. Therefore, it is possible that the racial/ethnic disparity in HPVs vaccination during college may have reduced.

To our knowledge, there are no published intervention studies assessing vaccine uptake among racial/ethnic minority college students in the US. The only study we found was a single-arm intervention focusing on promoting vaccine knowledge and intention and did not assess actual vaccine uptake or state its theoretical basis. Theory-based, well-designed interventions for racial/ethnic minority students, especially college men, are urgently needed.

Limitations and strengths

The present study has several limitations. First, this study is not a systematic review. Although we searched articles using different data sources and the reference lists of the primary papers identified, it is possible that we might not have included eligible studies in our review and results are vulnerable to publication bias. Second, due to the small number of studies conducted, our results (especially about correlates of HPVs vaccination and college men vaccination rates) are inconclusive. Third, as most articles reported cross-sectional, retrospective observational studies, causality cannot be established. Lastly, this review is unable to identify factors that uniquely predict HPVs vaccination initiation during college.

Nevertheless, to our knowledge, this is the first review to investigate HPVs-related outcomes (HPVs/HPVs vaccination knowledge and vaccine uptake) in racial/ethnic minority college students. Our results may be helpful to advance the existing evidence base regarding racial/ethnic disparities in HPVs vaccination, compile data on the very limited efforts made to increase vaccination knowledge/rates in these vulnerable populations, and suggest interventions to increase catch-up vaccination for college minorities.

IMPLICATIONS

Despite the recent improvements in HPVs vaccination among young adults, in general.11 Racial/ethnic disparities in HPV vaccination exist among college students. Studies based on racial/ethnic minority appropriate theories (or tailored theories) that investigate factors which uniquely predict racial/ethnic minority students’ vaccination during college will be helpful to develop future interventions. To enhance vaccination among racial/ethnic minority college students, not only increasing HPVs and HPVs vaccine knowledge, but also providing accessible environments may be important. For example, student health centers or infirmaries can impart that free-of-charge HPVs vaccine is available, provide HPVs and HPVs vaccination knowledge, and perform the vaccination. Future studies also need to focus on actual vaccine uptake and vaccine completion. Finally, as a large number of racial/ethnic minorities are not college educated, HPVs vaccination among young adults (not necessarily college-educated) needs to be investigated.

Acknowledgements:

This work was supported by a faculty fellowship from the University of Texas MD Anderson Cancer Center Duncan Family Institute for Cancer Prevention and Risk Assessment, United States.

Footnotes

CONFLICTS OF INTEREST

All authors declare no conflicts of interest.

Contributor Information

Dalnim Cho, The University of Texas MD Anderson Cancer Center, USA;

Lois Ramondetta, The University of Texas MD Anderson Cancer Center, USA;

Luz Garcini, Rice University, USA;

Qian Lu, The University of Texas MD Anderson Cancer Center, USA

REFERENCES

  • 1.Cancer IAfRo. (2007). IARC Monographs on the Evaluation of Carcinogenic Risks to Humans. Human Papillomaviruses, 90. [PMC free article] [PubMed] [Google Scholar]
  • 2.Siegel RL, Miller KD, & Jemal A (2018). Cancer statistics, 2018 CA: A Cancer J Clin, 68(1), 7–30. [DOI] [PubMed] [Google Scholar]
  • 3.Van Dyne E, Henley S, Thomas C, et al. (2018). Trends in human papillomavirus–associated cancers d United States, 1999–2015. MMWR Morb Mortal Wkly Rep, 67, 918–924. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 4.Torre LA, Sauer AMG, Chen MS, Kagawa-Singer M, Jemal A, & Siegel RL (2016). Cancer statistics for Asian Americans, native hawaiians, and pacific Islanders, 2016: converging incidence in males and females. CA: A Cancer J Clin, 66(3), 182–202. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 5.Chatterjee A (2014). The next generation of HPV vaccines: nonavalent vaccine V503 on the horizon. Expet Rev Vaccine, 13(11), 1279–1290. [DOI] [PubMed] [Google Scholar]
  • 6.M E, K A, & M M (2016). Use of a 2-dose schedule for human papillomavirus vaccination d updated recommendations of the Advisory committee on immunization practices. Morb Mortal Wkly Rep, 65, 1405–1408. [DOI] [PubMed] [Google Scholar]
  • 7.Walker T, Elam-Evans L, Yankey D, et al. (2018). National, regional, state, and selected local Area vaccination coverage among adolescents aged 13–17 Years – United States, 2017. MMWR Morb Mortal Wkly Rep, 67, 909–917. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 8.CDCP. (2017). Sexually Transmitted Disease Surveillance 2016. Atlanta: U.S. Department of Health and Human Services. [Google Scholar]
  • 9.Gargano JW, Unger ER, Liu G, et al. (2017). Prevalence of genital human papillomavirus in males, United States, 2013–2014. J Infect Dis, 215(7), 1070–1079. [DOI] [PubMed] [Google Scholar]
  • 10.Markowitz LE, Liu G, Hariri S, et al. (2016). Prevalence of HPV after introduction of the vaccination program in the United States. Pediatrics, 137(3), e20151968. [DOI] [PubMed] [Google Scholar]
  • 11.Boersma P, & Black LI (2020). Human papillomavirus vaccination among adults aged 18 26, 2013 2018. NCHS Data Brief, no 354. Hyattsville, MD: National Center for Health Statistics. [PubMed] [Google Scholar]
  • 12.NCES. (2016). Percentage of 18- to 24-year-olds enrolled in degree-granting postsecondary institutions, by race/ethnicity and state: 2015. https://nces.ed.gov/programs/digest/d16/tables/dt16_302.65.asp. Accessed October 25, 2018.
  • 13.Daley EM, Vamos CA, Buhi ER, et al. (2010). Influences on human papillomavirus vaccination status among female college students. J Wom Health, 19(10), 1885–1891. [DOI] [PubMed] [Google Scholar]
  • 14.Lee HY, Kwon M, Vang S, et al. (2015). Disparities in human papillomavirus vaccine literacy and vaccine completion among Asian American pacific islander undergraduates: implications for cancer health equity. J Am Coll Health, 63(5), 316–323. [DOI] [PubMed] [Google Scholar]
  • 15.Lefkowitz ES, Kelly KM, Vasilenko SA, & Maggs JL (2014). Correlates of human papillomavirus vaccination among female university students. Women Health, 54(6), 487–501. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 16.Licht AS, Murphy JM, Hyland AJ, Fix BV, Hawk LW, & Mahoney MC (2010). Is use of the human papillomavirus vaccine among female college students related to human papillomavirus knowledge and risk perception? Sex Transm Infect, 86(1), 74–78. [DOI] [PubMed] [Google Scholar]
  • 17.Nuño VL, Gonzalez M, Loredo SM, Nigon BM, & Garcia F (2016). A cross-sectional study of human papillomavirus vaccine utilization among university women: the role of ethnicity, race, and risk factors. J Low Genit Tract Dis, 20(2), 131–134. [DOI] [PubMed] [Google Scholar]
  • 18.Okafor C, Hu X, & Cook RL (2015). Racial/ethnic disparities in HPV vaccine uptake among a sample of college women. J Racial Ethn Health Disparities, 2(3), 311–316. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 19.Ratanasiripong NT (2015). Factors related to human papillomavirus (HPV) vaccination in college men. Publ Health Nurs, 32(6), 645–653. [DOI] [PubMed] [Google Scholar]
  • 20.Thompson EL, Vamos CA, Vázquez-Otero C, Logan R, Griner S, & Daley EM (2016). Trends and predictors of HPV vaccination among U.S. College women and men. Prev Med, 86, 92–98. [DOI] [PubMed] [Google Scholar]
  • 21.Thompson VLS, Butler-Barnes ST, Jones BD, Wells AA, Cunningham-Williams RM, & Williams S-L (2017). Factors associated with human papillomavirus vaccination status at U. S. Colleges and universities. Health Soc Work, 42(1), e1–e7. [DOI] [PubMed] [Google Scholar]
  • 22.Bynum SA, Brandt HM, Friedman DB, Annang L, & Tanner A (2011). Knowledge, beliefs, and behaviors: examining human papillomavirus–related gender differences among African American college students. J Am Coll Health, 59(4), 296–302. [DOI] [PubMed] [Google Scholar]
  • 23.Marchand E, Glenn BA, & Bastani R (2012). Low HPV vaccine coverage among female community college students. J Community Health, 37(6), 1136–1144. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 24.Sledge JA (2015). The male factor: human papillomavirus (HPV) and HPV4 vaccine acceptance among African American young men. J Community Health, 40(4), 834–842. [DOI] [PubMed] [Google Scholar]
  • 25.Gerend MA, & Magloire ZF (2008). Awareness, knowledge, and beliefs about human papillomavirus in a racially diverse sample of young adults. J Adolesc Health, 42(3), 237–242. [DOI] [PubMed] [Google Scholar]
  • 26.Lopez R, Tanjassiri SP, & McNahan S (2008). College-aged Men’s (18–24) knowledge and perceptions of Human Papillomavirus and cervical cancer. Californian J Health Prom, 6(1), 143–155. [Google Scholar]
  • 27.D’Urso J, Thompson-Robinson M, & Chandler S (2007). HPV knowledge and behaviors of black college students at a historically black university. J Am Coll Health, 56(2), 159–163. [DOI] [PubMed] [Google Scholar]
  • 28.Cohen TF, & Legg JS (2014). Factors associated with HPV vaccine use among hispanic college students. J Allied Health, 43(4), 241–246. [PubMed] [Google Scholar]
  • 29.Thomas TL, Stephens DP, Johnson-Mallard V, & Higgins M (2016). Young hispanic men and human papillomavirus vaccination choices. J Transcult Nurs, 27(2), 103–108. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 30.Rosenstock I (1974). Historical origins of the health Belief Model. Health Educ Monogr, 2. [DOI] [PubMed] [Google Scholar]
  • 31.Schmotzer GL, & Reding KW (2013). Knowledge and beliefs regarding human papillomavirus among college nursing students at a minority-serving institution. J Community Health, 38(6), 1106–1114. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 32.Kolar SK, Wheldon C, Hernandez ND, Young L, Romero-Daza N, & Daley EM (2015). Human papillomavirus vaccine knowledge and Attitudes, preventative health behaviors, and medical mistrust among a racially and ethnically diverse sample of college women. J Racial Ethn Health Disparities, 2(1), 77–85. [DOI] [PubMed] [Google Scholar]
  • 33.Schiffner T, & Buki L (2006). Latina college students’ sexual health beliefs about human papillomavirus infection. Cult Divers Ethnic Minor Psychol, 12, 687–696. [DOI] [PubMed] [Google Scholar]
  • 34.Ratanasiripong NT (2012). A review of human papillomavirus (HPV) infection and HPV vaccine–related Attitudes and sexual behaviors among college-aged women in the United States. J Am Coll Health, 60(6), 461–470. [DOI] [PubMed] [Google Scholar]
  • 35.Corriero R, Gay JL, Robb SW, Stowe EW. Human papillomavirus vaccination uptake before and after the Affordable care Act: variation according to insurance status, race, and education (NHANES 2006–2014). J Pediatr Adolesc Gynecol.31(1),23–27. [DOI] [PubMed] [Google Scholar]
  • 36.Staples JN, Wong MS, Rimel BJ. An educational intervention to improve human papilloma virus (HPV) and cervical cancer knowledge among African American college students. Gynecol Oncol.149(1),101–105. [DOI] [PubMed] [Google Scholar]
  • 37.Crosby RA, DiClemente RJ, Salazar LF, Nash R, Younge S, & Head S (2012). Human papillomavirus vaccine intention among college men: what’s oral sex got to do with it? J Am Coll Health, 60(1), 8–12. [DOI] [PubMed] [Google Scholar]
  • 38.Schiffner TA, Buki LP, & Sabet RF (2017). Mexican American college men’s (Mis)Understandings about HPV and cervical cancer. Fam Community Health, 40(2), 150–159. [DOI] [PubMed] [Google Scholar]

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