JOGNN
R E S E A R C H
Human Papillomavirus and Cervical
Cancer Knowledge, Health Beliefs, and
Preventative Practices in Older Women
Kymberlee Montgomery, Joan Rosen Bloch, Anand Bhattacharya, and Owen Montgomery
Correspondence ABSTRACT
Kymberlee Montgomery,
Objective: To explore knowledge of Human Papillomavirus (HPV) and cervical cancer, health beliefs, and preven-
DrNP, WHNP-BC, Drexel
tative practices in women 40 to 70 years.
University College of
Nursing & Health
Design: Cross-sectional descriptive.
Professions, 245 N. 15th
Setting: Three urban ambulatory Obstetrics and Gynecology offices connected with a teaching hospital s Depart-
Street, Bellet 1029,
Philadelphia, PA 19102.
ment of Obstetrics and Gynecology in the Mid-Atlantic section of the United States.
[e-mail]
Participants: A convenience sample of 149 women age 40 to 70.
Keywords Methods: To assess HPV and cervical cancer knowledge, health beliefs, and preventative practices a self-admin-
human papillomavirus
istered survey, the Awareness of HPV and Cervical Cancer Questionnaire was distributed to women as they waited for
HPV
their well-woman gynecologic exam.
cervical cancer
health beliefs Results: The mean knowledge score was 7.39 (SD 5 3.42) out of 15. One third of the questions about the rela-
preventative practices
tionship of HPV and risks for cervical cancer were answered incorrectly by more than 75% of these women. Although
most appreciate the seriousness of cervical cancer, they believed themselves not particularly susceptible.
Conclusion: There is a need for HPV and cervical cancer awareness and education for women older than age 40.
Women s health care professionals are well positioned to act as a catalyst to improve HPV and cervical cancer
knowledge, health beliefs, and preventative practice to ensure optimum health promotion for all women.
JOGNN, 39, 238-249; 2010. DOI: 10.1111/j.1552-6909.2010.01136.x
Accepted December 2009
enital Human Papillomavirus (HPV) infection Contrary to previous studies that demonstrate a de-
is the most common sexually transmitted dis- cline in HPV prevalence as women age, recent
G
ease in the United States (Centers for Disease evidence suggests HPV prevalence follows a
Kymberlee Montgomery, Control [CDC], 2009). Approximately 25 million bimodal distribution with a órst peak around age
DrNP, CRNP, is a certified
American women are currently infected with one or 20 years and a second smaller peak around age
women s health nurse
more strains of low risk (types 6 and 11) and/or high 40 to 50 years (Bosch & Harper, 2006; Chan et al.,
practitioner at Drexel
risk (types 16 and 18) HPV, while more than 6 million 2009; Ferreccio et al., 2004; Molano et al., 2002;
University College of
Medicine; the Women s
new infections are being reported every year (Dun- Munoz et al., 2004: Reis et al., 2006). It is not clear if
Health Nurse Practitioner
ne et al., 2007; Parkin, 2006). HPV infection is the the second peak around age 40 to 50 years is due
Program Track Coordinator
leading cause of cervical cancer (CDC). Recent ad- to new cases of HPV or HPV that was acquired
at Drexel University
College of Nursing and vances demonstrate that HPV, spread primarily many years before but not previously identióed. Yet
Health Professions; a nurse
through skin-to-skin contact during sexual activity, new incident cases at these years are certainly
colposcopist; and the
is the etiologic agent of genital warts and can be plausible. Fluctuations in relationship infrastructure
director of the
isolated in 99.7% of cervical cancer cases (Dunne with increased divorce rates and inódelity disclo-
transdisciplinary
colposcopy course at et al.; Munoz et al., 2002; World Health Organization, sures, and acceptance of nontraditional sexual
Drexel University,
2008). Cervical cancer is responsible for signiócant relationships place women at age 40 and older
Philadelphia, PA.
morbidity and mortality worldwide, including an es- at an increased risk of sexually transmitted dis-
timated 4,000 deaths in the United States in 2009 ease exposures (Baay et al., 2004; Castle et al.,
(Continued) alone (National Cancer Institute [NCI], 2008). 2005).
238 & 2010 AWHONN, the Association of Women s Health, Obstetric and Neonatal Nurses http://jognn.awhonn.org
Montgomery, K., Bloch, J. R., Bhattacharya, A. and Montgomery, O. R E S E A R C H
Previous research has demonstrated limited knowl-
Four out of five women who reach age 50 years will be
edge and health beliefs related to HPV in the
adolescent and college age populations (Baer, All- infected with HPV; 35% of women who die of cervical
cancer are older than age 65.
en, & Braun, 2000; Burak & Meyer,1997; Daley et al.,
2008; Dell, Chen, Ahmad, & Stewart, 2009; Fried-
man & Shepeard, 2007; Ingledue, Cottrell, & approved the órst vaccine to prevent HPV acquisi-
Bernard, 2004). However, despite emerging data tion and transmission for use in females age 9 to
showing every four out of óve women that reaches 26 years (CDC, 2009). After the Advisory Committee
50 years of age will be infected with HPV and that on Immunization Practices (ACIP) put forth vacci-
35% of women who die of cervical cancer are older nation recommendations in June of 2006, the CDC
than age 65 (CDC, 2009), women older than age 40 began a multilevel national health campaign to ed-
are rarely the focus of any initiatives on HPV and ucate the targeted population of women in the
cervical cancer awareness (Montgomery & Bloch, younger age group (Markowitz et al., 2007). In addi-
2010).The median age of diagnosis for cervical can- tion, the majority of cervical cancer cases and
cer is approximately 47 years ([7]CDC). It is possible deaths can be prevented through detection of pre-
that these women do not believe themselves at risk cancerous changes in the cervix by cytology using
of HPV infections and are less likely to practice pre- the Pap smear screening test.
ventive measures that can potentially minimize the
transmission of HPV infection and the development The American College of Obstetricians and Gyne-
of cervical cancer. In keeping with the goals of cologists (ACOG) (2009), the American Cancer
Healthy People 2010 (to help individuals of all ages Society (ACS) (2007), and the U.S. Preventive Ser-
increase life expectancy and improve quality of vices Task Force (USPSTF) (2007) have updated
life, as well as reduce the number of new cancer Pap smear guidelines. ACOG recommends that cer-
cases and illness, disability, and death caused by vical cancer screening should begin at age 21years
cancer) (U.S. Department of Health and Human (regardless of sexual history), because women
Services, 2000), it is essential to understand HPV younger than age 21 are at very low risk of cancer.
and cervical cancer knowledge needs of women In addition, ACOG advises Pap smears every 2
older than age 40. years for women between age 21 and 29 years and
every 3 years for women age 30 and older who
have had three consecutive negative cervical cy-
Background
tology screening test results and who have no
More than 100 HPV genotypes are currently known, high-risk Pap smear history. The ACS suggests that
and approximately 15 types of these potentially all women should begin cervical cancer testing 3
cause cervical cancer (Gerberding, 2004; Roden years after they start having sex (vaginal inter-
& Wu, 2006). Genotypes 16, 18, 31, and 45 are re- course). A woman who waits until she is older than
sponsible for almost 80% of cervical cancer cases age 18 to have sex should start screening no later
worldwide, with genotype 16 accounting for almost than age 21. The USPSTF continues to recommend
50% of these cases (CliĄord et al., 2006). Numer- a conventional Pap test at least every 3 years, re- Joan Rosen Bloch, PhD,
CRNP, is an assistant
ous studies indicate that more than 90% of all HPV gardless of age. These three organizations agree
professor in the doctoral
infections in women clear within the órst 2 years of that co-testing using the combination of cytology
Nursing Department in the
exposure (Gerberding Scheurer, Tortolero-Luna, & plus HPV DNA testing is an appropriate screening College of Nursing and
Health Professions and in
Alder-Storthz, 2005; SchiĄman & Kjaer, 2003). test for women older than age 30 years.
the Department of
However, when the clearance of the virus is incom-
Epidemiology in the School
plete, HPV can progress to precancerous lesions Since the inception of these campaigns and new
of Public Health at Drexel
and cervical cancer (Koutsky et al., 2002; Jeurissen Pap smear screening recommendations, aware- University, Philadelphia,
PA.
& Makar, 2009; SchiĄman & Kjaer). ness of HPV improved in women age 18 to 26 years
but remains decreased in women age 27 to 49 years
Anand Bhattacharya, MHS,
Acquisition of HPV infection of the genital tract usu- (Jain et al., 2009). There is a persistent HPV and cer- is a research associate at
Drexel University s College
ally occurs rapidly after sexual debut (Skinner et al., vical cancer knowledge gap of women older than
of Medicine, Philadelphia,
2008). Winer et al. (2003) showed a cumulative inci- age 26. Pairing this gap with the emerging evidence
PA.
dence of HPV infection of about 40% in women of a second peak in HPV prevalence in older wo-
after órst sexual intercourse or after sexual intimacy men where the preponderance risk of cervical Owen Montgomery, MD, is
the chairman of the
with a new partner. Hence primary prevention strat- cancer resides generates the compelling reason
Department of Obstetrics
egies in the preadolescent stage prior to HPV for investigating HPV and cervical cancer knowl-
and Gynecology at Drexel
exposure are optimal in eradicating cervical can- edge, health beliefs, and preventative practices in
University College of
Medicine, Philadelphia, PA.
cer. In 2006, the Food and Drug Administration women older than age 40 years.
JOGNN 2010; Vol. 39, Issue 3 239
R E S E A R C H Human Papillomavirus and Cervical Cancer Knowledge
Theoretical Framework found that among the general public, few women
are aware that an STI potentially causes cervical
This study was guided by the health belief model
cancer.
(HBM). There are óve core concepts: perceived
threat, perceived beneóts, perceived barriers, cues
The purpose of this exploratory descriptive study
to action, and self-eD cacy (Rosenstock, Strecher,
was to describe knowledge of HPV and cervical
& Becker, 1994; Strecher & Rosenstock, 1997). The
HBM has been previously used to explain and pre- cancer, health beliefs, and preventative practices
of women age 40 to 70 years. In addition, the study
dict health behaviors and health issues by focusing
on the knowledge, attitudes, and beliefs of individu- explored the relationships among knowledge of
HPV and cervical cancer and self-reported health
als. As suggested by theories based on the HBM
(Strecher & Rosenstock), the likelihood that individ- beliefs among women age 40 to 70 years.
uals will take action to prevent illness depends on
their perception that they are personally vulnerable
Methods
to the condition, the consequences of the condition
Design
would be serious, the precautionary behavior
This study was a cross-sectional descriptive de-
eĄectively prevents the condition, and the beneóts
sign. Anonymous data were collected over a 2-
of reducing the threat of the condition exceed
month period in 2008 using a self-administered
the costs of taking action (Redding, Rossi, Rossi,
pen-and-paper questionnaire.
Velicer, & Proschaska, 2000; Weistock et al., 2004).
Clinicians need to appreciate and understand their
Setting and Sample
patients health beliefs, especially in women age 40
A convenience sample of women age 40 to 70 years
and older who have not been the targets of the mar-
was recruited from the waiting rooms of three am-
keting information about HPV, cervical cancer, and
bulatory obstetrics and gynecology oD ces of a
the new vaccine.
large metropolitan university hospital in the Mid-At-
lantic section of the United States. All three oD ces
Previous Studies of HPV
were used in an attempt to get a racially heteroge-
Knowledge
neous sample in this urban area that has rate of
Knowledge related to HPV, its relationship to cervi- cervical cancer 1.7 times higher than the national
cal cancer, and cervical cancer itself is improving rate (NCI, 2008). The inclusion criteria were women
but continues to have deócits in younger and age 40 to 70 years, presenting to their health care
older women (Denny-Smith, Bairan, & Page, 2006; provider for an annual checkup, and who did not
Holcomb, 2004; Ingledue et al., 2004; Montgomery have a past or present history of HPV or cervical
& Bloch, 2010; Jain et al., 2009). In the Denny-Smith cancer.
et al. study, the Awareness of HPV and Cervical
Cancer tool was distributed to a convenience The sample size required for this study was guided
sample of 240 female nursing students, age 19 to by a power analysis using the software program
58 years with a mean age of 30 (SD 5 8.48) enrolled G Power (Version 3.0.10, Dusseldorf, Germany).
in a baccalaureate nursing program. The results The power analysis was based on the correlation
indicated a lack of knowledge combined with analysis between the subscales knowledge, sus-
low perceptions of susceptibility and seriousness ceptibility, and seriousness. Small to medium eĄect
of HPV and cervical cancer may make college size (Pearson s r 5 0.23) was postulated in keeping
women more likely to contract sexually transmitted with Cohen s (1992) recommendation for Pearson
infections (STIs) including HPV and therefore more correlation. Power was set to 0.80, meaning there
susceptible to cervical cancer. Numerous recent would be an 80% probability of reaching statistical
studies that examined public knowledge of HPV signiócance if the subscales were correlated. In
and this link to cervical cancer agree that public this study, for a signiócance level of a 5 0.05
awareness of HPV s connection to cervical cancer (two tailed), with an eĄect size of 0.23, to achieve
remains suboptimal (CDC, 2009; National Associa- a power of 0.80, a total sample size of 145 partici-
tion of Nurse Practitioners in Women s Health pants were required. To account for attrition due to
[NPWH][27][35][38], 2009; Sherris et al., 2006; missing data, we recruited an additional 10% for a
Vanslyke, Baum, Plaza, Otero, & Wheeler, 2008). total sample of 160. Out of 160 women who received
The most recent survey from the NPWH suggests study packets, 149 completed questionnaires that
that women still do not have a clear understand- were returned in the sealed envelopes; 11 question-
ing about the relationship between HPV and naires were incomplete and not used in these
cervical cancer. Marlow, Waller, and Wardle (2009) analyses.
240 JOGNN, 39, 238-249; 2010. DOI: 10.1111/j.1552-6909.2010.01136.x http://jognn.awhonn.org
Montgomery, K., Bloch, J. R., Bhattacharya, A. and Montgomery, O. R E S E A R C H
Procedure onstrated by subsequent studies that used the
Following approval by the university Institution Re- questionnaire on women from other age groups
view Board (IRB), the study began by training a (Denny-Smith et al., 2006). Using the same tool
research assistant (RA; receptionist) at each of the allowed comparison of results from this study to
three oD ces.The training entailed using data on the other published studies (Denny-Smith et al.; Ingle-
practice management program to identify potential due et al; McKeever, 2008).
eligible participants when women are checked in
for their visits, inviting potential participants, and The knowledge portion of the questionnaire con-
keeping all data anonymous by sealing all enve- sists of 15 multiple-choice items, with each
lopes and placing them in the research bin in a question permitting only one response. The knowl-
secured drawer or cabinet based on the specióc of- edge score for this instrument ranges from 0 to 15
óce. At each of the three sites, there were Łyers with higher scores indicative of more knowledge of
posted on the walls and a trained RA invited partic- HPV and cervical cancer. The perceived threat por-
ipants if they met eligibility. If the patient met the two tion of cervical cancer consists of 15 questions,
requirements of age and the reason for the visit using a 5-point Likert-type scale ranging from 1
(well-women check up), she was given a sheet to (strongly agree) to 5 (strongly disagree). Nine of
read to further determine eligibility (exclusion crite- the 15 questions relate to perceived susceptibility
ria if she had a history of HPV or cervical cancer). and have a possible subtotal score range from 9 to
After she read the sheet, the RA asked if she was el- 45. The remaining six questions relate to perceived
igible. If she said yes, she was given the survey seriousness and have a potential score that ranges
packet with a cover letter that accompanied the from 6 to 30. Higher scores imply greater level of
packet. The cover letter contained a brief descrip- perceived susceptibility and seriousness about
tion of the research project, assurance of HPV and cervical cancer. The last six questions fo-
anonymity, the voluntary nature of participation, cus on individual sexual behaviors, risk factors,
and IRB contact information. Completion of the sur- and history of pap smears and are multiple-choices
vey acted as consent for participation. Once the categorical variables.
survey was completed, it was placed in a sealed en-
velope to be returned to the researcher such that no Ingledue et al. (2004) supported content validity of
identity was disclosed. the instrument by using consensual validity via a
panel of experts that represented several health
professionals including two gynecologists, two pro-
Measures
fessors of health education, and a medical
Sociodemographic variables collected included
professional from the Breast and Cervical Cancer
age, race, education, health insurance status, relig-
program (Ingledue et al.). The authors also deter-
ious aD liation, marital status, and income level.
mined stability of the instrument over a 10-day
period through test^retest reliability procedure.
HPV and Cervical Cancer Knowledge, They reported that the instrument has high test^re-
Health Beliefs, and Preventative Practices test reliability for knowledge (r 5 0.90), perceptions
With permission from the authors, the Awareness of and beliefs (r 5 0.95), and preventative behaviors
HPV and Cervical Cancer Questionnaire (Ingledue (r 5 0.90) (Ingledue et al.). Internal consistency reli-
et al., 2004) was used to measure knowledge and ability was not reported in the study by Ingledue et
beliefs, as well as preventative measures in regards al. For the current study, the internal consistency re-
to HPV and cervical cancer. Ingledue et al. devel- liability for the Knowledge subscale was adequate
oped this self-administered 36-item questionnaire (Cronbach s a 5 0.77), but unacceptably low for
based on the HBM (Glanz, Rimer, & Lewis, 2002) to the Susceptibility subscale (a 5 0.49) and Serious-
investigate HPV/cervical cancer knowledge, health ness subscale (a 5 0.20). This low reliability makes
beliefs, and perception, and preventative measures any conclusions based on these subscales tenta-
in college-age women. The tool was used in this tive at best. Quantitative data were coded and
study because it was speciócally designed for HPV entered into SPSS-PC 16.0 (SPSS Inc, Chicago, IL)
and cervical cancer awareness and congruent and stored on a secured computer used for re-
to the HBM that guided the study. Although search purposes only. Descriptive statistics
the questionnaire was originally used on college including frequencies for categorical variables and
age women, a panel of experts (obstetricians/gyne- measures of central tendency (M) and variances
cologists, physicians, and nurse practitioners) (SD) for continuous variables were used to describe
reviewed the questions concluding they were the HPV/cervical cancer knowledge, health beliefs,
generalizable to women of all age groups as dem- and preventative practices in women age 40 to 70
JOGNN 2010; Vol. 39, Issue 3 241
R E S E A R C H Human Papillomavirus and Cervical Cancer Knowledge
years. Pearson product^moment correlations were
Table 1: SocioDemographic
calculated to describe the relationship among
Characteristics of the Sample (N 5 149)
HPV/cervical cancer knowledge, susceptibility,
and seriousness in these women.
SocioDemographic
Characteristics Mean (SD)
To further understand knowledge, health beliefs
Age�mean (SD) 50.86 (7.6)
(perceived susceptibility and perceived serious-
ness) and preventative practices in women age 40
Sexual partners�mean (SD) 1.45 (1.4)
to 70, these women were divided into age groups
Race/ethnicity n (%)
by decade: 40 to 50, 51to 60, and 61 to 70 years. Fol-
White (Caucasian/ 92 (61.7)
lowing testing for assumptions, a one-way analysis
of variance (ANOVA) was conducted to compare Non-Hispanic)
knowledge and health beliefs among the three sub-
African American/ 37 (24.8)
groups. If the ANOVAs were signiócant, post hoc
Non-Hispanic
analyses were conducted using a Bonferroni ad-
Asian/Hawaiian/Pacióc 6 (4)
justment. Preventative practices were compared
Islander
among the three subgroups using the chi-square
analysis. A Fishers Exact test was used when as-
Hispanic/Latino 9 (6)
sumptions of chi-square were not met. Level of
Other 5 (3.4)
signiócance for all tests were set at a 5 0.05.
Education
Results
High School graduate 38 (25.5)
Sample Characteristics
Some college courses 43 (28.8)
The sociodemographics of the participants are de-
College graduate 64 (43)
tailed inTable 1. The average age of the sample was
50.86 (SD 5 7.60) years old. Of the 149 women, one
Other 3 (2)
half reported being married (n 5 75), more than
Missing 1 (0.7)
80% had private health insurance (n 5126) and
more than 30% (n 5 47) had an annual household
Marital status
income of $80,000 and more.
Single 30 (20.1)
Knowledge Married 75 (50.3)
The mean score for knowledge, measured by the 15
Widowed 7 (4.7)
items on the Awareness of HPV and Cervical Cancer
Divorced 24 (16.1)
Questionnaire was 7.39 (SD 5 3.42) out of a possible
15.Table 2 represents the frequency of correct and in-
Living w/signiócant other 12 (8.1)
correct responses for each item of the Knowledge
Missing 1 (0.7)
subscale of the Awareness of HPV and Cervical
Cancer Questionnaire. It should be noted that more
Religion
than one half of the women responded incorrectly
Christian 41 (27.5)
to knowledge questions 1, 2, 3,10,12, and 15.
Catholic 65 (43.6)
Health Beliefs
Jewish 18 (12.1)
Health beliefs were measured under the subdimen-
sions of perceived threat: perceived susceptibility Muslim 2 (1.3)
and perceived seriousness. For susceptibility, mea-
Other 22 (14.8)
sured by nine items on the Awareness of HPV and
Missing 1 (0.7)
Cervical Cancer Questionnaire (Ingledue et al.,
2004) the mean score was 26.11 (SD 5 4.64) out of
Income level
a possible 45, and ranged from 18 to 44.Table 3 rep-
0 to 20k 10 (7.0)
resents the frequency and percentage of responses
for each item for susceptibility in the questionnaire.
21 to 40k 20 (13.4)
More than 50% of women in this age group report-
41 to 60k 37 (24.8)
edly worry about getting cervical cancer, however
just more than 32% are concerned about being in- 61 to 80k 24 (16.2)
242 JOGNN, 39, 238-249; 2010. DOI: 10.1111/j.1552-6909.2010.01136.x http://jognn.awhonn.org
Montgomery, K., Bloch, J. R., Bhattacharya, A. and Montgomery, O. R E S E A R C H
reportedly believe that they have the ability to avoid
Table 1. Continued
getting a HPV infection, with another 50% believ-
SocioDemographic
ing that they can control whether they get cervical
Characteristics Mean (SD)
cancer.
80k or more 47 (31.6)
Similarly, the mean score for seriousness, mea-
Missing 10 (7.0)
sured by six items from the health belief subscale
Health insurance n (%)
from the same instrument was 19.73 (SD 5 2.87).
Scores ranged between 13 and 29. Details of fre-
Private 126 (84.6)
quencies and percentage responses for items
Public funded 13 (8.6)
measuring seriousness are presented in Table 4.
No health insurance 4 (2.7) Approximately 33% of women view cervical cancer
as the most serious disease they could possibly
Unsure 4 (2.7)
acquire and one that is life threatening. More than
Missing 2 (1.4)
60% incorrectly believe that HPV is curable.
fected with HPV. Furthermore, only 23% consider
Preventative Practices
themselves at risk for developing cervical cancer,
Preventative practice behavior was proóled using
while a mere 13% perceive themselves at risk of ac-
six questions. A summary of frequencies for re-
quiring HPV. More than 62% of the women
sponses to each question is presented in Table 5. A
majority of the women (n 5100, 67.1%) reported
Table 2: Frequency of Correct Responses
being active in a sexual relationship at the time of
for Multiple Choice Questions Regarding
participation. Just more than one half of the women
HPV/Cervical Cancer Knowledge in
(n 5 78, 58.4) reported never using condoms. In ad-
Women Age 40 to 70 Years (N 5 149)
dition, 84.5% (n 5126) of the women revealed they
do not use any oral contraceptives. The majority of
Question Correct
women (n 5118, 79.2%) polled were nonsmokers
Multiple choice n (%)
with only 65.1% (n 5 97) of them receiving a Pap
1. The virus associated with cervical cancer is 66 (44.3)
smear test within the past year. Finally, almost three
transmitted by:
out of every four women answered that they were
unaware of a family member who had been previ-
2. Cervical cancer and pre cancer cells are 40 (26.8)
ously diagnosed with HPV or cervical cancer. Table
associated with the presence of:
5 depicts preventative practices in women age 40 to
3. Cervical cancer can be diagnosed by: 32 (21.5)
70 years classióed into three subgroups (40^50, 51^
60, and 61^70 years).
4. Prevention of cervical cancer may require: 84 (56.6)
5. HPV can cause: 98 (65.8)
Table 6 represents the Pearson product^moment
6. HPV can live in the skin without causing growths 82 (55.8) correlation (r) among knowledge, susceptibility
or changes: and seriousness. There was little, if any (r 5 0.06)
to low (r 5 0.38) positive relationship among knowl-
Risk factors (yes or no)
edge, susceptibility, and seriousness in women age
7. Multiple sex partners 100 (67.1)
40 to 70 years (Portney & Watkins, 2010). Although
the correlation coeD cient was signiócant between
8. Having genital warts 76 (51.7)
knowledge and seriousness (r 5 0.38, p .001),
9. Sexual intercourse before 18 75 (50.3)
the strength of the relationship was not. Caution in-
terpreting this relationship is warranted because
10. Taking illegal drugs 27 (18.1)
the subscale to measure seriousness in this popu-
11. Having contracted any STIs 85 (57.8)
lation had very low internal consistency reliability.
12. Smoking cigarettes 33 (22.3)
Subgroup Analysis
13. Poor diet or nutrition 79 (53.4)
Table 7 presents the mean (SD) for knowledge, sus-
14. Using tampons 101 (67.8)
ceptibility, and seriousness and the results from the
ANOVA. The data met the assumptions of normal
15. Use of oral contraceptives (birth control pills) 13 (8.8)
distribution and homogeneity of variances be-
Note. Items from HPV Questionnaire (Ingledue et al., 2004).
tween the groups. Signiócant diĄerences were
JOGNN 2010; Vol. 39, Issue 3 243
R E S E A R C H Human Papillomavirus and Cervical Cancer Knowledge
Table 3: Likert-Type Scale Responses for Susceptibility Items
Strongly Strongly
Question Disagree, Disagree, Neutral, Agree, Agree,
Number Question (Responses) n (%) n (%) n (%) n (%) n (%)
16 I worry about getting cervical cancer. 16 (10.7) 25 (16.8) 33 (22.1) 46 (30.9) 29 (19.5)
17 I worry about getting HPV. 25 (16.8) 36 (24.2) 40 (26.8) 28 (18.8) 20 (13.4)
18 I believe that I am at risk for developing cervical 25 (16.8) 46 (30.9) 41 (27.5) 29 (19.5) 7 (4.70)
cancer.
19 I believe I am at risk for contracting HPV. 34 (22.8) 51 (34.2) 45 (30.2) 12 (8.1) 7 (4.7)
20 All women have an equal chance of developing 29 (19.5) 42 (28.2) 27 (18.1) 39 (26.2) 12 (8.1)
cervical cancer, it is beyond my control.
21 My chances of getting HPV are high. 34 (22.8) 56 (37.6) 43 (28.9) 10 (6.7) 5 (3.4)
22 My chances of getting HPV are low. 7 (4.7) 26 (17.4) 39 (26.2) 45 (30.2) 31 (20.8)
23 I have the ability to avoid cervical cancer. 7 (4.7) 37 (24.8) 36 (24.3) 45 (30.2) 24 (16.1)
24 I have the ability to avoid HPV infection. 9 (6.0) 20 (13.4) 26 (17.4) 60 (40.3) 33 (22.1)
Note. Items from HPV Questionnaire (Ingledue et al., 2004).
noted between the three subgroups (age 40^50, and 61^70 years) are presented in Table 5. Chi-
51^60, 61^70 years) for seriousness scores only, square/Fisher s Exact analysis revealed signiócant
F(2,146) 5 4.14, p 5 .02; but not for knowledge, diĄerences in distribution of practice choices be-
F(2,146) 5 0.634, p 5 .53; and susceptibility, tween the three subgroups for   use of condoms, 
F(2,146) 5 2.92, p 5 .06. Post hoc analysis using w2(10, N 5148) 5 18.93, p 5 .02 and   use of oral
the Bonferroni adjustment revealed that the 61 to contraceptives  w2(4, N 5148) 5 16.90, p 5 .001
70 years age group had signiócantly less percep- only, but not for   sexual experience,  w2(4,
tion of seriousness compared to the 51 to 60 year N 5148) 5 7.81, p 5 .10,   cigarette smoking,  w2(2,
(p 5 .02) and 40 to 50 years age groups (p 5 .05). N 5148) 5 1.16, p 5 .58, and   Pap smear test,  w2(4,
N 5148) 5 0.90, p 5 .97. As evident from Table 5,
Preventative practices in women age 40 to 70 years most women age 51 to 60 years (68%) and age
classióed into the three subgroups (40^50, 51^60, 61 to 70 years (83.3%) indicated they did not use
Table 4: Likert-Type Scale Responses of Seriousness
Strongly Strongly
Question Disagree, Disagree, Neutral, Agree, Agree,
Number Question n (%) n (%) n (%) n (%) n (%)
25 All women who develop cervical cancer must 31 (20.8) 56 (37.6) 41 (27.5) 15 (10.1) 3 (2.0)
have their uterus removed.
26 Among the diseases that I can imagine getting, 24 (16.1) 55 (36.9) 21 (14.1) 32 (21.5) 16 (10.7)
cancer of the cervix is the most serious.
27 I believe HPV is curable with proper medical 10 (6.7) 16 (10.7) 32 (21.5) 73 (49.0) 17 (11.4)
treatment.
28 Cervical cancer is often curable with early 1 (.7) 9 (6.0) 17 (11.4) 80 (53.7) 42 (28.2)
detection and proper medical treatment.
29 HPV is a life-threatening disease. 7 (4.7) 52 (34.9) 38 (25.5) 32 (21.5) 18 (12.1)
30 No one dies anymore from cervical cancer. 49 (32.9) 62 (41.6) 21 (14.1) 12 (8.1) 4 (2.7)
Note. Items from HPV Questionnaire (Ingledue et al., 2004).
244 JOGNN, 39, 238-249; 2010. DOI: 10.1111/j.1552-6909.2010.01136.x http://jognn.awhonn.org
Montgomery, K., Bloch, J. R., Bhattacharya, A. and Montgomery, O. R E S E A R C H
Table 5: Responses to Preventative Practices Characterized by Age (40 50, 51 60, and
61 70 Years of Age)
Total Sample Group 1 Group 2 Group 3
(Age 40 70) (Age 40 50) (Age 51 60) (Age 61 70)
N 5149 N 5 73 N 5 58 N 5 18
Preventative Practices 100% 49% 39% 12%
Sexual experience: n (%)
Currently involved 100 (67.1) 56 (76.7) 33 (56.9) 11 (61.1)
Not currently involved 46 (30.8) 17 (23.3) 22 (37.9) 7 (38.9)
Never had sexual intercourse 2 (1.4) 0 2 (3.4) 0
Missing 1 (0.7)
Use of condoms: n (%)
Always 11 (7.4) 7 (9.6) 4 (6.9) 0
Usually 16 (10.7) 11 (15.1) 5 (8.6) 0
Sometimes 15 (10.1) 11 (15.1) 4 (6.9) 0
Occasionally 7 (4.7) 6 (8.2) 0 1 (5.5)
Rarely 11 (7.4) 4 (5.5) 5 (8.6) 2 (11.1)
Never 87 (58.4) 33 (45.2) 39 (67.2) 15 (83.3)
Missing 2 (1.3)
Use of oral contraceptives: n (%)
Yes 19 (12.8) 17 (23.3) 1 (1.7) 1 (5.5)
No 126 (84.5) 53 (72.6) 56 (96.5) 17 (94.4)
Don t know 1 (0.7) 1 (1.4) 0 0
Missing 3 (2.0)
Cigarette smoking: n (%)
Yes 30 (20.1) 17 (23.2) 9 (15.5) 4 (22.22)
No 118 (79.2) 56 (76.7) 48 (82.7) 14 (77.8)
Missing 1 (0.7)
Pap smear: n (%)
Never 2 (1.40) 1 (1.36) 1 (1.72) 0
Within the past year 97 (65.10) 49 (67.12) 36 (62.06) 12 (66.7)
Had one but not within past year 47 (31.50) 22 (30.13) 19 (32.75) 6 (33.33)
Missing 3 (2.00)
Family member diagnosed with HPV: n (%)
Yes 22 (14.8) 14 (19.1) 7 (12.1) 1 (5.5)
No 108 (72.5) 52 (71.2) 43 (74.1) 13 (72.2)
Don t know 16 (10.7) 7 (9.6) 5 (8.6) 4 (22.22)
Missing 3 (2.0)
Note. Items from HPV Questionnaire (Ingledue et al., 2004).
JOGNN 2010; Vol. 39, Issue 3 245
R E S E A R C H Human Papillomavirus and Cervical Cancer Knowledge
cancer that are associated with sexual behavior
More than 75% of the women answered one third of the
and sexually transmitted diseases (multiple sex
knowledge questions about the relationship of HPV and
partners, having STIs, having genital warts, and
risks for cervical cancer incorrectly.
sexual intercourse before age 18). However, these
women were unable to identify nonreproductive
system risk factors for cervical cancer (cigarette
smoking, use of illegal drugs, and use of oral con-
Table 6: Pearson Correlations Among
traception). Generally, the participants in the group
Scores of Knowledge, Susceptibility, and
exhibited health-conscious behavior. The majority
Seriousness
of the women had a Pap smear within the last year,
do not smoke, and are seeing their provider for a
Variable (N 5 149) Susceptibility Seriousness
well-woman annual exam.
Knowledge .06 .38
Susceptibility � .15
Regardless of their current marital status, the ma-
jority of this group does not use condoms. Almost
po.001.
60% of women in this age group are married or liv-
ing with their signiócant other and the majority of
condoms during sexual activity. In contrast, less
the group had only one sexual partner in the last 5
than one half (45.2%) of women age 40 to 50 years
years. Most acknowledge HPV as a STI but did not
selected never using condoms. The use of oral con-
associate HPV with cervical cancer (see Table 5).
traceptives was also less prevalent in the women
Likewise, the majority seemed unworried or per-
age 61 to 70 years (5.6%) and 51 to 60 years
ceived themselves at low risk for acquiring HPV.
(1.7%) compared to those age 40 to 50 years
These women believe that cervical cancer is seri-
(23.3%).
ous but curable with early detection and medical
treatment. However, a majority of this group incor-
Discussion rectly believed that HPV infection is curable with
proper medical treatment, and only one third
Women age 40 to 70 years participating in this
thought that the condition is life threatening. The
study demonstrated low-level knowledge of HPV
signiócant correlation between knowledge and
and cervical cancer with more than one half of them
responding incorrectly to around 50% of the ques- perceived seriousness revealed that the less
knowledge women had regarding HPV and cervical
tions regarding knowledge of cervical cancer/HPV.
cancer, the less they perceived the seriousness of
One third of the questions about the relationship of
HPV and risks for cervical cancer were answered in- their risk for cervical cancer. With insuD cient
knowledge and understanding of the pathophysiol-
correctly by more than 75% of these women. As
evident from Table 2, most women in the study ex- ogy of HPV and cervical cancer these women
remained worried about cervical cancer de-
hibited awareness that HPV is a sexually
spite the fact that they were not worried about its
transmitted disease that could potentially cause
genital warts. They were however unaware of its re- precursor.
lationship to cervical cancer, its diagnosis, and the
clinical manifestations from the disease. As evident Much of the knowledge associating HPV with cervi-
in Table 3, more than one half of the respondents cal cancer has evolved within the past decade.
were able to correctly identify risk factors of cervical Moreover, despite the extensive public educational
Table 7: Means and Standard Deviations Comparing Three Subgroups of Women Age 40
to 50, 51 to 60, and 61 to 70 Years for Knowledge, Susceptibility, and Seriousness
Scores
Knowledge Susceptibility Seriousness
Group N
Mean (SD) p Value Mean (SD) p Value Mean (SD) p Value
40 to 50 years 73 7.27 (3.31) .53 27.01 (4.58) .06 19.81 (2.92) .02
51 to 60 years 58 7.74 (3.62) 25.38 (4.36) 20.17 (2.60)
61 to 70 years 18 6.77 (3.28) 24.77 (5.24) 18.00 (3.05)
246 JOGNN, 39, 238-249; 2010. DOI: 10.1111/j.1552-6909.2010.01136.x http://jognn.awhonn.org
Montgomery, K., Bloch, J. R., Bhattacharya, A. and Montgomery, O. R E S E A R C H
campaigns through media and educational
websites sponsored by reputable government orga- Nurses need to be aware that HPV and cervical cancer
are not just diseases infecting young women as portrayed
nizations such as the CDC and the Food and Drug
in the media.
Administration, and major international pharma-
ceutical companies over the past 5 years (CDC,
2009), women age 40 to 70 years continue to pos-
sess an inadequate knowledge base regarding
revised for this age group, such as the question re-
HPV and cervical cancer compared to women from
garding yearly Pap smears. Practice guidelines
the original study by Ingledue et al. (2004) using
have been revised and Pap smear frequency for
this tool.
women not at high risk for cervical cancer is every
3 years (U.S. Census Bureau, 2000). Moreover, inter-
In clinical practice, new technology enables health
nal reliability for the subscales of seriousness and
care providers to appropriately stratify individuals
susceptibility were poor for this study. In women
perception of their susceptibility to cervical cancer.
older than age 40, the poor reliability may reŁect
The current American Society of Colposcopy and
that the subscales of seriousness and susceptibility
Cervical Pathology (2006) guidelines encourages
are actually measuring two dimensions: their health
practitioners to reassure women that they are less
beliefs about cervical cancer and their health be-
susceptible to cervical cancer if they test negative
liefs about HPV (see Tables 3 and 4). Because this
for high-risk HPV DNA and to appropriately identify
population has an inadequate knowledge of the re-
the subset of women in this group who are at an in-
lationship between HPV and cervical cancer, this
creased susceptibility for cervical cancer.
may be driving the poor reliability. The items in this
subscale may need to be revised to better represent
the construct of seriousness and susceptibility.
Limitations
However, for the exploratory nature of this study,
The óndings of this study should be interpreted in
using an existing tool with published data on HPV
light of the several existing limitations. Participants
knowledge and health beliefs adds strength to the
were primarily White, educated, and not of low in-
óndings.
come. Consequently the óndings may not be
generalized to other populations, especially urban
socioeconomically disadvantaged populations of
Clinical Implications
women of this age group. Secondly, this study relied
Pap smear screening has been one of the most suc-
on self-report with no attempt to independently ver-
cessful public health interventions for cervical
ify respondents information. In addition, although
cancer screening and prevention of the 20th cen-
this study used an anonymous questionnaire, limi-
tury (Markowitz et al., 2007). Only recently, in the
tations of a survey study may apply. Surveys
21st century, it has evolved into HPV screening and
provide only real-time descriptions of behaviors
diagnosis. Nurses need to be aware of the clinical
and feelings of the respondents and responses
implications for women of this particular age group.
cannot always be taken as accurate descriptions
The óndings of this study reveal obvious inconsis-
of what the respondents actually do or really feel.
tencies and gaps in the knowledge, health beliefs,
This is true particularly for behavior that is contrary
and preventative practices regarding HPV and cer-
to generally accepted norms of society, such as in-
vical cancer in women age 40 to 70 years. Are they
formation regarding sexual activity (Zia, 2000).
adequately informed that their   routine Pap smear 
Some of these women may have been unwilling to
also screens for HPV? Are they prepared to under-
indicate that they have engaged in controversial
stand what it means when they are told they have
behaviors, thus resulting in social desirability bias.
HPV? Nurses and doctors must be prepared to ex-
Although most women appreciated the seriousness
plain the new consensus guidelines, if and why
of cervical cancer, they believed themselves not
they may have a HPV test, and especially the mean-
particularly susceptible. However, data were anon-
ing of a positive test. A focus-tailored approach to
ymous and could not be verióed by medical records
appropriate educational and counseling is needed.
to validate their perceived HPV status and risk for
cervical cancer.
Implications for Future Research
Data collected were limited to the items contained in Development of Ingledue s tool is warranted to fur-
the Awareness of HPV and Cervical Cancer Ques- ther advance understandings of how knowledge,
tionnaire (Ingledue et al., 2004). Although the tool health beliefs, and preventive practices interact
was developed 5 years ago, some items need to be in all women, especially in populations with high
JOGNN 2010; Vol. 39, Issue 3 247
R E S E A R C H Human Papillomavirus and Cervical Cancer Knowledge
prevalence and risk of cervical cancer. Unclear is Burak, L. J., & Meyer, M. (1997). Using the health belief model to examine
and predict college women s cervical cancer screening beliefs
the impact of diĄerences in women s knowledge on
and behavior. Health Care for Women International, 18, 251-262.
their health beliefs and preventative practices,
Castle, P. E., SchiĄman, M., Herrero, R., Hildesheim, A., Rodriguez, A. C.,
and how to best design eĄective culturally sensi-
Bratti, M. C., et al. (2005). A prospective study of age trends in cer-
tive, age-appropriate educational awareness and
vical human papillomavirus acquisition and persistence in
health promotion campaigns to better equip women
Guanacaste, Costa Rica. Journal of Infectious Disease, 191, 1808-
to minimize their chances and their daughters
1816.
chances of acquiring HPV and cervical cancer. Center for Disease Control and Prevention. (2009). Human Papillomavi-
rus. Rockville, MD: National Prevention Network.
Chan, P., Chang, A.,Yu, M., Li, W., Chan, M.,Yeung, A., et al. (2009). Age dis-
Another area of research involves investigating cur-
tribution of human papillomavirus infection and cervical neoplasia
rent practice patterns regarding HPV and cervical
reŁects caveats of cervical screening policies. International Jour-
cancer knowledge in health care professionals,
nal of Cancer, 26(1), 297-301.
speciócally nurses that educate patients about this
CliĄord, G., Franceschi, S., Diaz, M., Munoz, N., & Villa, L. L. (2006). HPV
health condition. New evidence on HPV and cervi- type-distribution in women with and without cervical neoplastic
cal cancer is emerging at an explosive pace, and it diseases. Vaccine, 24, S26-S34.
Cohen, J. (1992). A power primer. Psychological Bulletin, 112,155-159.
is challenging for health care professionals to stay
Daley, E. M., Perrin, K. M., Vamos, C., Webb, C., Mueller, T., Packing-Ebuen,
current with the copious amount of information. De-
J. L., et al. (2008). HPV knowledge among HPV1 women.
termining the level of HPV and cervical cancer
American Journal of Health Behavior, 32, 477-487.
knowledge of healthcare professionals will help re-
Dell, D., Chen, H., Ahmad, F., & Stewart, D. (2009). Knowledge about
searchers identify if patients have access to the
human papillomavirus among adolescents. Obstetrics and Gyne-
appropriate information and services.
cology, 96, 653-656.
Denny-Smith, T., Bairan, A., & Page, M. (2006). A survey of female nursing
students knowledge, health beliefs, perceptions of risk, and risk
behaviors regarding human papillomavirus and cervical cancer.
Conclusion
Journal of the American Academy of Nurse Practitioners, 18(2),
More than 75% of the women answered one third of
62-69.
the knowledge questions about the relationship of Dunne, E. F., Unger, E. R., Sternberg, M., McQuillan, G., Swan, D. C., Patel, S.
S., et al. (2007). Prevalence of HPV infection among females in the
HPV and risks for cervical cancer incorrectly. Al-
United States. Journal of the American Medical Association,
though most women appreciated the seriousness
297(8), 813-819.
of cervical cancer, they believed themselves not
Ferreccio, C., Prado, R., Luzoro, A., Ampuero, S., Snijders, P., Meijer, C., et al.
particularly susceptible. Appropriate educational
(2004). Population based prevalence and age distribution of hu-
materials are needed to increase HPV and cervical
man papillomavirus among women in Santiago, Chile. Cancer
cancer prevention for all women regardless of their
Epidemiology, Biomarkers and Prevention, 12, 2271-2276.
age. Friedman, A., & Shepeard, H. (2007). Exploring the knowledge, attitudes,
beliefs, and communication preferences of the general public
regarding HPV: Findings from CDC focus group research and im-
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