Introduction

According to the Centers for Disease Control and Prevention, human papillomavirus (HPV) is the most common sexually transmitted infection, and more than 42 million people living in the United States currently have HPV [1, 2]. While most HPV infections disappear within 2 years, some last longer and cause various types of cancers in approximately 36,000 women and men [1]. HPV-related cancers include cervical cancer in women, penile cancer in men, and oropharyngeal cancer in both women and men [1]. In 2006 and 2009, the HPV vaccination was approved for use in females and males, respectively, aged 9 through 26 [3, 4]. In 2018, adults aged 27–45 became eligible for the HPV Vaccine [5]. The HPV vaccine can prevent cervical cancer and has potential to prevent more than 90% of HPV-related cancers [3].

During recent years, emphasis has been placed on public health communication campaigns to promote awareness about HPV and its vaccine, increasing vaccine uptake [6]. However, beginning in 2019 with the COVID-19 pandemic and a reduction in preventive health services, a decline in HPV vaccinations also resulted [7]. Given the age of college students and the availability of health centers or clinics on campus, most universities and colleges are ideal locations for HPV campaigns [8]. Yet, studies have shown that improving HPV knowledge and HPV vaccination uptake can be difficult in the college student population [9,10,11,12]. Thompson et al., found that among a total of 548 college students between the years of 2008–2015, HPV knowledge improved but misperceptions about HPV-related outcomes persisted [13]. However, Yahia et al. found that when conducting novel, multi-faceted, and interdisciplinary HPV campaigns, it is possible to increase HPV knowledge and vaccination rates [8]. Improving accurate knowledge about HPV, resulting cancers and outcomes, and increasing vaccination uptake requires a collaborative and coordinated effort among many including parents and family members [4, 14,15,16], healthcare professionals [17], adolescent boys and girls [15, 18], and those within the recommended age guidelines for the HPV vaccine [5, 19]. To expand the literature and encompass more adults within a range of the HPV vaccine age, we designed an HPV study to survey students, staff, and faculty at a public, state university at three-year increments between 2016 and 2022.

Methods

The study was conducted at a public state university located in the state of Indiana. The university has undergraduate and graduate programs housed within five academic colleges including Business, Education, Engineering, Health and Human Services, and Technology. A cross-sectional HPV knowledge survey was distributed during 2016, 2019, and 2022 to currently enrolled undergraduate and graduate students, and currently employed staff and faculty using a university-wide email list.

Procedures

Eligible participants were sent an email via a campus-wide email list following Institutional Review Board exemption. The email included a brief statement about the study, invitation to voluntarily participate in the anonymous survey, a link to the informed consent and survey. Study years 2016 and 2019 also included a reminder email sent to all students, staff, and faculty 1 week after the initial email, and an additional reminder email was sent a week later only to all students. In 2022, only the initial recruitment email was sent; no follow-up reminder emails were sent. During each year, the survey link remained open for a total of 8 weeks.

Instrument

A 27-item survey was administered. Sociodemographic questions included age, race/ethnicity, gender, health status, and educational level. Quantitative HPV knowledge and perception questions were modified from a previously validated instrument [20]. Fifteen HPV knowledge questions with Likert scale answers were aggregated to produce a single knowledge score with correct answers. Additional questions included HPV vaccination status, whether participants knew/had known anyone with HPV-related cancer, if they ever received HPV information (if so, from where), and level of interest in receiving more HPV information.

Statistical Analysis

Descriptive statistics were used to characterize the study participants and one-way analysis of variance assessed differences between knowledge mean scores of students, staff and faculty. Analyses were done using statistical Package for Social Sciences (SPSS) for windows version 29 (IBM, Armonk, NY, USA).

Results

Participant Characteristics

The three samples comprised a total of 1275, 1056, and 403 students, staff, and faculty respectively for the years of 2016, 2019, and 2022. Ages ranged from 18 to 70 + each year of the study (Table 1).

Table 1 Participant Demographic Information
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HPV Vaccination Rate

Among the overall sample who answered receiving the vaccine question (n = 1917), 39% had received the HPV vaccine. By role, students had significantly higher vaccination percentage among the three cohorts. The vaccination rate was lower among staff and faculty (Table 2). Female participants had significantly higher vaccination percentage (49.5%) among the vaccinated group, and in the three cohorts (Table 3).

Table 2 Vaccination Rate by Role
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Table 3 Vaccination Rate by Role and Gender
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HPV Knowledge Score

The overall sample average score was 10.22 (SD = 3.72). The unvaccinated group had an average knowledge score of 11.60 (SD = 2.51) compared to the vaccinated group score of 11.01 (SD = 2.71) and “don’t know if vaccinated” group score of 8.55 (SD = 4.07). Overall, there was a significant change between 2016 and 2019 but there was no change between 2019 and 2022. The knowledge score significantly increased among student participants from 2016 to 2019 but decreased in 2022. Among staff, there was a significant difference between 2016 and 2022. There was no significant difference among the faculty over the years. The changes are shown in Table 4.

Table 4 Composite HPV Knowledge Score by Role and Total Sample
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HPV Knowledge Items Between 2016, 2019, and 2022

Among the three cohorts, the 2016 participants were significantly (p < 0.01) less likely than 2019 and 2022 cohorts to accurately report that HPV always has visible signs and symptoms; HPV can cause throat cancer; HPV usually doesn’t need treatment; using condoms reduces the risk of getting HPV; only people who have many sexual partners get HPV. The 2019 cohort is less likely than the 2016 and 2022 cohorts to report having HPV is the same as having HIV/AIDS; HPV can cause HIV/AIDS; and HPV is rare. The 2016 cohort is less likely than the 2019 cohort to report HPV is very rare; HPV can be cured with antibiotics; a person could have HPV for many years without knowing it. Whereas the 2022 cohort is more likely than both 2016 and 2019 to report that a person could have HPV for many years without knowing it. There was a significant difference between the three cohorts on the following items: anyone can get HPV; HPV can cause throat cancer; and HPV can cause different types of cancer. About 86% of the total sample did not know that HPV usually does not need any treatment. Further, participants correct knowledge scores were less than average on the following items: HPV can cause throat cancer (49%); HPV can be transmitted by skin-to-skin contact (42%). These knowledge item comparisons are shown in Table 5.

Table 5 Comparison of HPV Knowledge items between 2016, 2019, and 2022
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Discussion

In this study examining HPV knowledge among students, staff, and faculty on a university campus at three points in time over a six-year period, we found that HPV knowledge increased among staff and faculty each year. However, among students, although HPV knowledge increased in 2019 as compared to 2016, knowledge decreased in 2022. Our findings suggest that HPV knowledge in general was increasing prior to the COVID-19 pandemic which occupied much of the public’s attention during 2020 and 2021. The HPV communication efforts (e.g. billboards, commercials) may account for the increased knowledge change from 2016 to 2019, and the shifted emphasis on the pandemic in 2020 and 2021 may account for the reduced knowledge and interest reflected in the 2022 survey. The decrease in HPV knowledge among students may be attributable to the COVID-19 pandemic, which is consistent with previous studies showing a disruption in primary care access, where the majority of HPV vaccines and education are provided, because of the pandemic [7, 21].

In the current study, females were shown to be more knowledgeable about HPV and had a higher vaccination percentage. This finding aligns with previous studies that report females to have more accurate HPV knowledge and HPV vaccine uptake than males [22,23,24]. However, there continues to be a lack of knowledge about the association between HPV and the types of cancer it can cause [15, 19]. While the majority of participants in our three studies correctly identified that “HPV can cause cervical cancer,” far fewer correctly identified that “HPV can cause throat cancer.” The lack of understanding that HPV can cause many different cancers, not just cervical cancer, contributes to the ongoing challenge of increasing accurate knowledge about HPV.

This study was unique in that it assessed HPV knowledge and HPV vaccine among participants representing different professional roles at the university as student, staff, and faculty. The study participants also spanned a continuum of age ranging from 18 to over 71 years. This particular study did not include demographic roles such as parents/guardians, grandparents, siblings, and others, but previous research has shown associations between parent opinion and adolescent HPV vaccination [25, 26]. Similarly, studies have shown associations between how faculty can influence student behavior [27, 28]. While the relationships among students, staff, and faculty was not specifically included in the parameters of this study, the extent to which staff and faculty can influence students and help to increase accurate HPV knowledge may help to improve HPV vaccine update and knowledge on university campuses.

Conclusion

This study assessed HPV knowledge among university students, staff, and faculty in the state of Indiana during 2016, 2019, and 2022. This study adds to the literature, offering a better understanding of HPV knowledge not previously identified. More education and campus-wide efforts need to be implemented to increase awareness and accurate HPV-knowledge. Targeted and individual messaging for students, staff, and faculty may be a way to increase awareness of HPV and improve HPV knowledge.