Understanding young adults’ perceptions regarding human papillomavirus vaccination: A qualitative study

Abstract

Background

Over 47,000 human papillomavirus (HPV) related cancers are newly diagnosed every year in the United States, yet HPV vaccination rates are below desirable levels. Young adulthood is critical for catch-up HPV vaccination. Previous research on HPV vaccine-seeking behavior among young adults is limited, particularly in Tennessee. This study aimed to understand HPV vaccine perceptions and experiences of young adults.

Methods

Virtual semi-structured interviews were conducted among 18–26-year-olds at a university in Tennessee from April to May 2022 (N = 25). Interview questions were based on the Health Belief Model and previous literature with a focus on gaining in-depth insights into young adults’ perspectives regarding HPV vaccination. Inductive and deductive thematic analysis approaches were used for data analysis.

Results

Five major themes were identified: (1) perceptions about HPV and HPV vaccination, (2) factors that may prevent HPV vaccination, (3) role of health care providers, (4) role of family and friends, and (5) HPV vaccine promotion strategies. Participants commonly discussed lack of knowledge and awareness as a factor preventing HPV vaccine uptake. Participants described some facilitators of HPV vaccination, including healthcare provider recommendations and family support, and perceived future benefits of receiving the HPV vaccine. Suggestions for promotion strategies included promotion through college health centers, community education, and awareness campaigns.

Conclusions

Young adults’ perceptions about the HPV vaccine and inadequate knowledge may influence uptake. Findings from this study showed that healthcare provider recommendations and parental support were facilitators for getting vaccinated. Future efforts may consider increasing awareness among young adults, exploring barriers to recommendation, and addressing parental concerns.

Introduction

Human papillomavirus (HPV) causes almost 90% of cervical and anal cancers; 70% of oropharynx, vulvar, and vaginal cancers; and 60% of penile cancers [1]. Every year in the United States (U.S.), over 47,000 HPV-associated cancers are newly diagnosed [2]. These new diagnoses could be prevented, as evidence shows that the HPV vaccine is safe and effective [3]. The Advisory Committee on Immunization Practices recommends HPV vaccination from age 11 or 12 years but can be started as early as nine years [4]. HPV vaccination rates are below the Healthy People 2030 goal of 80% [5]. In 2022, only 62.6% of adolescents aged 13–17 years reported receiving the recommended dose of the HPV vaccine [6]. Catch-up HPV vaccination is routinely recommended for individuals who missed vaccination up to age 26 years [4]. However, only 22% of U.S. young adults aged 18 − 26 years reported completing the HPV vaccine series in 2018 [7].

Findings from previous research suggest several factors may influence HPV vaccine-seeking behavior among young adults. These factors include lack of knowledge and awareness, healthcare provider recommendations, perceptions related to susceptibility to HPV infection, and benefits of receiving the HPV vaccine [8–11]. Additionally, misconceptions about the HPV vaccine could also influence vaccination. For example, in one study among college students, the perception that getting the HPV vaccine may be considered too late was reported among participants [12]. Other reported factors influencing HPV vaccination among young adults include social stigma, parental or peer influence, concerns about the HPV vaccine, cost of the HPV vaccine, time constraints with college responsibilities, and lack of information regarding locations to obtain the HPV vaccine [9,11,12].

HPV vaccination coverage varies across regions in the United States. Findings from previous research have shown lower HPV vaccination coverage in Southern U.S. compared with other regions of the country [13–15]. Specifically for Tennessee, in 2022, about 74.1% of adolescents aged 13–17 years have initiated the HPV vaccine series, while about 64.4% completed the series [16]. These HPV vaccination rates are below the desired target set by Healthy People 2030 [5]. However, limited studies have focused on HPV vaccination behavior and experiences among adult population in Tennessee [11,17]. Additionally, few studies have utilized a qualitative approach to describe and capture young adults’ perceptions and experiences regarding HPV vaccination [8,12,18]. Understanding young adults’ perceptions and experiences about HPV vaccination is an essential step to improving vaccine uptake. Catch-up HPV vaccination for individuals up to age 26 is vital to achieving timely population-level impact of HPV vaccination [19]. Therefore, the objective of this study was to examine young adults’ perspectives regarding the HPV vaccination in Tennessee using qualitative approach. The research question that guided this study include: How would young adults describe their perceptions and experiences about the HPV vaccine? Findings from this study will provide insight into the motivation for HPV vaccine uptake. This information is necessary to inform future strategies to address barriers preventing HPV vaccine uptake.

Methods

Study design and subjects

This qualitative study utilized semi-structured interviews to gain in-depth insights into contextual factors associated with HPV vaccine uptake among students on a university campus in Tennessee. Eligibility requirements include undergraduate and graduate students between 18 and 26 years who were currently enrolled at the time of study (Spring 2022). Recruitment was done from March 31^st 2022 to May 6^th 2022. Potential study participants were recruited through email and flyer distribution through campus organizations and by posting flyers around popular campus buildings. For email recruitment, a list of email addresses of 300 currently enrolled students between 18–26 years was obtained from the university for research purposes. An email with study information and the link to sign up for the study was sent to the obtained email addresses. A second follow-up email was sent to those who did not respond to the first email invitation. A total of 60 individuals signed up for the study. Among those who signed up, eligible participants were contacted via email to schedule a time for an interview. All interviews were conducted from April to May 2022. The data collection process continued until no new information was obtained from the interviews. (i.e., data saturation) [20].

Interview protocol

The interview guide was developed and adapted from previous research on HPV vaccination [21–24]. Interview questions were drafted to reflect the constructs of the Health Belief Model (HBM) [25]. The principle of HBM suggests that individual beliefs and perceptions likely influence the adoption of a health behavior [25]. The HBM comprises six key constructs that play a role in shaping an individual’s health-related behavior. These components include perceived severity, perceived susceptibility, perceived barriers, perceived benefits, cues to action, and self-efficacy [25]. Perceived severity describes a person’s beliefs about the gravity or impact of getting a disease [25]. Perceived susceptibility refers to individual beliefs about the chances of contracting a disease [25]. Perceived barriers refer to individual beliefs about hindrances to adopting a health behavior, including perceptions related to unfavorable effect of adopting the behavior [25]. Perceived benefits describe individual beliefs about the advantages of adopting a particular health behavior [25]. Cues to action refer to internal or external factors that stimulate the acceptance or adoption of behavior [25]. Lastly, Self-efficacy denotes a person’s belief in their capacity to perform a health behavior [25]. The HBM framework also acknowledges the role of modifying factors (demographic, structural, and psychosocial) related to health behavior change including age, race or ethnicity, sex, personality, socioeconomic status, and knowledge [25]. The interview questions focused on eliciting individual perceptions and beliefs that may influence HPV vaccine uptake. For example, results from a study among young adults by Jin and colleagues suggests that perceived barriers and perceived risk was associated with HPV vaccination among females [11]. Similarly, in a different study by Gerend et. al, perceived barriers and perceived susceptibility was associated with HPV vaccine uptake [26]. The interview questions are included as a supplemental file with this article.

The interview questions were reviewed for content and contextual appropriateness by experts in vaccination and college health research. Probes and follow-up questions were used to obtain detailed responses from participants. The interviews were conducted via Zoom in a private setting, with each session lasting about 16–53 minutes (mean = 30 minutes). Participants were asked to complete a brief (3–5 minutes) pre-interview questionnaire via Qualtrics (Provo, UT) to obtain sociodemographic and HPV vaccination information. Informed consent was obtained from participants online before administering the questionnaire and conducting the interview. One research team member conducted the interviews (O.O.), while another team member was present during the interviews to observe and provide feedback (C.N.). Detailed notes were taken during the interview and data collection procedures. Audio recordings and transcripts were automatically generated through Zoom Otter.ai transcription software (Mountain View, CA). Transcripts were reviewed manually for accuracy by a research team member (O.O.). Any personal identifying information was removed, and participants’ names generated in the transcripts were replaced with unique identification numbers. All participants who completed the interview received a $25 gift card.

Ethical considerations

This study was approved by the University of Tennessee Knoxville Institutional Review Board (UTK IRB-22–07245-XM). Study participants completed a written informed consent before data collection. An IRB approved informed consent statement was attached to the beginning of the pre-interview questionnaire via Qualtrics. Participants were given adequate time to read the consent document and were encouraged to ask any questions regarding any aspect of the study. Participants who agreed to participate in the study were asked to select “I Agree” at the end of the informed consent statement.

Data analysis

The data analysis for this study involved thematic analysis using both inductive and deductive approaches [20]. This involved the identification of themes that emerged during the interview (inductive), as well as using pre-determined themes based on HBM constructs and interview questions (deductive) [20]. Prior to data analysis, the research team met to discuss coding procedures. An initial codebook was created with pre-determined themes, and coders added additional themes as needed during the data analysis. Coding was an iterative process that involved the generation of common ideas shared by participants, as well as comparing and finding connections between themes by two of the researchers (O.O., C.N.). To ensure consistency in the analysis and interpretation of codes, the researchers met after coding the first three transcripts to discuss the coding process and any changes to the codebook. Thereafter, the two researchers (O.O. and C.N.) independently coded the transcripts and then met regularly to discuss themes and resolve conflicts. Decisions about unresolved disagreements were settled by a third research team member (K.W.K. or C.S.B.). Detailed notes about questions, findings, meanings, and thoughts that arose throughout the research process were recorded. The consolidated criteria for reporting qualitative research was referenced for this study [27]. NVivo software version 12 was used for data analysis, including computing interrater reliability which was 0.84.

Results

Participant characteristics

A total of 25 individuals participated in this study. The age of participants ranged from 19 to 26 years, with a mean of 21.2 years. Most participants identified as female (64%), White (72%), and non-Hispanic (64%). Most participants identified as heterosexual or straight (48%), were dating (60%), and resided in suburban areas (72%). All participants reported that they had heard about HPV, while 92% had heard about the HPV vaccine. About 68% reported that they had received the HPV vaccine. Table 1 presents the characteristics of study participants.

[Figure omitted. See PDF.]

Thematic analysis results

Data analysis revealed five major themes: (1) perceptions about HPV and HPV vaccination, (2) factors that may prevent HPV vaccination, (3) role of health care providers, (4) role of family and friends, and (5) HPV vaccine promotion strategies. Table 2 presents sample quotes for themes and subthemes.

[Figure omitted. See PDF.]

Theme 1: Perceptions about HPV and HPV vaccination

Perceived susceptibility.

Perceived susceptibility captures participants’ opinions regarding their risk of getting infected with HPV or being diagnosed with HPV-related cancers. Findings related to perceived risk were not unanimous among participants. Some participants discussed during the interviews that they did not consider themselves at risk because they were not currently sexually active or not in a relationship. Interestingly, other participants highlighted the need to be protected against HPV in the event of future relationships that may put them at risk. Another reason that some participants did not consider themselves at risk was being in monogamous or committed relationships, use of protection, and regular HPV testing/annual checks. A few participants felt that the presence or absence of a family history of cancer made them more or less at risk of cancer, respectively. Some participants also shared that a lack of knowledge about HPV prevented them from determining whether they were at risk of HPV infection.

Perceived severity.

This subtheme captures discussion related to participants’ perceptions about the seriousness and negative impact of HPV infection and HPV-related cancer. Most participants agreed that being diagnosed with HPV-related cancer would have a severe negative impact on their lives. The majority of participants were not particularly concerned or worried about the negative impact of HPV infection because they had received the HPV vaccine. However, some participants felt they did not know enough about HPV to determine the extent to which they would be affected by HPV-related cancers.

Perceived benefits.

This subtheme describes participants’ beliefs and opinions regarding the benefits of receiving the HPV vaccine. The ideas and perspectives related to benefits included cancer prevention, peace of mind, and future protection. Most participants believed the HPV vaccine would protect against cancer. However, some participants expressed lack of knowledge about the benefits of the HPV vaccine. A commonly reported benefit of the vaccine was peace of mind. Participants explained that getting vaccinated for HPV made them feel they would not have to worry about the possibility of getting HPV infection or HPV-related disease. Several participants talked about how receiving the HPV vaccine offers future protection against HPV. While some participants did not feel that they were currently at risk of HPV infections, they were motivated to receive the vaccine because they believed lifestyle changes or future relationships may predispose them to contracting HPV. Another benefit of receiving the HPV vaccine was protecting their future partners in addition to protecting themselves. A few participants expressed lack of perceived sense of urgency about the vaccine and therefore, it was not a priority for them.

Theme 2: Factors that may prevent HPV vaccination

This theme describes participants’ perceptions and experiences regarding factors that prevent HPV vaccination. Most participants who had been vaccinated reported minimal barriers to receiving the HPV vaccine. This was largely attributed to several facilitators of HPV vaccination such as parental support/decision, having health insurance, attending annual clinic visits, and healthcare provider recommendations. Participants who reported having no specific barriers to vaccination were asked to discuss barriers among young adults like them.

Lack of knowledge and awareness was commonly reported, with several participants expressing that they did not know much about the HPV vaccine. In terms of actual barriers preventing vaccine uptake, one participant expressed dislike of needles as a barrier. Lack of regular access to healthcare was highlighted as a factor preventing completion of the HPV vaccine series. Others expressed logistical barriers, such as finding time to drive to the doctor’s office in the presence of competing school activities. Cost was also discussed as a barrier, particularly in the context of lack of insurance. Both lack of time and cost were barriers to receiving multiple doses and requiring more than one appointment to receive the HPV vaccine, which may influence the uptake of the second or third doses of the HPV vaccine. Another barrier shared by a participant was a negative experience when transferring medical records from pediatric to adult care that made it difficult to access HPV vaccination status/records. Several participants discussed stigma related to HPV infection as a sexually transmitted illness (e.g., parental perceptions of promiscuity associated with HPV vaccination) and misinformation or concerns about vaccine side effects.

Theme 3: role of healthcare providers

This theme details participants’ discussion related to how their healthcare provider stimulated HPV vaccine uptake. Most participants acknowledged the influential role of their healthcare provider recommendations in their HPV vaccine decision-making process. Some participants mentioned that a combination of their parent/caregiver and doctor’s influence motivated them to receive the HPV vaccine. Several participants noted that their healthcare provider is their preferred source of HPV vaccine information. Participants explained that they trust the recommendations regarding the HPV vaccine when provided by their healthcare provider. For one participant, having a consistent patient-provider relationship was important to build trust. Similarly, another participant discussed that incorporating HPV vaccine recommendations into routine doctor’s visits was important to their HPV vaccine decision-making. Other perspectives shared by participants regarding the role of providers included perceived lack of a sense of urgency and importance during discussions about HPV vaccination and the need for reminder emails to prompt individuals.

Theme 4: role of friends and family

This theme captures common ideas related to perceptions, attitudes, and influence of family and friends towards HPV vaccination. Findings related to family and friends’ influence on HPV vaccine decision-making were mixed. While some felt that their family or friends’ attitude (negative or positive) towards HPV vaccination was influential, others expressed that they make personal health decisions using their own research or that they would ultimately trust their doctor’s advice over family or friends. Notably, one participant decided to receive the HPV vaccine at the age of 18 years even though parental refusal had prevented uptake of the vaccine as an adolescent. A commonly expressed thought among participants who have been vaccinated as an adolescent or before college was that parental/caregiver support or decision made them get the HPV vaccine.

Theme 5: vaccine promotion strategies

Increase accessibility/promoting accessible vaccination options.

A common suggestion among participants was to promote the HPV vaccine through the university student health services. Some respondents suggested HPV vaccine information can be promoted by the student health services to those presenting for care, including the use of posters around the clinic areas. Participants felt that a key benefit of promoting availability through student health services was the ease of getting the vaccine due to the proximity of the health center to campus. Students would not need to find time to drive longer distances to their doctor’s office. However, concerns related to cost and affordability were raised, especially for uninsured individuals. Participants suggested that student health services could partner with student organizations such as sororities and fraternities to promote HPV vaccination. Participants highlighted alternative ways to increase accessibility including vaccination at pharmacies, free clinics, and drive-through options. Reducing disparities in access to healthcare was also discussed as this may encourage regular doctor visits and, ultimately, routine preventive care such as vaccination.

Community awareness campaign and education.

Several participants expressed the need for HPV vaccine education and creating more awareness. Examples discussed by participants include tabling events or vaccination booths at popular campus locations, incentives, social media campaigns, promotion emails through university listservs, and use of flyers and posters around campus buildings. A few participants discussed the promotion of the HPV vaccine to adolescents, for example, incorporating HPV vaccine education in high school settings.

Information preferences.

Participants expressed their preferred type of educational information related to HPV infection and HPV vaccination. These included statistics related to the prevalence of HPV infection and vaccine efficacy, benefits of HPV vaccine, risk factors for HPV, vaccine side effects, vaccine schedule, and vaccine locations. Participants also highlighted sources of HPV vaccine information. Commonly shared sources of HPV vaccine information by participants included internet searches, healthcare providers, pharmacies, social media, and health departments. Some participants expressed the need for more information from trusted sources such as healthcare or public health institutions, especially in a simple and easy to understand format.

Discussion

This study explored young adults’ perceptions and experiences regarding HPV vaccination. Findings from the study revealed five major themes, including perceptions about HPV and HPV vaccination, factors that may prevent HPV vaccination, role of healthcare providers, role of family and friends, and HPV vaccine promotion strategies.

A noteworthy observation from our results was the discussion related to inadequate knowledge or awareness about the HPV vaccine. This finding is consistent with other qualitative studies. In a study by Meta and colleagues, focus groups were conducted among men to explore HPV vaccine acceptability [8]. The study found a lack of knowledge as a common theme, which may also translate to other beliefs or perceptions. In other words, participants may not have adequate knowledge to evaluate susceptibility to HPV and weigh the benefits of getting vaccinated against the severity of HPV infection and HPV-related cancer or overcoming barriers to getting vaccinated. This lack of knowledge shows the need for increasing education and awareness among unvaccinated young adults. Future HPV vaccination efforts should incorporate young adults’ information preferences to increase education and awareness. Examples may involve promoting credible internet sources and social media campaigns.

Another notable finding from this study was the influential role of healthcare provider recommendation in HPV vaccine decision-making. Participants commonly discussed that having personal conversations with their healthcare provider was a strong motivation for receiving the HPV vaccine. For some, these conversations often involved discussion between their parents/caregivers and doctors as adolescents. The influential role of healthcare providers may be due to several participants’ belief that their healthcare provider was a trusted source of HPV vaccine information. Previous studies have suggested that individual or parental trust in their healthcare provider was associated with HPV vaccine uptake or intention to receive the vaccine [28–30]. Hence, it is important for healthcare providers to foster or leverage established patient-provider relationships to increase HPV vaccine recommendation and uptake.

While previous studies have demonstrated a strong association between provider recommendation and HPV vaccine initiation and completion [31,32], recommendations may not be consistently provided across different patient populations [33]. Barriers to healthcare providers recommending the HPV vaccine may occur at different levels, including individual level (e.g., lack of provider knowledge or confidence, low quality and strength of provider recommendation), clinic level (e.g., time constraints, lack of reminder and recall system), and policy level (e.g., practice guidelines, school requirement) [34]. Future HPV vaccination strategies may consider exploring opportunities to address hindrances preventing recommendations by healthcare providers.

Another influential factor for vaccination described among participants was parental or caregiver approval and support. This corroborates findings from previous research that showed an association between the perception of approval from family and friends and HPV vaccination among adults on a college campus [35]. This depicts the importance of addressing barriers preventing family acceptance or approval of HPV vaccination. For example, a previous study based on data from the 2010–2016 National Immunization Survey – Teen reported several parental reasons for refusing to vaccinate their female children, which included safety concerns, beliefs that vaccination is unnecessary, perceptions that the child is sexually inactive, lack of knowledge and not receiving provider recommendations [36]. Safety concerns as a reason for not vaccinating persisted among female parents and increased among male parents from 2010 to 2016 [36]. With substantial research demonstrating the safety, efficacy, and long-term benefits of HPV vaccination [3], innovative communication approaches may be needed to debunk misconceptions related to safety concerns. Furthermore, it is important to consider targeted catch-up HPV vaccination campaigns and programs for young adults who may have missed HPV vaccination in childhood due to parental refusal.

One approach for increasing HPV vaccination among adults on college campuses identified by participants was promotion through college or university student health services. University or college campuses present a unique setting for health promotion among young adults including improving HPV vaccination [37]. Healthcare providers that serve college student populations at university student health services are uniquely positioned to provide education and effective recommendations regarding the HPV vaccine since they already offer related healthcare services [38,39]. The College Health Surveillance Network conducted a study on healthcare utilization by college students across 23 four-year universities in the United States over a 41-month period [40]. The study found that there were 4.17 million clinical visits made by 802,255 individuals to the university student health center [40]. Of these visits, 60% were for primary care, 13% for mental health, 9% for vaccinations, and 13% for other reasons [40]. College students may also view their school’s health center as their source of routine care. For example, in a previous study among students in a southeastern university, approximately 56% reported receiving care from a healthcare provider at their institution’s student health center within the past year [41]. In the same study, 47% of participants reported that they would seek both preventive and acute care for illness at their university’s student health center [41]. Despite these findings, students may not be familiar with the opportunity to vaccinate at student health centers. About 48% of college students in one study reported being unaware that the HPV vaccine was provided by their school’s health center [42]. This suggests the importance of improving awareness about the availability and accessibility of HPV vaccination on college campuses with health centers that administer the HPV vaccine. Additionally, healthcare providers serving college students may consider leveraging opportune clinic visits to assess and recommend HPV vaccination.

A few of the participants in this study were unsure about their HPV vaccination status. This may be related to the transition of vaccination records from pediatric to adult care. Findings from the interviews reflect logistical challenges associated with transferring pediatric records to primary care providers to facilitate vaccination. This is particularly important for individuals who are within the HPV vaccination catch-up age group who are not aware of their vaccination status. Immunization information systems can be important facilitators to ensure vaccination records are available for patients and providers as children transition into adulthood [43]. However, several barriers have limited the widespread use of such systems across the U.S. [44].

Strengths and limitations

This qualitative study provide useful insights into the perceptions and experiences of young adults regarding HPV vaccination on a college campus in Tennessee. Study findings will be useful for the development and implementation of HPV vaccination intervention among young adults. This study has a few limitations. First, all study participants have heard about HPV, and most have heard about the HPV vaccine. Hence, our participants’ perspectives may differ from those who have not heard about the HPV vaccine. Second, this study was conducted during the COVID-19 pandemic. Hence, participants’ perspectives and experiences about HPV vaccination may vary before and after the pandemic. Third, our study population was mostly vaccinated which may reflect discussions related to positive perceptions about the HPV vaccine. Despite these limitations, trustworthiness of the data was ensured in different ways, including providing a thick description of study procedures, keeping detailed notes on study procedures and findings, regular team meetings, and peer debriefing [45].

Conclusions

Healthcare provider recommendation was discussed as a facilitator for HPV vaccine uptake in this study. Future studies may consider examining barriers preventing timely and effective HPV vaccination recommendations. Future research may also consider exploring how sociodemographic characteristics such as sex, race/ethnicity, sexual orientation, and geographical residence influence HPV vaccination decision-making. Additionally, future HPV vaccine education programs should consider incorporating evidence for vaccine safety and effectiveness over the years. Lastly, given the limited availability of evidence-based interventions to improve HPV vaccination rates among college or university students, future HPV vaccine intervention should partner with college or university health services, since they are uniquely positioned to reach HPV vaccination catch-up population.

Supporting information

S1 Appendix. Interview Questions.

https://doi.org/10.1371/journal.pone.0323063.s001

(DOCX)

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Citation: Oyedeji O, North C, Kintziger KW, Ehrlich S, Maples J, Gatwood J, et al. (2025) Understanding young adults’ perceptions regarding human papillomavirus vaccination: A qualitative study. PLoS One 20(5): e0323063. https://doi.org/10.1371/journal.pone.0323063

About the Authors:

Oluwafemifola Oyedeji

Roles: Conceptualization, Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Visualization, Writing – original draft, Writing – review & editing

Affiliation: Department of Public Health, The University of Tennessee, Knoxville, Tennessee, United States of America

ORICD: https://orcid.org/0000-0001-7548-2508

Carman North

Roles: Data curation, Formal analysis, Writing – review & editing

Affiliation: Student Health Center, The University of Tennessee, Knoxville, Tennessee, United States of America

Kristina W. Kintziger

Roles: Conceptualization, Formal analysis, Funding acquisition, Methodology, Writing – review & editing

Affiliation: Department of Environmental, Agricultural, and Occupational Health, College of Public Health, University of Nebraska Medical Center, Omaha, Nebraska, United States of America

ORICD: https://orcid.org/0000-0003-3555-7805

Samantha Ehrlich

Roles: Validation, Writing – review & editing

Affiliation: Department of Kinesiology, Recreation, and Sport Studies, The University of Tennessee, Knoxville, Tennessee, United States of America

Jill Maples

Roles: Validation, Writing – review & editing

Affiliation: Department of Obstetrics and Gynecology, The University of Tennessee Graduate School of Medicine, Knoxville, Tennessee, United States of America

Justin Gatwood

Roles: Validation, Writing – review & editing

Affiliation: United States of America Health Outcomes GlaxoSmithKline, Philadelphia, Pennsylvania, United States of America

Cristina S. Barroso

Roles: Conceptualization, Formal analysis, Methodology, Project administration, Supervision, Validation, Writing – review & editing

E-mail: [email protected]

Affiliations: Department of Public Health, The University of Tennessee, Knoxville, Tennessee, United States of America, Department of Health, Behavior and Society, University of Texas School of Public Health San Antonio, San Antonio, Texas, United States of America, College of Nursing, The University of Tennessee, Knoxville, Tennessee, United States of America

ORICD: https://orcid.org/0000-0002-4354-9058

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[/RAW_REF_TEXT]

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38. Nunez AT. College health centers: An update on medical issues. Curr Probl Pediatr Adolesc Health Care. 2024;54(5):101584. pmid:38493024

39. Oyedeji O, Kintziger KW, Springer CM, Ehrlich S, Maples J, Gatwood J, et al. Examining HPV vaccination behavior among young adults: Insights from applying the Health Belief Model. PLoS One. 2024;19(11):e0312700. pmid:39485768

40. Turner JC, Keller A. College health surveillance network: epidemiology and health care utilization of college students at US 4-Year Universities. J Am Coll Health. 2015;63(8):530–8. pmid:26086428

41. James TG, Sullivan MK, Dumeny L, Lindsey K, Cheong J, Nicolette G. Health insurance literacy and health service utilization among college students. J Am Coll Health. 2020;68(2):200–6. pmid:30526397

42. Kellogg C, Shu J, Arroyo A, Dinh NT, Wade N, Sanchez E, et al. A significant portion of college students are not aware of HPV disease and HPV vaccine recommendations. Hum Vaccin Immunother. 2019;15(7–8):1760–6. pmid:31166148

43. Groom H, Hopkins DP, Pabst LJ, Murphy Morgan J, Patel M, Calonge N, et al. Immunization information systems to increase vaccination rates: a community guide systematic review. J Public Health Manag Pract. 2015;21(3):227–48. pmid:24912082

44. Scharf LG, Coyle R, Adeniyi K, Fath J, Harris L, Myerburg S, et al. Current challenges and future possibilities for immunization information systems. Acad Pediatr. 2021;21(4S):S57–64. pmid:33958094

45. Nowell LS, Norris JM, White DE, Moules NJ. Thematic analysis. Int. J. Qual. Methods. 2017;16(1).