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American Journal of Health Studies: 25(1) 2010
YOUNG ADULT LEARNING ABOUT HUMAN PAPILLOMAVIRUS ON
THE INTERNET: WHAT ARE THE COMMON MISCONCEPTIONS?
Jonathan Hilpert, PhD
Melissa Carrion, MA
Sarah K. Brem, PhD
Maria Ciani, BA
Keith Ciani, PhD
Abstract: e purpose of this study was to examine young adult learning about Human
Papillomavirus (HPV) during a realistic internet search. e 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. ese 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.
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 activi-
ties that involve the sharing of bodily fluids, HPV in-
fects 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 infec-
tions (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). e high risk oncogenic strains cause asymp-
tomatic microscopic lesions (CDC, 2006). is fact
makes oncogenic strains of HPV particularly danger-
ous 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 can-
cers of the vulva, anus, and oral cavity further elu-
cidate 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 com-
plex manner of transmission and complex health
outcomes, difficult for young people to understand,
protect against, and respond to in cases of infec-
tion. 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 in-
fection 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
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 inking in Multi-
media Environments.
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every year, as compared to 2.8 million cases of gon-
orrhea and 1 million new cases of herpes.
Accordingly, examination of human papilloma-
virus (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 activ-
ity before marriage (Balog, 2009; Habel, Lindon, &
Striker, 2009; Springen, 2008), and sexual health in-
formation can be dominated by ideological messages
(Kirby, 2007; Mathematica, 2007; Young, 2004).
Gardasil spawned debate about the value-laden mes-
sages embedded in vaccinating young girls against
sexually transmitted infections. Many religious and
conservative groups feel it is inappropriate to pre-
vent 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. e 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 ben-
efit most from intervention (Doherty & Graff Low,
2009).
is creates new challenges for health educators
who are charged with using “community organiza-
tion principles to facilitate change conducive to
health,” engaging in “culturally sensitive techniques
when promoting programs,” and analyzing the so-
ciocultural 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 search-
ing for information about sex and sexual health on the
internet, including information about HPV (Habel,
et al., 2009; Fox, 2005; Hoff, Greene, & Davis,
2003). e 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 “tech-
nologies, 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 com-
bat or enhance these misconceptions. e 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 mis-
conceptions 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 con-
troversial topics there is an intermingling of moti-
vational and value-based factors that influence their
ability to acquire and use new knowledge. During
controversial learning tasks peoples’ deeply held be-
liefs 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 rec-
oncile 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 cur-
rent 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-ac-
knowledged 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 sup-
port healthy understanding and decision-making.
In the context of learning about HPV, this re-
search suggests that young adults who are aware of
gaps or problems in their knowledge, and are mo-
tivated to remedy those shortcomings, will be more
likely to improve their knowledge through educa-
Hilpert, Carrion, Brem, Ciani & Ciani
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American Journal of Health Studies: 25(1) 2010
tion, and, in the context of this study, when seek-
ing information on the internet. ose 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 alterna-
tives 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 individu-
als 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 pro-
grams, and contraceptive availability (Elders, 2008;
Gilman, Gilman & Johns, 2009).
Young adults who place a high value on abstain-
ing from premarital sex or believe premarital sex to be
immoral may face cognitive and affective challenges
to learning about sexual health. ey may be unwill-
ing 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 (Brückner & Bearman,
2005).
STUDY RESEARCH QUESTIONS AND
HYPOTHESES
e purpose of this study is to examine young
adults understanding of HPV, how their under-
standing is affected by searching for information
about HPV on the internet, and how psychological
and demographic factors are related to their under-
standing 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 encounter-
ing a realistic scenario in which they might perceive
the need to search for information about HPV on-
line? How is their knowledge satisfaction and moral
values related to their understanding and misconcep-
tions?
2. What misconceptions persist despite such
an information search? How are knowledge satisfac-
tion 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 scien-
tifically accurate knowledge about HPV during their
internet search, but that some evidence of distor-
tion would remain. We also hypothesized that par-
ticipants 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. e 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 com-
prised 66% of the participants. e ethnic break-
down 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.” e sample mirrored
the ethnic breakdown of the university, with less
than a 5% difference per category.
MEASURES
Moral Values. ese items addressed whether
participants’ believed that people who contract
sexually transmitted infections engage in immoral
behavior (α = .76). Example items read, “sexually
transmitted infections are spread by people who en-
gage in immoral behavior” and “premarital sex is an
immoral act.” High scores equaled high conventional
moral values about premarital sex.
HPV Knowledge Satisfaction. ese items ad-
dressed participants’ satisfaction with their knowl-
edge about the six dimensions of STI’s: contraction,
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rate of infection, prevention, health effects, symp-
toms, and tests (α = .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 publica-
tions (e.g. Gellene, 2006), and guidance from sexual
health experts at a local Planned Parenthood. e
content was constructed using the above mentioned
sources and then validated by the sexual health ex-
perts at Planned Parenthood. Sample items read, “the
human immune system often destroys HPV infec-
tions 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 in-
fected, may have influenced the amount of accurate
knowledge a participant had before the study. us,
participants were asked whether or not anyone they
know, including themselves, have ever found out
they had HPV. is was a dichotomous variable.
PROCEDURE AND ANALYSIS
In this pre/post within-subjects design, partici-
pants were given a scenario in which they were asked
to imagine that a close friend had been diagnosed
with HPV. en they were given the study measures.
e participants were then given the opportunity to
search the internet for information about HPV
1
.
When their searches were completed, they respond-
ed to a final set of measures.
Descriptive statistics for all of the study variables
were calculated and assumption checking was con-
ducted. e 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 vari-
ables 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 vari-
ables. 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 in-
dicated that all of our variables were appropriate for
our statistical tests (see Table 1 for descriptive statis-
tics), 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. is variable was corrected us-
ing a log transformation to improve the distribution
of the data (Tabachnick & Fidell, 2007).
Correct responses and dependent samples t-tests.
e percentages of correct responses indicated that
many of the participants held important misconcep-
tions about HPV before the search, including errors
in their knowledge about the mechanisms of trans-
mission, 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
1. ough 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.
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.
Hilpert, Carrion, Brem, Ciani & Ciani
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American Journal of Health Studies: 25(1) 2010
Table 2. Percent correct for HPV knowledge items and corresponding dependent samples t-test
Items
Before After
N % N % t df p
1.
HPV is spread by genital to genital contact (no
intercourse).
71 53.5 74 79.7 -3.41 70 0.00
2. HPV is spread by sharing bodily fluids. 72 48.6 73 52.1 -0.81 70 0.42
3.
More than 50% of people have at one time been
infected with HPV.
67 67.2 74 91.9 -4.31 66 0.00
4. Only women can be infected with HPV. 71 76.1 74 95.9 -3.56 70 0.00
5.
Most types of HPV infection can have high-risk
health effects.
71 47.9 74 67.6 -2.88 70 0.01
6.
Only a few types of HPV infection have high-
risk health effects.
69 65.2 74 83.8 -2.89 68 0.01
7. Some types of HPV do not cause cancer. 66 81.8 74 95.9 -3.06 65 0.00
8. All types of HPV can cause genital warts. 66 83.3 73 80.8 0.22 64 0.83
9.
If my partner had previously contracted HPV I
would be able to tell.
73 94.5 74 97.3 -0.82 72 0.42
10.
Many HPV infections will disappear without
causing physical symptoms.
70 68.6 73 87.7 -3.00 68 0.00
11.
Life threatening HPV infections do not have
symptoms that can be seen by the carrier.
67 62.7 74 75.7 -1.73 66 0.09
12.
ere is a vaccine that can prevent life
threatening types of HPV.
69 84.1 74 86.5 -0.30 68 0.77
13.
Condoms are a highly effective method for
preventing HPV.
70 28.6 73 37.0 -1.22 68 0.23
14.
e human immune system often destroys HPV
infections without medical treatment.
71 46.5 74 83.8 -5.89 70 0.00
15. Antibiotics are effective for treating HPV. 67 49.3 73 79.5 -5.04 66 0.00
16. A pap smear is an effective test for HPV. 68 73.5 74 82.4 -1.84 67 0.07
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.
symptoms that can be seen by the carrier, 5) con-
doms 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, depen-
dent samples t-tests provided no evidence that, over-
all, 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 meth-
ods of prevention, and 4) effective methods of test-
ing. However, these results do not look at differences
that may be present due to knowledge satisfaction,
values, prior exposure, or other demographic char-
acteristics.
Independent samples t-tests. Results of the inde-
pendent 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. ose 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.
e 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. e results of the correlational
analysis (see Table 4) indicated a number of signifi-
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cant relationships between the variables of interest.
Participant HPV knowledge satisfaction was signifi-
cantly and positively correlated with HPV knowledge
before and after the search, as well as significantly and
negatively correlated with the difference between the
two. us, the more satisfied participants were with
their knowledge, the more they knew at the begin-
ning 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. e 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
2
= .60, adjusted R
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. e
linear combination of moral values and HPV prior
knowledge was significant, F(2,71) = 20.35, p <
.001; R
2
= .58, adjusted R
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 pre-
dictors 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.
Table 3. Independent samples t-tests for study variables
t df p M
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.
Hilpert, Carrion, Brem, Ciani & Ciani
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American Journal of Health Studies: 25(1) 2010
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’ under-
standing 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. is
acknowledgment is therefore important when de-
signing interventions, engaging in community or-
ganization, 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 regard-
ing 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 car-
rier. 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’ per-
ception 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 be-
ing 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 signifi-
cantly more likely to have HPV misconceptions after
the search. ese authors argue that this is important
justification for preventative dissemination of accu-
rate HPV information.
Furthermore, females in the sample were sig-
nificantly more likely to respond accurately to HPV
knowledge questions both before and after the search.
ese results support previous findings (Doherty &
Graff Low, 2009; Gerend & Magliore, 2008) as well
as literature that suggests HPV is embedded in a gen-
dered 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 af-
fective 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) sug-
gests 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 con-
text 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) on-
cogenic strains can be detected by the carrier pro-
vides an ineffective model for HPV prevention. is,
coupled with the reliance on marriage as a strategy
for preventing HPV infection, could place young
adults at increased risk.
e 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.
ere 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 ac-
curate responses to HPV knowledge items; thus, our
sample lends to underestimating common miscon-
ceptions, and may not accurately portray male mis-
conceptions. Along similar lines, the small sample
size and the oversampling of women also warrants
caution in generalizing the results to male popula-
tions. Finally, the current study did not include fol-
low-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 sat-
isfaction, they should also consider the moral values
of students in planning interventions and interacting
with communities.
e United States has high rates of teenage preg-
nancy and sexually transmitted infection compared
to other western industrialized countries, and many
-49-
REFERENCES
Bailey, W., Young, M., Knickerbocker, C ., & Doan, T. A. (2002). Cautionary tale about conducting research
on abstinence education: How do state abstinence coordinators define “sexual activity?” American Journal
of Health Education, 33, 290-296, 2002.
Balog, J. E. (2009). e moral justification for a compulsory human papillomavirus vaccination program.
American Journal of Public Health, 99, 616-622.
Bersamin, M. M., Fisher, D. A., Walker, S., Hill, D. L., & Grube, J. W., (2007) Defining Virginity and
Abstinence: Adolescents’ Interpretations of Sexual Behaviors. Journal of Adolescent Health, 41, 182-
188.
Bogart, L. M., Cecil, H., Wagstaff, D. A., Pinkerton, S. D., & Abramson, P. R. (2000). Is it “sex”?: college
students’ interpretations of sexual behavior terminology. Journal of Sex Research, 37, 108 –116.
Brückner, H. & Bearman, P. (2005). After the promise: e STD consequences of adolescent virginity
pledges. Journal of Adolescent Health, 36, 271-278.
Burchell, A. N., Winer, R. L., Sanjose, S., & Franco, E. L., (2006). Chapter 6: Epidemiology and transmission
dynamics of genital HPV infection. Vaccine, 24S3, 52-61.
Centers for Disease Control and Prevention (2006). Sexually transmitted diseases treatment guidelines,
2006. MMWR, 55(No. RR-11), 1-93.
Chi, M. T. H., & Brem, S. K. (2009). Contrasting Ohlsson’s resubsumption theory with chi’s categorical
shift theory. Educational Psychologist, 44, 58-63.
Deci, E. L., & Ryan, R. M. (1985). Intrinsic motivation and self-determination in human behavior. New York:
Plenum.
Deci, E. L., & Ryan, R. M. (2000). e “what” and “why” of goal pursuits: Human needs and the self-
determination of behavior. Psychological Inquiry, 11, 227-268.
Deci, E. L., & Ryan, R. M. (1990). A motivational approach to self: Integration in personality. In R.
Dienstbier (Ed.), Nebraska symposium on motivation: Vol. 38. Perspectives on motivation (pp. 237-288).
Lincoln, NE: University of Nebraska Press.
Doherty, K., & Graff Low, K. (2008). e effects of a web-based intervention on college student knowledge
of human papillomavirus and attitudes toward vaccination. International Journal of Sexual Health, 20,
223-232.
Elders, M. J. (2008). Contraceptive Availability to Adolescents: Do American Values Violate Our Most
Vulnerable? Clinical Pharmacology & erapeutics, 84, 741–745.
Evans, E. M. (2001). Cognitive and contextual factors in the emergence of diverse belief systems: creation
versus evolution. Cognitive Psychology, 42, 217–66.
Ferlay, J., Bray, F., Pisani, P., & Parkin, D. M. (2001). Globocan 2000: cancer incidence, mortality and
prevalence worldwide, version 1.0. IARC CancerBase no. 5. Lyons, France: IARC Press.
Fox, S. (2005). Health Information Online. Pew Internet and American Life Project. Washington, DC:
1-16.
Gellene, D. (2006, June 9). e Nation; Cervical Cancer Vaccine Approved; e FDA OKs a drug that could
prevent a leading killer of women worldwide. But some fear the cost of the shots will be a deterrent. Los
Angeles Times. Retrieved March 14th , 2008, from http://www.latimes.com/
Gerend, M. A., & Magloire, Z. F. (2008). Awareness, Knowledge, and Beliefs about Human Papillomavirus
in a Racially Diverse Sample of Young Adults. Journal of Adolescent Health, 42, 237-242.
Gerend, M. A., Shepherd, J. E., & Monday, K. A. (2008). Behavioral frequency moderates the effects of
message framing on HPV vaccine acceptability. Annals of Behavioral Medicine, 35, 221–229.
sexual health experts believe our problems are exacer-
bated 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). e primary message has been character-
ized 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 in-
terfere with acquiring medically accurate informa-
tion 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 un-
derstand their detrimental health effects. Our results
support this conclusion, and extend it to autono-
mous searching for information on the internet.
Hilpert, Carrion, Brem, Ciani & Ciani
-50-
American Journal of Health Studies: 25(1) 2010
Gilman, M., Gilman, S. L., & Johns, M. M. III. (2009). Human papillomavirus, abstinence, and the other
risks. e Lancet, 373, 1420-1421.
Habel, M. A., Liddon, N., & Stryker, J. E., (2009). e HPV Vaccine: A content analysis of online news
stories. Journal of Women’s Health, 18, 401-407.
Hoff, T., Greene, L., & Davis, J. (2003). National survey of adolescents and young adults: Sexual health
knowledge, attitudes and experiences. Menlo Park, CA: Kaiser Family Foundation.
Hoffman, J. (2008, February 24). Vaccinating boys for girls’ sake? New York Times. Retrieved Feburary 27th,
2008, from http://www.nytimes.com/2008/02/24/fashion/24virus.html?pagewanted=1&_r=1
Horan, P. E, Phillips, J., & Hagan, N. E. (1998). e meaning of abstinence for college students. Journal of
HIV/AIDS Prevention &Education for Adolescents &Children, 2, 51-66.
Howell, M. & Keefe, M. (2007, July). e history of federal abstinence-only funding. Advocates for Youth.
Retrieved February, 27th, 2008 from, www.advocatesforyouth.org
Irvine, J. M. (2002). Talk about sex: e battles over sex education in the United States. Berkeley: University of
California Press.
Kahn, J. A., Rosenthal, S. L., Hamann, T., & Bernstein, D. I. (2003). Attitudes about human papillomavirus
vaccine in young women. International Journal of STD&AIDS, 14, 300–306.
Kaiser Family Foundation (Feburary, 2007). CDC Says Gardasil’s Side Effects Minor, Additional Warning
Labels Unnecessary. Medical News. Retrieved February, 27th, 2008 from http://www.medicalnewstoday.
com/articles/63651.php
Kirby, D. (2001). Emerging answers: Research findings on programs to reduce teen pregnancy (summary).
Washington, DC: National Campaign to Prevent Teen Pregnancy.
Kirby, D. (2007). Emerging answers: Research findings on programs to reduce teen pregnancy (summary).
Washington, DC: National Campaign to Prevent Teen Pregnancy.
Kohlberg, L. (1969). Stage and sequence: e cognitive-developmental approach to socialization. In D. A.
Goslin (Ed.), Handbook of socialization theory and research (pp. 347-480). Chicago: Rand McNally.
Kuhn, T. (1971). e structure of scientific revolutions (2nd ed.) Chicago: University of Chicago Press.
Levine, J. (2002). Harmful to minors: e perils of protecting children from sex. Minneapolis: University of
Minnesota Press.
Markowitz, L. E., Dunne, E. F., Saraiya, M., Lawson, H. W., Chesson, H., & Unger, E. R., (2007).
Quadrivalent Human Papillomavirus Vaccine: Recommendations of the Advisory Committee on
Immunization Practices (ACIP). Centers for Disease Control. Retrieved July, 1st, 2008 from http://
www.cdc.gov/mmwr/preview/mmwrhtml/rr5602a1.htm
Mathematica Policy Research, Inc. (2007, April). Impacts of for title 5, section 510 abstinence only education
programs: Final report. (MPR Reference No. 8549-110). Washington, DC: Trenholm, Christopher.
Merck Newsroom (2008, November 13). Merck’s Cervical Cancer Vaccine, Demonstrated Efficacy in
Preventing HPV-Related Disease in Males in Phase III Study. Merck. Retrieved July 5th, 2009 from,
http://www.merck.com/newsroom/press_releases/research_and_development/2008_1113.html
Munoz, N., Bosch, F. X., de Sanjose, S., Herrero, R., Castellsague, X, Shah, K. V., Snijders, P. F. J., & Meijer,
C. J. L. M., (2003). Epidemiologic classification of human papillomavirus types associated with cervical
cancer. New England Journal of Medicine, 348, 518-527.
Murphy, K. P, & Mason, L. (2006). Changing Knowledge and Beliefs. In P.A. Alexander & P. H. Winne (Eds.),
Handbook of Educational Psychology (pp. 369-390). Mahwah, NJ, Lawrence Erlbaum Associates.
National Commission for Health Education Credentialing (2008). Responsibilities and competencies
of health educators. Retrieved September 30th, 2009 from, http://www.nchec.org/credentialing/
responsibilities/
Ohlsson, S. (2009). Resubsumption: A possible Mechanism for Conceptual Change and Belief Revision.
Educational Psychologist, 44, 20-40.
Popper, K. (1959). e logic of scientific discovery. London: Hutchinson.
Posner, G. J., Strike, K. A., Hewson, P. W., & Gertzog, W. A. (1982). Accommodation of a scientific
conception: Toward a theory of conceptual change. Science Education, 66, 211-227.
Rojas, M., Schlecht, N., Nucci-Sack, A., Lorde-Rollins, E., Strickler, H., Burk, R., & Diaz, A. (2007)
Cervical, anal, and oral HPV among sexually active urban adolescent females. Journal of Adolescent
Health, 40, S9.
Ross, L., & Lepper, M. R. (1980). e perseverance of beliefs: Empirical and normative considerations. In R.
A. Shweder (Ed.), Fallible judgment in behavioral research: New directions for methodology of social and
behavioral science (Vol. 4, pp. 17-36). San Francisco: Jossey-Bass.
Ryan, R. M., & Deci, E. L. (2000). Intrinsic and external motivations: Classic definitions and new directions.
-51-
Contemporary Educational Psychology, 25, 54-67.
Sanders S. A., & Reinisch J. M., (1999). Would you say you had sex if? Journal of the American Medical
Association, 281, 275–277.
Sawyer, R. G., Howard, D. E., Brewster-Jordan, J., Gavin, M., & Sherman, M. (2007). “We didn’t have sex,
did we?” College students’ perceptions of abstinence. American Journal of Health Studies, 22, 46-55.
Schraw, G. (2006). Knowledge: Structures and Processes. In P.A. Alexander & P. H. Winne (Eds.), Handbook
of Educational Psychology (pp. 369-390). Mahwah, NJ, Lawrence Erlbaum Associates.
Sinatra, G. M., & Mason, L. (2009). Beyond knowledge: Learner characteristics influencing conceptual
change. In S. Vosniadou (Ed.), Handbook on conceptual change. Mahwah, NJ: Erlbaum.
Sinatra, G. M., Brem, S. K., & Evans, E. M. (2008). Changing minds? Implications of conceptual change for
teaching and learning about biological evolution. Evolution Education Outreach, 1, 189-195.
Springen, K. (2008, February 25). Why are HPV vaccine rates so low? Newsweek. Retrieved Feburary 27th,
2008, from http://www.newsweek.com/id/115329
Tabachnick, B. C., & Fidell, L. S. (2007). Using Multivariate Statistics. Pearson Education.
e FUTURE II Study Group (2007). Quadrivalent Vaccine against Human Papillomavirus to Prevent
High-Grade Cervical Lesions. New England Journal of Medicine, 356, 1915-1927.
Williams, G. C., & Deci, E. L. (1996). Internalization of biopsychosocial values by medical students: A test
of self-determination theory. Journal of Personality and Social Psychology, 70, 767-779.
Wind, R. (2008, May 20). Perception that teens frequently substitute oral sex for intercourse a myth: Oral
sex “epidemic” not supported by facts. Guttmacher Institute Media Center News Release. Retrieved
May 30th, 2008 from, http://www.guttmacher.org/media/nr/2008/05/20/index.html
Winer, R. L., Feng, Q., Hughes, J. P., O’Reilly, S., Kiviat, N. B., & Koutsky, L. A. (2008). Risk of Female
Human Papillomavirus Acquisition Associated with First Male Sex Partner. Journal of Infectious Disease,
197, 279-282.
Wisniewski, E. J., & Medin, D. L., (1094). On the interaction of theory and data in concept learning.
Cognitive Science: A Multidisciplinary Journal, 18, 221–281.
Young, M. (2004). What’s wrong with abstinence education? American Journal of Health Studies, 19, 148-
157.
Hilpert, Carrion, Brem, Ciani & Ciani
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