Young adult learning about human papillomavirus on the internet: what are the common misconceptions?
Abstract: The purpose of this study was to examine young adult learning about Human Papillomavirus (HPV) during a realistic internet search. The results indicated that before the search there were widespread misconceptions about the virus and many potentially dangerous misconceptions remained after the search. Persistent misconceptions were related to gender, lack of prior HPV exposure, knowledge dissatisfaction, and moral values. These findings provide empirical results for health information providers about what HPV content is difficult for young adults to learn and which sub populations of young adults experience difficulty when learning scientifically accurate information about HPV in a realistic setting.
Subject: Papillomaviruses (Health aspects)
Sex education (Health aspects)
Teenagers (Sexual behavior)
Teenagers (Health aspects)
Youth (Sexual behavior)
Youth (Health aspects)
Internet (Health aspects)
Papillomavirus infections (Health aspects)
Sexually transmitted diseases (Health aspects)
Sex education for youth (Health aspects)
Cancer (Care and treatment)
Cancer (Health aspects)
Authors: Hilpert, Jonathan
Carrion, Melissa
Brem, Sarah K.
Ciani, Maria
Ciani, Keith
Pub Date: 01/01/2010
Publication: Name: American Journal of Health Studies Publisher: American Journal of Health Studies Audience: Professional Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2010 American Journal of Health Studies ISSN: 1090-0500
Issue: Date: Wntr, 2010 Source Volume: 25 Source Issue: 1
Topic: Computer Subject: Internet
Product: Product Code: E121930 Youth; 8000432 Cancer Therapy NAICS Code: 621 Ambulatory Health Care Services
Organization: Government Agency: United States. Centers for Disease Control and Prevention
Accession Number: 308741530
Full Text: In a program of sexual health education, the topic of human papillomavirus (HPV) can pose some unique challenges. Unlike many other sexually transmitted infections (STIs), which are transmitted primarily through intercourse or other sexual activities that involve the sharing of bodily fluids, HPV infects squamous epithelial cells and can be transmitted through epithelial, or skin-to-skin, contact. Popular, seemingly safe practices such as "outercourse" are therefore capable of resulting in HPV infection, as is manual manipulation (Burchell, Winer, San Jose, & Franco, 2006). In addition, there are over 100 forms of HPV, some of which produce non-genital infections (such as warts on the hands and feet), while others affect mucosal membranes (including those of the mouth, nose, vagina, and anus).

Some of those which infect mucosal membranes are highly associated with the eventual development of cancer. HPV is the most common cause of cancer in women worldwide (Ferlay, Bray, Pisani & Parkin, 2001). The high risk oncogenic strains cause asymptomatic microscopic lesions (CDC, 2006). This fact makes oncogenic strains of HPV particularly dangerous as there are no physical symptoms noticeable to the carrier. Recent studies linking HPV types 16 & 18 to not only cervical cancer, but also invasive cancers of the vulva, anus, and oral cavity further elucidate the significance of effective HPV prevention (Rojas, et al., 2007). However, others present little or no risk of cancer and in over 90% of cases, the body's immune system clears HPV from the body in 24 months or less; adolescents and young adults may be infected and recover multiple times without ever knowing it, or be infected for years before the appearance of warts or mucosal dysplasia.

In short, HPV is a complex virus, with a complex manner of transmission and complex health outcomes, difficult for young people to understand, protect against, and respond to in cases of infection. Furthermore, it is a STI that young people are increasingly likely to have heard of because of the recent FDA approval of Gardasil and subsequent media campaigns, along with the fact that HPV infection has the highest rate of new infection of any STI in the United States; the CDC estimates 6.2 million new cases of HPV are diagnosed in the US every year, as compared to 2.8 million cases of gonorrhea and 1 million new cases of herpes.

Accordingly, examination of human papillomavirus (HPV), especially with regard to young adult knowledge and attitudes about the infection, has received increased attention (Doherty & Graff Low, 2009; Gerend & Magloire, 2008; Gerend, Shepard, & Monday, 2008; Habel, Lindon, & Striker, 2009; Kahn, Rosenthal, Hamann, & Bernstein, 2003). In part, such research has shown that HPV prevention has been placed in the center of a gendered moral discourse about the appropriateness of sexual activity before marriage (Balog, 2009; Habel, Lindon, & Striker, 2009; Springen, 2008), and sexual health information can be dominated by ideological messages (Kirby, 2007; Mathematica, 2007; Young, 2004).

Gardasil spawned debate about the value-laden messages embedded in vaccinating young girls against sexually transmitted infections. Many religious and conservative groups feel it is inappropriate to prevent a viral infection caused by what they perceive as immoral behavior--namely premarital sex (Balog, 2009). A second controversy stemmed from the issue of gender bias raised by the vaccine's approval and marketing. The implicit placing of responsibility for HPV prevention on mothers and daughters has been criticized (e.g. Hoffman, 2008), and recent studies have found that females are more likely to know more about the infection and benefits of the vaccine (Gerend & Magloire, 2008) while males may benefit most from intervention (Doherty & Graff Low, 2009).

This creates new challenges for health educators who are charged with using "community organization principles to facilitate change conducive to health," engaging in "culturally sensitive techniques when promoting programs," and analyzing the sociocultural factors when developing interventions and advising on matters of policy (NCHEC, 2008). Simultaneously, many young adults are turning not to formal programs of health education or the health educators in their community, and are instead searching for information about sex and sexual health on the internet, including information about HPV (Habel, et al., 2009; Fox, 2005; Hoff Greene, & Davis, 2003). The Pew Internet and American Life Project reports that, as of 2007 and 2008, young adults (age 18-29) are more likely than any other cohort to seek out information about sexual health; although the absolute percentage of young people engaging in this use of the internet remains low (21-31%), this is an increase of 47% over the year 2000 (Pew Internet, 2005, 2009). As health educators adapt to this new situation, they will have to select appropriate "technologies, methods and media for their acceptability to diverse groups" (NCHEC, 2008).

For these reasons, it is important to know both what misconceptions young people hold about HPV, and how their excursions on the internet may combat or enhance these misconceptions. The purpose of this study was to examine young adult learning about HPV during a realistic internet search. Measures were taken before and after the search to examine 1) what common misconceptions participants had about HPV before the search activity, 2) what misconceptions remained after the search and 3) if there were psychological and demographic factors related to participants' prior knowledge, acquisition of new knowledge, and remediation of any misconceptions about HPV.

In particular, psychological research suggests that there are a number of factors likely to affect learning about complex topics, especially complex topics that create emotional and moral reactions in young adults (Sinatra & Mason, 2009; Murphy & Mason, 2006). When young people learn about controversial topics there is an intermingling of motivational and value-based factors that influence their ability to acquire and use new knowledge. During controversial learning tasks peoples' deeply held beliefs can conflict with scientific explanations creating barriers to knowledge acquisition (Sinatra, Brem, & Evans, 2008; Evans, 2001).

Several factors have been shown to affect the ability to learn, integrate new knowledge and reconcile contradictions or overcome misconceptions; we focus on two that we believe are likely to be of particular importance in the area of sexual health: knowledge satisfaction and values.

Knowledge satisfaction. Learning theorists argue that peoples' level of satisfaction with their current understanding can influence whether and how they engage in the learning process (Posner, Strike, Hewson, & Gertzhog, 1982). In most cases, when faced with new information, people will interpret that new information in line with their existing beliefs (e.g., Popper, 1959; Kuhn, 1971; Ross & Lepper, 1980; Wisniewski & Medin, 1994). It is only when the learner becomes dissatisfied with their current knowledge that they engage in revising their understanding and concepts. Learners with a self-acknowledged lack of knowledge in an area will strive to remedy their current state of understanding (Deci & Ryan, 2000; Ryan & Deci, 2000). If a learner is required to interpret new information within the context of flawed prior knowledge, there is a high possibility that the learner will blend accurate and inaccurate information in a way that does not support healthy understanding and decision-making.

In the context of learning about HPV, this research suggests that young adults who are aware of gaps or problems in their knowledge, and are motivated to remedy those shortcomings, will be more likely to improve their knowledge through education, and, in the context of this study, when seeking information on the internet. Those who do not experience such dissatisfaction will be less motivated to find new information, and new information will be less likely to improve their understanding.

Moral values. A commonly discussed barrier to HPV prevention are debates about the morality of premarital sex and policy positions that impact the ability of health educators to discuss alternatives to abstinence (Balog, 2009; Habel, et al., 2009; Springer, 2008). One of the most widely accepted psychological frameworks for examining moral values is Kohlberg's (1969) theory of moral development. Kohlberg suggests that the development of moral values is based on a negotiation between individuals and social influences. At the conventional stage (commonly found in adolescent responses to moral dilemmas), peoples' moral values are subordinated to the laws and conventions of a society. In regard to sexual relationships, conventional moral values in modern American culture often suggest that sexual activity outside of marriage is immoral, and this can affect education efforts, community health programs, and contraceptive availability (Elders, 2008; Gilman, Gilman & Johns, 2009).

Young adults who place a high value on abstaining from premarital sex or believe premarital sex to be immoral may face cognitive and affective challenges to learning about sexual health. They may be unwilling to engage, or have less prior knowledge about sex and sexual health, making it difficult for them to integrate new knowledge effectively, or develop misconceptions due to using definitions of sexual activity (Sanders & Reinische, 1999; Bogart, Cecil, Wagstaff, Pinkerton & Abramson, 2000) that leave them vulnerable to STI (Nicoletti, 2005; Bersamin, Fisher, Walker, Hill & Grube, 2007). In addition, they may be less likely to engage in screenings for STIs; teenagers who have taken pledges to remain virgins until marriage are less likely to undergo STI testing despite the fact that many substitute other high-risk sexual behaviors for intercourse in an effort to preserve their virginity (Bruckner & Bearman, 2005).

STUDY RESEARCH QUESTIONS AND HYPOTHESES

The purpose of this study is to examine young adults understanding of HPV, how their understanding is affected by searching for information about HPV on the internet, and how psychological and demographic factors are related to their understanding and information inquiries. Specifically, we designed the study to address the following research questions:

1. What understanding and misconceptions do young adults have about HPV before encountering a realistic scenario in which they might perceive the need to search for information about HPV online? How is their knowledge satisfaction and moral values related to their understanding and misconceptions?

2. What misconceptions persist despite such an information search? How are knowledge satisfaction and moral values related to the information search and what participants learn from the search?

We hypothesized that participants who were dissatisfied with their understanding of HPV would have less prior knowledge about the infection and would be more likely to construct increasingly scientifically accurate knowledge about HPV during their internet search, but that some evidence of distortion would remain. We also hypothesized that participants who reported holding conventional moral values about the immorality of premarital sex would be more satisfied with their knowledge about HPV and would be less likely to construct scientifically accurate information about HPV during the search. Such information about the existing knowledge, search activity, and learning could be of considerable help to health educators planning and implementing educational programs on sexual health.

METHOD

PARTICIPANTS

Data were gathered from 74 college students enrolled in a women's studies course at a large public university in the Southwest. Students were given 1% extra credit for participating. HPV was not discussed in the course and students were not informed ahead of time about the study topic. The mean age for the participants was 21.73. Of the participants, 21.4% were freshman, 28.6% were sophomores, 25.7% were juniors, and 24.3% were seniors. Females comprised 66% of the participants. The ethnic breakdown of the sample was as follows: 71.4% White; 7.8% Hispanic; 3.9% Black; 2.6% Asian; 1.3% Pacific Islander; 5.2% "other." The sample mirrored the ethnic breakdown of the university, with less than a 5% difference per category.

MEASURES

Moral Values. These items addressed whether participants' believed that people who contract sexually transmitted infections engage in immoral behavior ([alpha] = .76). Example items read, "sexually transmitted infections are spread by people who engage in immoral behavior" and "premarital sex is an immoral act." High scores equaled high conventional moral values about premarital sex.

HPV Knowledge Satisfaction. These items addressed participants' satisfaction with their knowledge about the six dimensions of STI's: contraction, rate of infection, prevention, health effects, symptoms, and tests ([alpha] = .86). Example items read, "I believe I have a lot to learn about how HPV is spread" and "I know about the tests for HPV." High scores equaled more HPV knowledge satisfaction.

HPV Knowledge. Participants' HPV knowledge was measured using a survey created by combining information about HPV from the CDC (CDC, 2006), the young adult version of the Sexual Health Knowledge, Attitudes, and Experiences scale from the National Survey of Adolescents and Young Adults (Hoff et al., 2003), scholarly publications (e.g. Gerend & Maglorie, 2008), popular media publications (e.g. Gellene, 2006), and guidance from sexual health experts at a local Planned Parenthood. The content was constructed using the above mentioned sources and then validated by the sexual health experts at Planned Parenthood. Sample items read, "the human immune system often destroys HPV infections without medical treatment," and "all types of HPV can cause genital warts." Seven of these items were false. Students were asked to respond "yes" or "no" to each item. High scores equaled more correct answers.

Exposure. Prior experience with HPV, either by being infected or knowing someone who has been infected, may have influenced the amount of accurate knowledge a participant had before the study. Thus, participants were asked whether or not anyone they know, including themselves, have ever found out they had HPV. This was a dichotomous variable.

PROCEDURE AND ANALYSIS

In this pre/post within-subjects design, participants were given a scenario in which they were asked to imagine that a close friend had been diagnosed with HPV. Then they were given the study measures. The participants were then given the opportunity to search the internet for information about HPV (1). When their searches were completed, they responded to a final set of measures.

Descriptive statistics for all of the study variables were calculated and assumption checking was conducted. The difference between number of correct responses to the pre and post measures of the HPV knowledge items were examined using dependent samples t-tests, and percentages of correct responses for each item were calculated. Independent samples t-tests were then conducted to determine if there were significant mean differences in the study variables between males and females and between those who had been exposed to HPV in the past and those who had not. A correlation matrix was constructed to examine the bivariate relationships among the variables. Finally, a multiple regression was performed to examine the influence of knowledge satisfaction and moral values on participants' HPV knowledge at the first and final time points.

RESULTS

Descriptive statistics. Assumptions checking indicated that all of our variables were appropriate for our statistical tests (see Table 1 for descriptive statistics), except moral values which was slightly positively skewed--suggesting that there were few participants in our sample who believed that premarital sex was extremely immoral. This variable was corrected using a log transformation to improve the distribution of the data (Tabachnick & Fidell, 2007).

Correct responses and dependent samples t-tests. The percentages of correct responses indicated that many of the participants held important misconceptions about HPV before the search, including errors in their knowledge about the mechanisms of transmission, rates of infection, types, and treatment (see Table 2). Our examination of the HPV knowledge items suggested the following misconceptions were common before the search (i.e. < 65% correct): 1) HPV is contracted through exchange of bodily fluids, 2) HPV is not contracted through genital to genital contact, 3) most types of the infection are high risk, 4) life threatening types of HPV have symptoms that can be seen by the carrier, 5) condoms are a highly effective method for preventing HPV, 6) the immune system cannot combat HPV infection without medical treatment, 7) antibiotics can effectively treat HPV.

Comparing pre- and post-test scores, dependent samples t-tests provided no evidence that, overall, participants corrected their understanding on a number of important issues. Participants did not significantly increase their mean number of correct responses for 1) the symptoms associated with the dangerous types of HPV, 2) whether HPV can be transmitted through bodily fluids, 3) effective methods of prevention, and 4) effective methods of testing. However, these results do not look at differences that may be present due to knowledge satisfaction, values, prior exposure, or other demographic characteristics.

Independent samples t-tests. Results of the independent samples t-tests (see Table 3) indicated that there were significant differences between those who had been exposed to HPV or knew someone who had been exposed and those who had not. Those in the exposure category were more likely to be satisfied with their understanding of HPV, less likely to report that premarital sex is immoral, more likely to have accurate knowledge both before and after the search, and less likely to experience change in knowledge.

The independent samples t-test also indicated that females were more likely to respond accurately to the HPV questions than males before and after the search.

Correlations. The results of the correlational analysis (see Table 4) indicated a number of significant relationships between the variables of interest. Participant HPV knowledge satisfaction was significantly and positively correlated with HPV knowledge before and after the search, as well as significantly and negatively correlated with the difference between the two. Thus, the more satisfied participants were with their knowledge, the more they knew at the beginning and the end of the search, and the less satisfied participants were with their knowledge before the search, the more knowledge they gained during the search. In addition, participants with conventional moral values had less HPV knowledge at the final time point.

Multiple Regression. The results of the multiple regression indicated that the linear combination of moral values, HPV knowledge satisfaction, and prior knowledge was significantly related to the difference in HPV knowledge, F(3,70) = 34.50, p < .001, [R.sup.2] = .60, adjusted [R.sup.2] = .57. However, only HPV prior knowledge t(3,70) = -7.31,p < .001 and moral values t(3,70) = -2.71, p = .008 were significant predictors in the equation; HPV knowledge satisfaction was not t(3,70) = -.73, p = .465.

HPV knowledge satisfaction was removed, and we again conducted the multiple regression. The linear combination of moral values and HPV prior knowledge was significant, F(2,71) = 20.35, p < .001; [R.sup.2] = .58, adjusted [R.sup.2] = .58. Both moral values t(2,73) = -2.65, p = .01 and HPV prior knowledge t(2,73) = -10.15, p < .001 remained significant predictors of the difference in HPV knowledge before and after the search. When controlling for HPV prior knowledge, for every 1 unit increase in self-reported conventional moral values about premarital sex there was a .2 unit decrease in HPV knowledge change.

DISCUSSION

HPV is a serious STI and has the highest rate of new infection in the United States. Because it is not transmitted by bodily fluids, young adults' understanding of other STIs may not transfer well to HPV, leaving them vulnerable to infection. Increasingly, the place where young adults learn about STIs is not the classroom or home, but the internet. This acknowledgment is therefore important when designing interventions, engaging in community organization, and assessing the resources available for fostering an understanding of sex and sexual health.

Our findings suggest that there are persistent misconceptions about HPV, including errors regarding who can be infected, how they can be infected, and how they can be treated. Even after searching the internet, misconceptions remained. Most notably, a large percentage of the sample still reported that HPV is spread through the exchange of bodily fluids and that potentially life threatening strains of the infection have symptoms that can be seen by the carrier. Statistically there was no change in participant responses to these HPV knowledge items. We view these two misconceptions in particular as extremely problematic as they can impact young adults' perception of risk as well as their perceived need for testing. Health educators may want to focus HPV prevention material on these aspects of the infection to ensure young adults understand the asymptomatic nature of oncogenic strains as well as the importance of regular testing, even after marriage.

However, misconceptions were not uniform across participants. Young adults who reported being dissatisfied before the search were more likely to increase the number of correct HPV knowledge responses. Not surprisingly, those with less prior knowledge were more likely to increase their number of accurate responses to HPV questions; yet, those who had not been previously exposed were significantly more likely to have HPV misconceptions after the search. These authors argue that this is important justification for preventative dissemination of accurate HPV information.

Furthermore, females in the sample were significantly more likely to respond accurately to HPV knowledge questions both before and after the search. These results support previous findings (Doherty & Graff Low, 2009; Gerend & Magliore, 2008) as well as literature that suggests HPV is embedded in a gendered discourse (Springer 2008; Hoffman, 2008).

Finally, those who espoused conventional moral values regarding the morality of premarital sex showed less accurate HPV knowledge after the search; multiple regression results suggested those with conventional moral values were at a higher risk for errors.

It may have been that those participants with conventional moral values experienced a negative affective response when they encountered the material which impeded knowledge construction. Another possibility is errors with the way new knowledge was categorized. Learning research (Schraw, 2006) suggests people interpret new information using prior knowledge. Independent samples t-tests indicated participants with conventional moral values were less likely to be exposed to HPV in the past and thus may have been trying to understand HPV within the context of other more familiar STIs, making it difficult to accurately acquire and integrate new knowledge.

Reliance on existing knowledge structures may be especially problematic with regard to effective HPV prevention. Specifically, the misconceptions that 1) risky sexual activity is limited to behaviors which include exchange of bodily fluids and 2) oncogenic strains can be detected by the carrier provides an ineffective model for HPV prevention. This, coupled with the reliance on marriage as a strategy for preventing HPV infection, could place young adults at increased risk.

The discovery that one or one's partner has contracted HPV should not be the primary catalyst for learning about the infection. Another important component is the role of gender in our findings.

There are several limitations to the current study including oversampling of women, the small sample size, and the timing of study measures. Previous research has found women tend to report more accurate responses to HPV knowledge items; thus, our sample lends to underestimating common misconceptions, and may not accurately portray male misconceptions. Along similar lines, the small sample size and the oversampling of women also warrants caution in generalizing the results to male populations. Finally, the current study did not include follow-up measures. It is possible that participant HPV knowledge may have deteriorated after the search or the desire to learn led them, eventually, to more accurate information. Future studies could include one month follow-up questions and a larger, more representative sample.

Nevertheless, to the authors' knowledge this is the first study to examine realistic HPV learning on the internet, and many of our findings align with recent relevant studies conducted on the topic (e.g. Gerend & Magliore, 2008; Doherty & Graff Low, 2009). Perhaps of greatest importance, the results suggest that health educators need not only target misconceptions in a way that fosters knowledge satisfaction, they should also consider the moral values of students in planning interventions and interacting with communities.

The United States has high rates of teenage pregnancy and sexually transmitted infection compared to other western industrialized countries, and many sexual health experts believe our problems are exacerbated because of federally mandated abstinence-only sex education programs which rely upon traditional conceptions of gender roles and focus on refusal skills in heterosexual relationships (e.g. Kirby 2001 & 2007). The primary message has been characterized as morally based, and abstinence-only education has been criticized for its support of a conventional moral ideology (Irvine, 2002; Levine, 2002; Young, 2004).

Our results suggest that moral values may interfere with acquiring medically accurate information about sexually transmitted infections (Howell & Keefe, 2007; Mathematica., 2007), including the findings that students exposed only to an abstinence curriculum were less likely to be able to identify the names of sexually transmitted infections and to understand their detrimental health effects. Our results support this conclusion, and extend it to autonomous searching for information on the internet.

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(1.) Though not presented, data were also gathered regarding what internet sites the participants visited, what types of keyword searches they used, how long they searched, and what types of search strategies they used. Recordings of the searches were also taken and analyzed.

Jonathan Hilpert, PhD

Melissa Carrion, MA

Sarah K. Brem, PhD

Maria Ciani, BA

Keith Ciani, PhD

Jonathan C. Hilpert, is affiliated with the Department of Educational Studies, School of Education, Indiana University--Purdue University at Fort Wayne. Melissa L. Carrion, is affiliated with the Department of Communication, Purdue University. Sarah K. Brem, is affiliated with the Division of Psychology in Education, School of Education, Arizona State University. Maria L. Ciani, is affiliated with the School of Medicine, University of Missouri--Kansas City. Keith D. Ciani, is affiliated with the Department of Educational, School, and Counseling Psychology, University of Missouri. Correspondence concerning this article should be addressed to: Jonathan C. Hilpert, Department of Educational Studies, School of Education, Indiana University--Purdue University at Fort Wayne (IPFW); 2101 E. Coliseum Blvd., Fort Wayne, IN 46805. Email: hilpertj@ipfw.edu. Office Phone: 1.260.481.6455. Dept Phone: 1.260.481.6441. Funding for the current study was provided by National Science Foundation Grant, CAREER: Critical Thinking in Multimedia Environments.
Table 1. Descriptive statistics for all study variables

                      Min     Max      M      SD

HPV satisfaction     1.00    6.00    3.39    1.31
Moral Values         1.00    5.50    1.70    0.93
HPV knowledge A      1.00    15.00   9.64    3.22
HPV knowledge B      6.00    16.00   12.73   2.23
HPV knowledge Diff   -3.00   13.00   3.09    2.99

Note. N = 74; A = before the search; B = after the search;
Diff = Difference between number correct before and after.

Table 2. Percent correct for HPV knowledge items and
corresponding dependent samples t-test

                     Items                   Before

                                            N     %

1.    HPV is spread by genital to           71   53.5
      genital contact (no intercourse).
2.    HPV is spread by sharing              72   48.6
      bodily fluids.
3.    More than 50% of people have at       67   67.2
      one time been infected with HPV.
4.    Only women can be infected            71   76.1
      with HPV.
5.    Most types of HPV infection can       71   47.9
      have high-risk health effects.
6.    Only a few types of HPV infection     69   65.2
      have high-risk health effects.
7.    Some types of HPV do not cause        66   81.8
      cancer.
8.    All types of HPV can cause genital    66   83.3
      warts.
9.    If my partner had previously          73   94.5
      contracted HPV I would be able to
      tell.
10.   Many HPV infections will disappear    70   68.6
      without causing physical symptoms.
11.   Life threatening HPV infections do    67   62.7
      not have symptoms that can be seen
      by the carrier.
12.   There is a vaccine that can prevent   69   84.1
      life threatening types of HPV.
13.   Condoms are a highly effective        70   28.6
      method for preventing HPV.
14.   The human immune system often         71   46.5
      destroys HPV infections without
      medical treatment.
15.   Antibiotics are effective for         67   49.3
      treating HPV.
16.   A pap smear is an effective test      68   73.5
      for HPV.

                     Items                   After

                                            N     %

1.    HPV is spread by genital to           74   79.7
      genital contact (no intercourse).
2.    HPV is spread by sharing              73   52.1
      bodily fluids.
3.    More than 50% of people have at       74   91.9
      one time been infected with HPV.
4.    Only women can be infected            74   95.9
      with HPV.
5.    Most types of HPV infection can       74   67.6
      have high-risk health effects.
6.    Only a few types of HPV infection     74   83.8
      have high-risk health effects.
7.    Some types of HPV do not cause        74   95.9
      cancer.
8.    All types of HPV can cause genital    73   80.8
      warts.
9.    If my partner had previously          74   97.3
      contracted HPV I would be able to
      tell
10.   Many HPV infections will disappear    73   87.7
      without causing physical symptoms
11.   Life threatening HPV infections do    74   75.7
      not have symptoms that can be seen
      by the carrier.
12.   There is a vaccine that can prevent   74   86.5
      life threatening types of HPV.
13.   Condoms are a highly effective        73   37.0
      method for preventing HPV.
14.   The human immune system often         74   83.8
      destroys HPV infections without
      medical treatment
15.   Antibiotics are effective for         73   79.5
      treating HPV.
16.   A pap smear is an effective test      74   82.4
      for HPV.

                     Items

                                              t     df    p

1.    HPV is spread by genital to           -3.41   70   0.00
      genital contact (no intercourse).
2.    HPV is spread by sharing              -0.81   70   0.42
      bodily fluids.
3.    More than 50% of people have at       -4.31   66   0.00
      one time been infected with HPV.
4.    Only women can be infected            -3.56   70   0.00
      with HPV.
5.    Most types of HPV infection can       -2.88   70   0.01
      have high-risk health effects.
6.    Only a few types of HPV infection     -2.89   68   0.01
      have high-risk health effects.
7.    Some types of HPV do not cause        -3.06   65   0.00
      cancer.
8.    All types of HPV can cause genital     0.22   64   0.83
      warts.
9.    If my partner had previously          -0.82   72   0.42
      contracted HPV I would be able to
      tell
10.   Many HPV infections will disappear    -3.00   68   0.00
      without causing physical symptoms
11.   Life threatening HPV infections do    -1.73   66   0.09
      not have symptoms that can be seen
      by the carrier.
12.   There is a vaccine that can prevent   -0.30   68   0.77
      life threatening types of HPV.
13.   Condoms are a highly effective        -1.22   68   0.23
      method for preventing HPV.
14.   The human immune system often         -5.89   70   0.00
      destroys HPV infections without
      medical treatment
15.   Antibiotics are effective for         -5.04   66   0.00
      treating HPV.
16.   A pap smear is an effective test      -1.84   67   0.07
      for HPV.

Note: Valid N = 74; % = valid percent of participants
who answered the item correctly not including those
who chose "no comment"; p-values < .05 were considered
significant.

Table 3. Independent samples t-tests for study variables

                       t      df    p     [M.sub.diff]

                   Exposure (Yes = 37)

HPV satisfaction      6.07    72   0.00      1.51
Moral Values         -3.18    72   0.00     -0.31
HPV knowledge A       6.28    72   0.00      3.81
HPV knowledge B       4.14    72   0.00      1.95
HPV knowledge Diff   -2.81    72   0.01     -1.86

                  Sex (Female = 49)

HPV satisfaction     -1.65    72   0.10     -0.52
Moral Values          1.69    72   0.09      0.18
HPV knowledge A      -4.11    72   0.00     -2.95
HPV knowledge B      -4.48    72   0.00     -2.19
HPV knowledge Diff    1.04    72   0.30      0.76

Note. Diff = Difference between before and after; Mdiff = mean
difference. Mean differences were calculated: Exposure =
Yes-No; Sex = Male - Female; p-values < .05 were considered
significant.

Table 4. Correlation coefficients among study variables

                          1.        2.        3.       4.     5.

1. HPV satisfaction       1
2. Moral Values          -.21       1
3. HPV knowledge A      .65 **     -.19       1
4. HPV knowledge B       .26*     -.35 **   .45 **     1
5. HPV knowledge Diff   -.51 **    -.10     -.74 **   .26 *   1

Note: N = 74; * = p < .05; ** = p < .001; A = before the search;
B = after the search; Diff = Difference between before and after.
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