In this study, we developed and tested the effectiveness of a comprehensive, evidence-based HPV educational protocol developed specifically for adolescents. The protocol significantly increased knowledge about HPV among adolescents of varying age, race and gender. We found that prior to receiving the educational protocol, adolescents had fair knowledge of HPV infection, its transmission, and its consequences. Previous studies similarly have demonstrated that most adolescent and young adult women have a poor understanding of HPV. In one study, 87% or high school students had never heard of HPV.(10
) After receiving the educational protocol, knowledge scale scores increased significantly and these changes were sustained after two weeks.
In adolescents participating in the first phase of testing, but not the second, knowledge scale scores were lower before the educational protocol in black compared to white participants, those with Medicaid compared to private insurance, and those who reported using condoms compared to those who did not. The baseline differences by race and insurance status may be related to differences in access to preventive services and education about STIs.(23
) The inverse association between condom use and STI knowledge has been noted in other studies.(24
) One possible explanation is that adolescents who practice riskier sexual behaviors have received more education about STIs from parents and providers. Differences in knowledge scores before the educational protocol were not noted after participants received the protocol, suggesting that the protocol is effective regardless of adolescent sociodemographic characteristics or risk behaviors.
The incorporation of HPV DNA testing into cervical cancer screening guidelines, along with a growing understanding among providers and adolescents about the link between HPV infection and abnormal Pap tests, presents a challenge to health care providers in terms of patient education about HPV. Many adolescent and young adult women will learn that their abnormal Pap test indicates they have been exposed to an STI or that they are HPV-positive. In preliminary studies of both adults and adolescents, HPV testing has been associated with anxiety, distress, perceived stigma, and fear of further testing and treatment procedures.(13
) These types of responses may adversely impact adolescent decisions about future STI screening and follow-up.(26
) Our previous work has demonstrated that cognitive understanding of HPV infection and Pap tests is a key factor in predicting psychosocial and behavioral responses to HPV infection and abnormal Pap tests.(15
) These responses may be negative, as noted above, but adolescents also report positive responses to test results, including empowerment based on knowledge of test results and intention to practice safer sexual behaviors and return for Pap screening. Providers who educate adolescents effectively about HPV infection may be able to prevent the potentially harmful psychosocial and interpersonal responses to HPV and Pap test results, while promoting healthy sexual behaviors and regular Pap screening. The protocol developed in this study may serve as a tool for providers as they design educational strategies for their patient populations.
Another challenge to health care providers in terms of patient counseling about HPV is the ongoing development of guidelines for cervical cancer screening. Different guidelines from various organizations allow flexibility in decisions about screening and follow-up.(3
) In the context of different and sometimes inconsistent guidelines, some experts have advocated for shared decision-making regarding choices about cervical cancer screening procedures.(18
) However, some adolescents may find it difficult to make an informed choice about such a complex issue given their evolving cognitive development, poor understanding of HPV infection, and the psychological implications of positive test results. Educational protocols such as the one developed in this study may help providers to guide adolescents as they participate in decisions about testing.
There are many possible approaches to education about HPV, based on provider and patient preferences as well as educational objectives. Written brochures and internet-based materials are useful for reaching large numbers of women and providing answers to the most commonly-asked questions about HPV. However, most women with positive HPV or abnormal Pap test results will present in clinical settings and require one-on-one education. Some women also prefer to receive information about HPV directly from their providers due to accessibility, trust and privacy issues.(17
) These women may benefit from protocols such as the one developed in this study, which allows clinicians to share information interactively in a private setting. Individualized educational protocols that rely on simple graphics and are delivered in a clinical setting, such as this one, may be particularly useful for adolescent or adult women who have difficulty reading or do not have access to the internet. These women may in fact be at particularly high risk for HPV infection and cervical cancer, given that there are substantial socioeconomic dispartities in cervical cancer screening, incidence, and mortality in the U.S.(29
) Finally, protocols such as this may be useful in school-based settings. School health educators may recognize the importance of teaching their students about HPV, but many lack the knowledge and resources to do so.(22
) Although developed as a tool for one-on-one education, this protocol was effective in improving knowledge about HPV among a small sample of peer educators involved in a school-based program to postpone sexual initiation. The protocol has since been used in this city-wide program to educate middle school and high school students about HPV infection and its prevention and could serve as a model to develop similar curricula in other schools.
One limitation of this study is that most, but not all, participants were recruited from a hospital-based teen health center. These adolescents were already seeking care, and thus may have had higher baseline knowledge about HPV and more motivation to learn about STIs and/or health-related behaviors than adolescents who were not recruited from a health-care setting. There was not a control or comparison group who received a different protocol with which we could compare this one. Thus, this study cannot demonstrate that this protocol is superior or inferior to other educational interventions. Furthermore, most participants were black and had Medicaid health insurance. Therefore, the results may not be generalizable to adolescents recruited from non-clinical settings or from different racial or socioeconomic backgrounds. Future research should focus on testing the effectiveness of educational protocols such as this in adolescents recruited from other settings. In addition, we were unable to assess whether changes in knowledge were sustained beyond two weeks or translated into healthy attitudes about HPV and Pap testing or safer sexual behaviors. Finally, although the focus of this educational protocol included HPV infection, transmission, clinical consequences and behavioral strategies for prevention, education about HPV vaccines must now be incorporated into educational protocols about HPV. Key information will include data regarding the safety and efficacy of HPV vaccines, recommendations for vaccination, and the importance of safe sexual behaviors and continued Pap screening after vaccination.
Despite these limitations, this protocol may be useful in increasing adolescent knowledge and understanding of HPV infection in both clinical and research settings. The process by which we developed and tested the protocol could be used as a model for the development of other educational interventions for adolescents. Education about HPV, using protocols such as this, is a critical first-line approach to the prevention of HPV infection and HPV-related disease.