Journal of Adolescent Health
Volume 42, Issue 3 , Pages 237-242, March 2008

Awareness, Knowledge, and Beliefs about Human Papillomavirus in a Racially Diverse Sample of Young Adults

  • Mary A. Gerend, Ph.D.

      Affiliations

    • Corresponding Author InformationAddress correspondence to: Mary A. Gerend, Ph.D., Department of Medical Humanities and Social Sciences, College of Medicine, Florida State University, 1115 West Call Street, Tallahassee, FL 32306-4300.
    • ,
  • Zita F. Magloire, B.S.

Florida State University College of Medicine, Tallahassee, Florida

Received 7 June 2007; accepted 24 August 2007. published online 13 December 2007.

Article Outline

Abstract 

Purpose

To assess current levels and correlates of awareness, knowledge, and beliefs about human papillomavirus (HPV) in a racially diverse sample of young adults. Correlates of interest in HPV education and the HPV vaccine were also examined.

Methods

A total of 124 students 18–26 years of age from two southeastern universities (including a historically black university) completed a survey assessing demographic characteristics, sexual history, awareness and knowledge of HPV, HPV-related beliefs (perceived risk of HPV infection, perceived shame associated with HPV infection), interest in learning more about HPV, and interest in the HPV vaccine (women only).

Results

More than 75% of the sample had heard of HPV. Although some misunderstandings were observed, HPV knowledge was relatively high. Women reported greater awareness and knowledge of HPV than did men. Higher perceptions of risk were observed among sexually active participants and those with multiple sexual partners. Younger participants, men, and those with less HPV knowledge indicated they would feel more ashamed if diagnosed with HPV. Black/African-American and sexually active participants reported greater interest in HPV education. Greater interest in the HPV vaccine was observed among women who were sexually active, had multiple sexual partners, and felt vulnerable to HPV infection.

Conclusions

This study is one of the first to assess awareness, knowledge, and beliefs about HPV since the HPV vaccine was approved. Findings suggest that awareness of HPV may be increasing, yet many misconceptions remain. Continued efforts are needed to promote further understanding of HPV infection, the HPV vaccine, and the importance of routine cervical screening.

Keywords: Sexually transmitted infections, Human papillomavirus vaccines, Students

 

Human papillomavirus (HPV) is the most common sexually transmitted infection (STI) in the United States [1], [2]. The highest rates of infection are found among sexually active young adults under age 25 [2]. Certain types (HPVs 6 and 11) cause genital warts, whereas other types (predominantly HPVs 16 and 18) can cause cervical cancer [1], [2], [3], [4]. Most HPV infections are asymptomatic [5]. Risk factors include early age at first intercourse, smoking, previous history of STIs, and multiple sexual partners [1], [3]. Papanicolaou (Pap) testing has significantly reduced the incidence of cervical cancer in the U.S.; however nearly 4,000 American women died of cervical cancer in 2006 [6]. The purpose of the present study was to assess awareness, knowledge, and beliefs about HPV in a diverse sample of young adults at risk for HPV infection.

Despite the high prevalence of HPV, numerous studies have shown consistently that awareness of this disease is limited. Awareness of genital HPV infection (typically assessed by the question, “Have you ever heard of HPV?”) ranges from 13–72% [7], [8], [9], [10], [11], [12], [13], [14], [15]. Higher awareness tends to be reported in studies that included only women [14] or adults [9] or that used unusual recruitment methods (e.g., offering free HPV testing) [12]. Compared with general HPV infection, awareness of genital warts is much higher, ranging from 87–96% [7], [9], [10], [12].

Even among those aware of the virus, misconceptions about HPV abound. Studies suggest much confusion surrounding the difference between genital warts and genital herpes, the asymptomatic nature of HPV, the link between HPV and cervical cancer, and the purpose of Pap testing [7], [8], [10], [13], [14], [15], [16], [17]. Greater knowledge of HPV is typically observed among older, female, and sexually active individuals as well as individuals with a history of genital warts or cervical dysplasia [8], [9], [12], [14], [15].

Research suggests that HPV infection is viewed as a relatively minor health threat. For example, Dell et al found that only 15% of high school seniors believed that they were at risk for contracting HPV [8]. Risk perceptions tend to be higher among sexually active individuals [8], [12]. A recent study of male college students found that HPV was rated as the least severe STI after human immunodeficiency virus (HIV), syphilis, gonorrhea, chlamydia, and genital herpes [11].

In June 2006 the U.S. Food and Drug Administration approved a prophylactic HPV vaccine (Gardasil; Merck Pharmaceuticals) for girls and women ages 9–26 years [4]. The vaccine protects against infection by HPVs 6, 11, 16, and 18—strains responsible for more than 90% of all genital warts and 70% of all cervical cancers [1]. Clinical trials have found the vaccine to be effective, safe, and well tolerated [18]. Thus far the HPV vaccine has been well accepted among women, parents, and clinicians [19], [20], [21], [22]. In the months leading up to and immediately following its release, Gardasil generated a flurry of media attention. For many individuals, this may have been their first exposure to information about HPV infection.

Very few studies have assessed levels of HPV awareness and knowledge since the introduction of the HPV vaccine. Given the recent emphasis on HPV in the media along with the availability of the vaccine, it is important to gain a current understanding of young men’s and women’s awareness, knowledge and beliefs about HPV. Furthermore most previous studies have failed to recruit racially diverse samples, with the majority of studies consisting primarily of participants of white ethnicity [7], [9], [11], [13], [14], [15]. Assessing awareness and knowledge in a diverse sample is essential to gaining a balanced picture of the public’s understanding of HPV. The purpose of the present study, therefore, was to assess HPV awareness, knowledge, and beliefs in a diverse group of young men and women at risk for HPV infection and to identify correlates of those factors. We also sought to assess students’ interest in HPV education and to identify predictors of women’s interest in receiving the HPV vaccine.

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Methods 

Participants and procedure 

Students from Florida State University (FSU; n = 58) and Florida Agricultural and Mechanical University (FAMU; n = 66), a historically black university, were recruited to participate in the study during February and March of 2007. Data from both universities were collected on “Market Day,” a weekly event during which various student organizations, vendors, and performers gather on campus. Data from FSU were collected in the Union courtyard on three “Market Wednesdays.” Data from FAMU were collected on “The Set” (the main walkway on campus) on two Fridays. Both events are well attended by students. A member of our research team set up a table at each event to recruit participants. Students passing by the table were invited to complete a brief, anonymous survey for a study called “20 Questions: A Health Study.”

Interested students were seated and given a survey packet that contained a cover page, informed consent form, and the survey. Two dividers, one on each end of the table, were used to increase participant privacy and to promote honest reporting. Upon completion, students placed their packet in an envelope and received a granola bar for their participation. All procedures were approved by the FSU and FAMU Institutional Review Boards.

The mean age of the participants was 19.03 years (SD = 1.09, range 18–26 years), and 52% (n = 64) were women. Most participants were undergraduate students: 27% freshmen; 30% sophomores, 18% juniors, and 15% seniors; graduate students comprised 11% of the sample. The majority of participants were black or African-American (57%; 32% white; 5% biracial; 3% Asian; 3% Latino/Latina). The racial/ethnic distribution of students was generally representative of their respective universities; however, a larger proportion of black/African-American students were recruited from FSU (24%) than is typically represented in the FSU student body (11%). All students were single, with 29% in a committed relationship, 38% dating, and 33% not dating.

Measures 

Participants provided information about demographic characteristics (age, gender, university attended, year in college, race/ethnicity, relationship status), sexual history (whether they had ever had sexual intercourse, number of lifetime sexual partners, frequency of using protection against sexually transmitted diseases during sex, history of HPV infection), and Pap testing history (women only). To assess HPV awareness, participants were asked if they had ever heard of HPV and, if so, to indicate the source(s) of that information (parents, friends, a health care provider, the Internet, or public media such as television, radio, or magazines). Respondents who knew of HPV were asked to complete six true/false HPV knowledge items drawn from previous research [9], [11], [19] (Table 1). Participants were given one point for each correct answer. Points were then summed to create an HPV knowledge score. Two HPV-related beliefs were assessed with a five-point scale (1 = strongly disagree to 5 = strongly agree): perceived risk of HPV infection (“I am at risk for HPV infection”) and perceived shame associated with an HPV diagnosis (“I would feel ashamed if I found out I had HPV”). Female participants were asked if they had received the HPV vaccine (Gardasil) and, if not, whether they were interested in receiving it (0 = no; 1 = yes). Finally participants were asked whether they were interested in learning more about HPV (0 = no; 1 = yes) and were informed that HPV-related handouts were available from the researcher after survey completion.

Table 1. Human papillomavirus (HPV) knowledge among participants who had heard of HPV (n = 97)
Knowledge item% With correct answer
A person usually has symptoms when infected with HPV (false)77
A person’s chances of getting HPV increases with the number of sexual partners they have (true)84
Most types of HPV cannot clear up on their own (false)29
Certain types of HPV can lead to cervical cancer (true)92
HPV can cause genital warts (true)69
An abnormal Pap test result may indicate an HPV infection (true)85

Data analyses 

We computed means and frequencies to summarize background characteristics, sexual history, HPV awareness, and knowledge about HPV. We examined differences in HPV awareness by age, gender, and race. We then examined correlates of five primary outcome variables (i.e., HPV knowledge, perceived risk of HPV infection, perceived shame associated with HPV infection, interest in learning more about HPV, and interest in receiving the HPV vaccine). Potential correlates included the demographic characteristics of age, gender (0 = female; 1 = male), university (0 = FSU; 1 = FAMU), race (0 = white; 1 = black), and current dating status (0 = not dating; 1 = dating or in a committed relationship), sexual history (sexually active, number of lifetime sexual partners, frequency of using protection), HPV awareness (whether participants had heard of HPV), HPV knowledge (based on the composite score), and HPV-related beliefs (perceived risk, perceived shame). Table 2 summarizes the predictors examined for each outcome variable.

Table 2. Correlations between predictor variables and primary outcome variables in a study of human papillomavirus (HPV) knowledge among youth
Predictor variableHPV knowledgePerceived riskPerceived shameInterest in HPV educationVaccine interesta
Demographics
Age−.01.18−.20⁎.09−.03
Gender.39⁎⁎.05−.34⁎⁎−.02—
University.18−.04.10.24⁎⁎.01
African American.01−.07.09.35⁎⁎.04
Dating status−.08.12−.01−.14.30⁎
Sexual history
Sexually active.00.30⁎⁎.07.27⁎⁎.39⁎⁎
No. of partners−.05.27⁎⁎.02.18.30⁎
Use protection−.13−.06.07.02−.07
HPV awareness—.15−.14.10−.01
HPV knowledge—.12−.21⁎.01−.05
HPV beliefs
Perceived risk———.00.37⁎
Perceived shame———.05−.25

aAnalyses were conducted among the 60 women who had not been vaccinated for HPV.

⁎p ≤ .05.

⁎⁎p ≤ .01.

We conducted regression analyses to identify the independent predictors of each primary outcome variable. Variables correlated with HPV knowledge and HPV-related beliefs at p < .05 or less were entered into a multiple regression analysis. Variables that correlated with interest in learning more about HPV infection and interest in the HPV vaccine at the level of p < .05 or less were entered into a logistic regression analysis.

Participants who had been previously diagnosed with HPV (based on self-reported history of HPV infection) and participants who had received the HPV vaccine were excluded from correlation and regression analyses for HPV knowledge, HPV-related beliefs, and interest in HPV education. Predictors of HPV vaccine interest were examined only among female respondents who had not been vaccinated for HPV.

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Results 

Sexual history 

Of the participants, 78% (n = 97) had engaged in sexual intercourse. The average number of lifetime sexual partners was five (SD = 8.4; median = 2.5; range = 1–63). The mean response for frequency of using protection among sexually active students was 4.3 (SD = 1.0), with 58% indicating that they “always” used protection. Approximately 75% (n = 48) of female participants had received a Pap test (smear). Of these women, 8 (17%) had had abnormal Pap test results. Seven participants (all women) indicated that a health care provider told them that they had been infected with HPV. Four women had received the HPV vaccine.

HPV awareness and knowledge 

Of the participants, 78% (n = 97) had heard of HPV. A significantly larger proportion of women (94%) than men (62%) had heard of HPV: χ2 = (1, n = 124) = 18.71, p < .001. The majority of respondents (60%) heard about HPV from public media (television, radio, and magazines), followed by health care providers (39%), friends (32%), the Internet (28%), and parents (27%). Age was not associated with source of HPV knowledge; however, some differences were observed by gender and race. Men (38%) were more likely than women (20%) to report that they had heard about HPV on the Internet: χ2 = (1, n = 88) = 3.59, p = .058. White students (48%) were more likely than black/African-American students (26%) to report that they had heard about HPV from their friends: χ2 = (1, n = 77) = 3.85, p = .05.

The mean HPV knowledge score was 3.5 of 6 (SD = 2.1; median = 4). The majority of respondents were quite knowledgeable about HPV, with 87% achieving a knowledge score of 4 or higher (Table 1). A total of 92% correctly identified the causal link between HPV and cervical cancer. The greatest misunderstanding was observed for the statement highlighting the transient nature of most HPV infections (69% answered this item incorrectly). In addition, 31% were unfamiliar with the connection between HPV infection and genital warts.

The only significant correlate of HPV knowledge was gender (Table 2), such that women (mean = 4.33, SD = 1.53) scored higher on the HPV knowledge scale than did men (mean = 2.65, SD = 2.35).

HPV-related beliefs 

Perceived risk of HPV infection was relatively low (mean = 2.29; SD = 1.33), with most participants (56%) disagreeing, either strongly or moderately, with the statement that they were at risk for HPV infection. Higher perceptions of risk were associated with being sexually active and having a greater number of sexual partners (Table 2). Both sexual activity (β = .24, p < .05) and number of partners (β = .19, p < .05) were unique predictors of perceived risk, accounting for 13% of the variance in risk perceptions: F (2, 107) = 7.65, p < .001.

Across the sample, mean level of perceived shame was just above the midpoint of the scale (mean = 3.31; SD = 1.34). Higher perceptions of shame were observed for younger participants, men, and participants with less HPV knowledge (Table 2). Age (β = −.27, p < .01) and gender (β = −.37, p < .001) emerged as unique predictors of perceived shame, accounting for 19% of the variance in perceptions of shame: F (3, 108) = 8.50, p < .001.

Interest in HPV education 

Of the participants, 64% were interested in learning more about HPV. Students attending FAMU, black/African-American participants, and sexually active participants reported greater interest in HPV education (Table 2). Sexual activity (odds ratio [OR] = 3.30, p < .05) and black/African-American race (OR = 3.30, p = .06) emerged as unique predictors of HPV education interest, although race was only marginally significant.

Interest in obtaining the HPV vaccine 

Of the 60 women who had not been previously vaccinated for HPV, 65% (n = 39) were interested in receiving the HPV vaccine. Greater interest in the vaccine was associated with being in a committed relationship or dating, being sexually active, having a greater number of sexual partners, and feeling vulnerable to HPV infection (Table 2). Dating status (OR = 4.38, p < .05) and sexual activity (OR = 4.31, p < .10) emerged as unique predictors of HPV vaccine interest, although sexual activity was only marginally significant.

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Discussion 

The present study is one of the first to assess awareness, knowledge, and beliefs about HPV infection since the HPV vaccine was approved. Moreover this study is unique in that these factors were assessed in a racially diverse sample of college students. The present study provides a detailed picture of college students’ awareness, knowledge, and beliefs about HPV. It also sheds light on factors associated with HPV knowledge and beliefs, as well as interest in HPV education and the HPV vaccine.

Contrary to previous findings, awareness of HPV was relatively high, with more than 75% of study participants indicating that they had heard of HPV. Furthermore, despite some misconceptions, knowledge about HPV infection on the whole was also quite good. One of the most intriguing findings was the high proportion of students who understood the causal relationship between certain types of HPV and cervical cancer. Previous studies have reported much poorer understanding of this relationship [9], [14], [15]. The one exception is a study of male college students, in which 89% knew that HPV can lead to cervical cancer [11]. Notably, however, men in that study were informed of the relationship between HPV and cervical cancer during recruitment, which likely accounted for the large proportion who answered the item correctly.

The present results are consistent with the possibility that awareness of HPV infection is on the rise, perhaps as a result of recent media attention. Studies conducted in the early 1990s reported that less than 15% of students had heard of HPV. HPV awareness has been noticeably higher in recent studies, with rates between 30% and 45% in college student samples [7], [9], [11], [14]. Findings from the present study provide support for the hypothesis that awareness of HPV among university students may be increasing even further.

Greater awareness, however, does not necessarily imply correct knowledge. Indeed our data suggest that many students do not understand the transient nature of most HPV infections, the asymptomatic quality of the virus, and the connection between HPV and genital warts. Poor understanding may reflect the inherently complex nature of HPV (some infections are transient while others are persistent; some types can cause cancer whereas others cause warts). but it may also reflect minimal attempts at increasing HPV knowledge.

Although public education about HPV historically has trailed behind HIV and other STIs [15], [23], educational efforts have increased in recent years, particularly with the integration of HPV testing into cervical screening and the emergence of the HPV vaccine. Before Gardasil was available, Merck Pharmaceuticals launched its “Make the Connection” and “Tell Someone” campaigns, the goals of which were to raise awareness of HPV infection, the connections among HPV, genital warts and cervical cancer, and the importance of Pap testing. With the release of Gardasil, Merck has since initiated its “One Less” marketing campaign (“Become one less life affected by cervical cancer”), which has received regular television airplay. High levels of awareness observed in the present study, coupled with the fact that television, radio, and magazines were cited as the most common sources of HPV information, provide some evidence for the effectiveness of these campaigns.

Predictors of perceived risk to HPV infection were consistent with previous research [8], [12]. Participants who were sexually active and those with multiple partners felt more vulnerable to HPV. Previous studies have demonstrated little overlap between risk perceptions for HPV infection and actual risk. Ramirez et al [12] reported that a significant proportion of women who believed they were not at risk for HPV infection subsequently tested positive for the virus. Risk perceptions in the present study appear to reflect some degree of accuracy, as sexual activity and multiple sexual partners are indeed risk factors for HPV infection. However as the time frame was not stated explicitly in the question, it is unclear whether participants were rating their risk of HPV infection at present, in the immediate future, or over their lifetime, which would also affect the accuracy of their ratings.

Younger participants, men, and students with lower HPV knowledge associated HPV infection with higher levels of shame. Some research suggests that the extent to which an HPV diagnosis is perceived as shameful depends on awareness of whether the infection is common and/or sexually transmitted [24], [25]. Waller et al [25] found that compared with participants who were not aware that HPV is sexually transmitted, those who were aware of this fact believed they would feel more shame and stigma if they tested positive for HPV. In contrast participants who understood that HPV is extremely common reported less shame and stigma than individuals not aware of its high prevalence. These findings suggest that advertising the high prevalence of HPV, as done in recent media campaigns, may help to reduce feelings of shame. At the same time some research has shown that medical conditions perceived to be common also tend to be perceived as less serious [26], [27] Thus, advertisements that emphasize the high prevalence of HPV should simultaneously highlight the potential seriousness of HPV infection.

Consistent with previous research [19], [20], [21], [22], HPV vaccine interest was relatively high; greater vaccine interest was observed among sexually active women, women with multiple sexual partners, and women who felt vulnerable to HPV infection. One notable finding has emerged across studies of HPV vaccine acceptability, including the current study: Women who may benefit from the HPV vaccine the most—those who are not yet sexually active—tend to express the least interest in getting vaccinated. Thus it is important for future HPV vaccination campaigns to direct efforts at sexually inexperienced individuals.

The current research has important implications for HPV education campaigns. Findings suggest that continued health education is needed to promote better knowledge of HPV. Characteristics of HPV infection, about which there is considerable confusion, as well as behavioral recommendations for HPV prevention and the importance of routine Pap testing should be highlighted. HIV education campaigns may provide a good role model for increasing public knowledge of HPV [28], [29]. Brief educational interventions have been found to increase HPV knowledge [23]. As learned from other STI prevention programs, however, it is important to keep in mind that greater awareness and knowledge of HPV may not necessarily translate into HPV prevention behaviors [16]. Knowledge is typically one of many predictors of protective sexual behavior [30]. Yet given the relatively low levels of HPV knowledge typically observed in the general public, increasing HPV education is an essential starting point.

Study limitations should be considered when interpreting the present findings. Although we recruited a racially diverse sample, the sample as a whole was relatively small. As it was a convenience sample, findings may not generalize to all U.S. university students. Furthermore awareness and knowledge of HPV are likely to be higher in university populations than in the general population. Larger studies are needed to evaluate whether HPV awareness is indeed increasing in student populations as well as in the general population. Findings also support national efforts to monitor trends in HPV awareness and knowledge. Another limitation is that acceptability of the HPV vaccine was examined among women only. As clinical trials are currently evaluating the feasibility of the HPV vaccine for men, future studies should assess men’s receptivity to HPV vaccination and identify effective ways to inform men about HPV infection and the HPV vaccine.

In conclusion, low levels of HPV knowledge coupled with low perceptions of risk could weaken efforts to prevent HPV infection, to seek follow-up care after abnormal Pap test results, or to be vaccinated against HPV. Findings from the present study suggest that awareness of HPV infection may be increasing. At the same time, many misconceptions remain. Campaigns to further increase understanding of the prevalence and consequences of HPV are needed, along with efforts to promote HPV prevention and routine cervical screening.

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PII: S1054-139X(07)00404-1

doi:10.1016/j.jadohealth.2007.08.022

Journal of Adolescent Health
Volume 42, Issue 3 , Pages 237-242, March 2008

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