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Logo of nihpaAbout Author manuscriptsSubmit a manuscriptNIH Public Access; Author Manuscript; Accepted for publication in peer reviewed journal;
Am J Health Behav. Author manuscript; available in PMC Nov 11, 2012.
Published in final edited form as:
PMCID: PMC3495067

Men’s Responses to HPV Test Results: Development of a Theory-Based Survey



To develop and perform psychometric testing on an instrument designed to assess cognitive/ emotional responses among men receiving HPV testing.


Men enrolled in an HPV natural history study (N=139) completed a computer-assisted survey instrument based on Leventhal’s parallel processing/common-sense model. Data were analyzed using SPSS and Mplus.


Reliability analyses resulted in Cronbach α of 0.72 (knowledge), 0.86 (perceived threat), 0.83 (self-efficacy), and 0.55 (response efficacy). A revised measurement model exhibited evidence of construct validity, as indicated by acceptable model fit statistics.


To our knowledge, this is the only validated instrument assessing men’s reactions to an HPV test result.

Keywords: HPV, behavioral, instrument development, theoretical framework

Human papillomavirus (HPV) comprises over 100 different types, with approximately 30–40 types that are anogenital and can be transmitted through sexual contact. HPV, the necessary cause of invasive cervical cancer, has a prevalence of 99.7% in cervical cancer cases.1,2 Globally, more than one million women may have cervical cancer, with over 500,000 new cases and nearly 260,000 deaths attributed to cervical cancer annually. 3 HPV is also strongly associated with invasive vulvar and vaginal cancers, penile cancer, anal cancer, oropharyngeal cancer, and anogenital warts. According to the World Health Organization, without intervention the number of HPV-associated deaths is estimated to increase by 40% (to approximately 435,000) by the year 2030.36

Genital HPV is the most common sexually transmitted infection (STI) in the United States, with an estimated incidence of 6.2 million/year and a prevalence of 20 million.79 In the United States, an estimated 11,070 women will be diagnosed with and 3870 women will die of cervical cancer in 2008.10 More than 50% of sexually active people will be infected with a genital HPV infection during their lifetime, and 80% of women will acquire a genital HPV infection by age 50.11

Male HPV infection significantly contributes to HPV acquisition and subsequent cervical disease in women. Previous research suggests that the sexual behavior of male partners may be as important as or more important than a woman’s personal sexual behavior in estimating her risk of HPV infection and cervical disease.1219 Thus, a greater understanding of HPV infection in men is an essential component of cervical cancer prevention efforts. There is a paucity of information, however, regarding men’s attitudes, perceptions, and sexual behaviors in response to the cancer risk associated with HPV and its psychological sequelae.

Psychosocial Impact of an HPV-Related Diagnosis

The literature is replete with studies of the psychosocial impact of an HPV diagnosis among women. These studies reveal a lack of overall knowledge about the virus and its association with cervical cancer, as well as negative emotional responses such as anxiety and fear.1927 Few studies, however, have examined men’s knowledge of HPV infection and cervical cancer. In one small cross-sectional study seeking to measure college males’ knowledge, attitudes, and behaviors after receiving an HPV diagnosis, researchers found limited knowledge of the virus but an overall intention to use condoms with future sexual partners.28 Results of other studies have also suggested poor HPV knowledge among different groups of men.20,2932 However, these studies have limited generalizability, as they include small cross-sectional samples of men. Additionally, few studies have devoted sufficient attention to the reliability and validity of data obtained from measures used to assess both knowledge and psychosocial responses related to HPV and HPV testing.

The Theoretical Model

In framing the research questions for the current study, researchers sought an appropriate model to explain the lack of understanding about an HPV test result and the complex emotional responses expressed by women diagnosed with HPV, such as fear about cancer, anxiety and embarrassment related to stigma.19,21 Leventhal’s Parallel Processing Model (PPM) has been applied as a framework for understanding the cognitive and emotional responses to other complex reproductive tract infections33 and was subsequently chosen as the theoretical framework for the present study, which is called the Cognitive and Emotional Responses to HPV in Men (CER) study.

Leventhal’s PPM has been employed in studies measuring effects of threat communications on a variety of health beliefs and behaviors.3436 Figure 1 represents a schematic of Leventhal’s PPM, showing the dual course involved with receiving a diagnosis or illness threat that, in the CER study, is receiving an HPV test result. The PPM is particularly well suited for a study seeking to measure the impact of an HPV test result because of the complexity involved with an HPV diagnosis, the emotional impact of a STI, and the uncertainty associated with HPV’s progression to cervical cancer.

Figure 1
Leventhal’s Parallel Processing Model

The most recent version of the PPM, the Parallel Processing /Common-Sense Model (PP/CSM), posits that a diagnosis or illness threat, such as a positive HPV test result, generates a dual reaction of emotional fear and danger. The PP/CSM theorizes that a cognitive response seeks to manage the threat’s danger through recognition and processing of the illness. The parallel processing refers to the 2 mechanisms an individual uses in response to an illness threat, through fear control (an emotional process) and danger control (a cognitive process). The progression of the parallel processing determines how an individual regulates the sense of fear and danger through the development of action plans, sometimes referred to as coping procedures.37

Witte added an element to the PPM that describes the manner in which fear is regulated through an assessment of perceived threat and perceived efficacy. Her addition to the theory is referred to as the expanded parallel-processing model (EPPM).38,39 Regarding HPV, perceived efficacy—including self-efficacy and response efficacy—and perceived threat could refer to an HPV+ male’s ability to use condoms during intercourse and his expectations about what will happen if he increases the use of condoms in terms of reducing the threat of genital warts and/or cervical cancer for his partner. That is, does he believe using condoms will reduce his chances of getting genital warts or his partner’s risk for developing cervical cancer?

The PP/CSM assesses the cognitive process through the use of 5 domains: (1) identity (eg, symptoms, name of the disease or illness), (2) timeline (eg, time of onset and expected duration), (3) consequences (eg, expected outcomes such as severity of pain and impact of life functions), (4) cause (eg, infection, genetics), and (5) control (ie, is the illness preventable, curable, and controllable?).40 The PP/CSM posits that these cognitive domains help a person to go from fear and anxiety to implementing a plan for coping with the diagnosis. Gorbach applied the PPM in her assessment of the impact of an HPV-related diagnosis in women (Figure 2) through the adaptation of the following components: (1) health threats (ie, a high-risk HPV diagnosis), (2) danger and fear regulation, (3) coping strategies, and (4) reappraisal.33

Figure 2
Gorbach’s Application of the PPM with Reproductive Tract Infections

The purpose of this manuscript is to describe the development, pilot testing, and refinement of an instrument that follows the PP/CSM and EPPM in assessing the cognitive and emotional responses to an HPV test result in men. Psychometric testing was conducted to examine the instrument’s 4 main constructs: knowledge, perceived threat, response efficacy, and self-efficacy. Figure 3 depicts the final model from which the CER study instrument was developed and includes constructs measured through scales and index scores.

Figure 3
Application of Leventhal’s Parallel Processing Model to an HPV Diagnosis in Men


Study Population

The 139 respondents in this analysis were participants in a study assessing the psychosocial responses to an HPV test result among US men. This study, called the CER study (named to represent the cognitive and emotional responses to an HPV test result), is nested within a large natural history study of HPV in men (the HIM study). Although much is known about HPV in women, there has not been a comparable study of HPV in men, and the HIM study will provide important data about how HPV affects men, including how long the infection is present. In the HIM study, participants are tested for HPV every 6 months over a period of 4 years, and at each visit, they are told their HPV test results from the previous visit. After receiving their test results the first time, they are enrolled in the CER study, where they are asked to complete a computer-assisted survey instrument (CASI). The CER study aims to evaluate how receiving an HPV diagnosis impacts men’s behaviors such as disclosure of HPV test results to sexual partners, recommendations that their partner get cervical cancer screening, sexual risk-reducing behaviors, and intentions to receive vaccinations against HPV.


Male participants were recruited into the CER study from a series of convenience samples derived from the HIM study. Eligibility criteria included the following: males enrolled in the HIM study aged 18-70 years; residents of central Florida; fluent in English; no prior diagnosis of penile or anal cancers, genital warts, or HIV/AIDS; no symptoms of an STI; no participation in an HPV vaccination study; no homelessness, imprisonment, or in a drug rehabilitation in the last 6 months; willingness to comply with scheduled visits every 6 months for 4 years; and no plans to move within the next 4 years. After participants receive their first test result (after 6 months of enrollment in the HIM study), the CER study will administer 4 quantitative surveys every 6 months over a 2-year follow-up period. This paper summarizes the psychometric characteristics of the measures, described below, using data collected from the first 139 males enrolled in the CER study. Demographic characteristics of these 139 study participants are presented in Table 1.

Table 1
Demographic Characteristics of Participants by Self-Reported HPV Status (N=139)


This study was approved by the institutional review board of the lead author’s institution. Several major steps were followed to develop the instrument, pilot test it with members of the priority population, refine the instrument, and administer it again to assess its psychometric characteristics (Table 2).

Table 2
Instrument Validation Activities

The pile sorting technique41 was first employed to arrange all survey items used in a previous HPV study in women21 into theoretically sound categories. This sorting exercise aimed to confine, as well as reduce, the number of items per model construct. Next, a panel of experts, investigators who have experience working on psychosocial and HPV-related research (n=9), reviewed the items sorted into each construct and further refined the number of items by identifying items that most clearly represented that construct. The pile sort and expert review helped to provide evidence of content validity (eg, for the HPV knowledge items).

The instrument was then administered via paper-and-pencil format to graduate students enrolled in health education courses (n=15) and to HPV+ males enrolled in a separate HPV study4244 at the same location (n=12) for item reduction and clarification. Next, semistructured qualitative interviews were conducted with 8 males (4 HPV+ and 4 HPV- participants) enrolled in the HIM study to assess the clarity/readability and flow of survey items as well as any issues related to content. General responses by the 8 male participants were constructive, and biases were identified in a number of items that were directed towards men having the virus and having a female partner. Each interview lasted approximately 30 minutes, and participants were remunerated with $30 for their involvement. Based on information gained from the paper-and-pencil survey administered to graduate students and the qualitative interviews, revisions were made to the survey. To assess initial reliability and validity of data obtained from the instrument, the survey was subsequently pilot tested with HPV+ (n=15) and HPV- (n=15) men participating in the HIM study.

The next step involved the transitioning of the paper-and-pencil version into a computer-assisted survey instrument (CASI), using Ultimate Survey Enterprise.NET Version In this step, the CASI was first tested with several men who participated in the pilot sample. The second step, which is the major focus of this manuscript, consisted of the CASI administration to males in the clinic setting of the HIM and CER studies, approximately 2–4 weeks after they received their HPV test results. A unique feature of this study is that the same Advanced Registered Nurse Practitioner disclosed the test results to every male, thus ensuring a consistent delivery of HPV-related information. Men participating in this study portion were remunerated with $25. See Table 2 for the complete sequence of instrument development and refinement activities.


The CER study instrument contains 167 items pertaining to the psychosocial measures described below, as well as sexual behavior assessments, and questions related to partnership status, information- seeking and vaccine intentions. The CASI took respondents between 14 and 59 minutes to complete, with a mean time of 33 minutes. A modified version containing the measures assessed for this article can be found in Appendix A.

The instrument measures components of the PPM/CSM and the Emotional Processes section in the EPPM, as described previously. The model posits that receiving notice of an “illness threat,” such as an HPV diagnosis, results in a dual process of cognitive and emotional responses related to the diagnosis. Cognitive responses include those factors that help an individual understand what the illness or disease represents, such as its cause, how long it lasts, expected outcomes, what symptoms are associated with the illness, and whether it can be treated or cured. Participants answered 20 yes/no response items that assess cognitive responses. Sample items include “Most HPV infections clear up within a short time” (timeline), “You can transmit HPV even if you do not see a wart” (identity), “HPV can be passed to a newborn at birth” (consequences), “HPV is a bacterial infection” (cause), and “Antibiotics can cure HPV” (control).

Emotional responses, also included in the revised model, address the fear response to the diagnosis; that is, to what extent does the illness pose a threat to the individual (perceived threat), how severe is the threat, and to what extent can that individual exert some kind of control over its effects (response efficacy and self-efficacy)? Emotional responses, in terms of perceived threat, were assessed using 7 items measured with a 6-point Likert-type response format (strongly agree to strongly disagree). Sample items include “I am concerned that I will get genital warts” and “It is likely my partner will have an abnormal Pap test.”

Response efficacy and self-efficacy were each assessed using 5 and 7 items, respectively, with the same 6-point Likert-type response format. Sample response efficacy items include “Suggesting that my partner have a Pap test helps prevent her from getting cervical cancer” and “By using condoms I could reduce the risk of getting/spreading HPV.” Sample self-efficacy items include “I feel that I can tell my partner my most recent HPV test result” and “I feel that I can suggest that my partner get a Pap test.”

Data Analysis

Descriptive statistics (means, standard deviations, and proportions) for the study participants were calculated using SPSS 15.0 for Windows®. Evidence of reliability and validity was assessed for all ordinal-level variables—survey items inferring perceived threat, self-efficacy, and response efficacy—by creating a measurement model. Measurement model testing was conducted using Mplus 5,46 which allows for the sophisticated handling of missing data47 and unparalleled flexibility in working with data from small samples.48 Measurement model testing procedures were employed following guidelines outlined elsewhere.49 The purpose of measurement model testing was to assess indicator/construct relationships (which assists in establishing construct validity) and is equivalent to performing a confirmatory factor analysis.49 To assess evidence of such validity, individual item-to-factor correlation estimates were first examined; and then, one-by-one, items with poor estimates (ie, <0.40)50 were eliminated from the model. Next, model fit was assessed by examining the recommended statistics: the chi-square test statistic with degrees of freedom (df), the Tucker-Lewis Index (TLI) and the root mean square error of approximation (RMSEA).51 Cronbach alpha (α) was analyzed to assess reliability for scale scores, as an index of internal consistency.52 Regarding the knowledge questions, a point biserial correlation coefficient was also calculated to determine whether items on the knowledge scale were associated with a high scale score (that is, did participants who chose the correct answer on a knowledge item do well on the overall knowledge scale?).


Table 1 contains an overview of participants’ demographic characteristics by their self-reported HPV test result status (ie, positive, negative, not sure). The knowledge level of participants was generally high, as measured on the 20-item scale (Mean or M [SD] = 16[3]; or 80%). The percentage of participants who selected the correct answer varied from 22% to 98%. The 2 questions concerning pregnancy/ childbearing, “HPV can be passed to a newborn at birth” and “HPV can affect a woman’s ability to get pregnant,” and the question concerning timeline, “Most HPV infections clear up within a short time,” had low correct response rates (45%, 22%, and 34%, respectively); whereas 3 questions concerning identity (“You can always tell when someone else has HPV,” “You can have HPV without knowing it,” and “You can transmit HPV even if you do not see a wart”) and 1 item regarding cause (“You can get/transmit HPV through sexual contact with another person”) had high correct response rates (97% or greater; see Table 3).

Table 3
Knowledge of HPV Timeline, Identity, Consequences, Cause, and Control (N=139)

Table 3 presents the initial reliability analysis for data obtained from the 20-item knowledge scale resulted in α =0.68 (n=139). Point biserial correlation coefficients ranged from 0.18 (for the item “HPV can affect a woman’s ability to get pregnant”) to 0.61 (for the item “HPV is a bacterial infection”), demonstrating that items varied in discriminating between participants who scored well and those who scored poorly on the knowledge scale. There were no point biserial correlation coefficients with a negative sign for any of the knowledge items. Because the 2 pregnancy/childbearing items—“HPV can be passed to a newborn at birth” and “HPV can affect a woman’s ability to get pregnant”—demonstrated poor item discrimination (ie, point biserial correlation coefficients <.3053), they were eliminated from the knowledge scale, as were the items “Most HPV infections clear up within a short time,” “You can transmit HPV even if you do not see a wart,” and “HPV causes HIV/AIDS.” Once these items were deleted, a reliability analysis for data obtained from the 15 retained knowledge items resulted in α =0.72 (n=139).

Table 4 presents item mean scores and standardized item-to-factor correlations for the psychosocial scaled variables. The initial measurement model included 7 items, 7 items, and 5 items that were designed to assess the latent factors perceived threat, self-efficacy, and response efficacy, respectively (Table 4). On average, participants’ scores on the perceived threat (M=2.54) items were lower than participants’ scores on the self-efficacy M=4.05) and response efficacy (M=4.30) items. Initial measurement model fit statistics indicated poor model fit, with chisquare = 397.49 (df = 149), P<0.001; TLI = 0.54; and RMSEA = 0.11.

Table 4
Initial and Revised Measurement Models: Standardized Item-to-Factor Correlations of Items for Perceived Threat, Self-efficacy, and Response Efficacy (N=138)

Reliability analyses of data obtained from the 7 perceived threat items resulted in α =0.72 (n=139) (Table 4). Whereas items asking about the seriousness of a partner’s abnormal Pap test and genital warts on health failed to correlate with the larger factor (perceived threat), participants’ concern about contracting or transmitting genital warts and/or an STI to a partner and the likelihood of a partner having an abnormal Pap test correlated highly. The former items were deleted one by one to test a revised measurement model. A reliability analysis for data on the retained 4 perceived threat items resulted in an improved α of 0.86 (n=139).

Initial reliability analyses of data obtained from the 7 self-efficacy items resulted in α =0.65 (n=106) (Table 4). Participants’ responses about efficacy regarding using condoms, being monogamous, practicing safer sex, and getting the HPV vaccine when it becomes available to men did not correlate well with the larger factor, self-efficacy. These 4 self-efficacy items were removed from the analysis to subsequently test a revised measurement model. Participants’ efficacy regarding partner communication (as measured by the items “I feel that I can tell my partner my most recent HPV test result,” “I feel that I can suggest that my partner get a Pap test,” and “I feel that I can ask my partner if she has gotten a Pap test”) did correlate highly with the larger factor. Cronbach α for data on the 3 retained self-efficacy items was 0.83 (n=108). Although, theoretically, the 4 deleted items did “hang together” to represent self-efficacy to practice HPV preventive behaviors, a subsequent exploratory analysis of these items indicated poor score reliability (α =0.52) and insufficient evidence of construct validity; that is, these items together failed to infer a unique factor/construct.

Reliability analyses of data obtained from the 7 response efficacy items resulted in α=0.69 (n=109) (Table 4). For response efficacy, there was less theoretical connection between the items statistically correlated and, similarly, the items not correlating well with the larger factor. This finding may be attributable to variable nonnormality. For instance, all of the response efficacy items were highly kurtotic (≥3), and although the maximum likelihood estimator used in Mplus is robust to conditions of nonnormality,54 it may not be robust enough to withstand the effect of a small sample coupled with severe conditions of variable nonnormality. Reliability analyses conducted with the 3 retained items also indicated potential issues with the data in hand or with the scale itself, resulting in α=0.55 (n=136). Despite the issues surrounding response efficacy, the revised measurement model fit statistics indicated acceptable model fit, with chisquare = 35.81 (df=32), P= 0.29; TLI = 0.98; and RMSEA = 0.03.


This paper summarizes the development and initial psychometric testing of an instrument designed to assess the cognitive and emotional responses to an HPV diagnosis among men. The development of this instrument involved a multiphase, multimethod approach. Items were developed based on previous research and guided by Leventhal’s Parallel Processing/Common-Sense Model and the Emotional Processes section of the expanded parallel-processing model. Initial versions of the instrument were administered to both students enrolled in health education classes and HPV+ men enrolled in another study. The instrument was then pilot tested with men participating in the parent study. These activities led to multiple revisions to produce the final survey instrument, which has been administered to 139 men participating in the CER study. Such activities were conducted to assess evidence of face, content, and construct validity and the reliability of the data collected.

Participants’ knowledge levels in this study were high. However, initial reliability of these data, as evidenced by Cronbach α, was low. Score reliability may have been impacted by several factors, including the ease of the knowledge items, as easy tests generally yield less reliable scores than do more difficult ones.55 In this assessment, 15 of the 20 knowledge items were answered correctly by 73% or more of participants. Further, there were some questions that all, or nearly all, of the participants answered correctly. This finding was reflected in the generally low point biserial correlation coefficients for these items. The poor score reliability derived from items in this scale could also be due to the complexity and uncertainty of specific aspects of HPV leading to confusion among participants on certain subscales within the knowledge scale, such as timeline and consequences. However, the 5 items failing to discriminate between people who answered the related knowledge items correctly versus those who answered these items incorrectly were eliminated. A subsequent reliability analysis of data obtained with the knowledge scale demonstrated acceptable score reliability (α=0.72).

A factor analysis was not conducted with items from the knowledge scale. Content validity, which was established based on previous scientific research and through a panel of experts, and score reliability were considered to be the more important psychometric aspects of this scale. Therefore, it is believed that the revised knowledge scale, consisting of 15 items, adequately and consistently assesses HPV knowledge of the participants.

Score reliability of data derived from 2 scales—perceived threat and self-efficacy—as evidenced by Cronbach α, was acceptable, whereas score reliability from the response efficacy scale was poor (α=0.55). Such psychometric results may be due to the small sample size coupled with severe conditions of variable nonnormality on several of the response efficacy items. The poor score reliability may also be due to the low variance exhibited by the retained response efficacy items—the response efficacy variable mean was 4.38, which could potentially demonstrate a variable ceiling effect. As the CER study continues and additional men are recruited to participate, further psychometric testing is warranted to examine these limitations. Nonetheless, the revised measurement model fit statistics and individual parameter estimates provided sufficient evidence of construct validity.

The factor analytic results regarding perceived threat warrant further, perhaps qualitative, exploration. For instance, the mean scores for the 3 deleted perceived threat items (M=3.28) were higher than the mean scores for the 4 retained perceived threat items (M=1.98). These mean score differences may possibly indicate 2 distinct levels of threat for participants. Moreover, the wording of questions in the 2 sets of items may represent different aspects for research participants: concern versus a serious threat with consequences. Whereas the 4 retained items contained a derivative of the word concern (eg, “I am concerned that I will get genital warts”), all 3 of the deleted items contained the words serious threat and may have represented a danger to respondents’ or their partners’ health (eg, “I believe that genital warts would be a serious threat to my health”). Accordingly, it is possible that research participants were influenced by social desirability when responding to these items. That is, it seems logical that respondents would answer with consistency to similarly worded items and with higher intensity to items with stronger, more threatening language (concern versus serious threat).

The factor analytic results regarding self-efficacy were perhaps the most theoretically sound findings. The 3 retained items all pertained to self-efficacy to communicate with a sexual partner (eg, “I feel that I can tell my partner my most recent HPV test result”). This factor represents a central construct in Leventhal’s Parallel Processing Model, as applied to HPV diagnoses in men. For instance, self-efficacy to communicate, as an emotional response, is an important mediator between appraisal of the diagnosis and subsequent coping procedures, such as actual disclosure of diagnosis to sexual partners, suggestions for cervical cancer screening, and decreases in sexual risk behaviors.

A limitation of the present research is the wide age range (18–70) of the males participating in the study. The original design for this study included men ages 18–45; however, the parent study increased the upper age limit to 70 years shortly after the CER study began recruiting participants, which increased the age limit of this study as well. There may be differences in how males of different ages respond to receiving an HPV test result, and an analysis of cognitive and emotional responses by age will be conducted when there are greater numbers of participants enrolled in the study.

Men responding to this CASI were provided their actual test results; however, the data suggest that participants were reacting to their perceived HPV results. Of the 139 initial participants, 17.3% did not accurately report their test results. Most of those incorrectly reporting their test results responded that they were unsure of their diagnosis, and most of those who were unsure actually tested positive. Participants who reported that they were unsure of their diagnosis had mean scores for the knowledge, efficacy, and perceived threat scales that were more comparable to those who reported being HPV negative. Therefore, once a larger sample size is obtained to allow stratification by groups, it will be important to look at any possible differences in how men respond to the survey according to their actual versus perceived HPV test result in future analyses.

With nearly 1 in 5 participants unsure of their diagnosis or responding to the wrong diagnosis, this could have affected the results. If positive men are more likely to have higher knowledge, self-efficacy, and perceived threat, as hypothesized, then these scales could be biased toward cognitive and emotional reactions consistent with a negative HPV diagnosis perception (eg, lower knowledge, lower self-efficacy, and reduced perceived threat) because some men who tested positive were answering as if they were negative. It is also possible that the small sample size may have limited the ability to detect differences between positive and negative participants and may have made the results of the factor analysis unstable. As the CER study continues and additional men are recruited to participate, further psychometric testing is warranted.

This study was conducted among men participating in a natural history study of HPV who receive counseling and information on HPV at every study visit, and therefore, the findings may not be generalizable to the general population. Nevertheless, the scales developed and tested in this study—knowledge, perceived threat, self-efficacy, and response efficacy—may be useful for other researchers investigating the cognitive and emotional responses to a variety of illnesses and populations. In addition, as men complete the CASIs every 6 months over a 2-year follow-up period, it will be important to address other limitations such as respondent burden and social desirability issues. However, this study has great significance as it is the first of its kind, and it is imperative to include men in HPV prevention efforts. Moreover, the theory-based constructs that were validated in this study may assist in the development of practical psychoeducational interventions and will improve the overall quality of life of individuals diagnosed with fear-provoking conditions and illnesses.


The project described was supported by Award Number 1R01CA123346 from the National Cancer Institute. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Cancer Institute or the National Institutes of Health.

Appendix A

                                              Patient Number: __________________
                                              Date of Survey: __________________

                           THE CER STUDY
            (Modified version for Validation Purposes -
                    For use by permission only)

                       PART 1: HPV DIAGNOSIS

Please place a check next to the answer that best applies to you. If you do not want to answer a
specific question, check Decline to answer.

1. Please tell us what your HPV test result was on your last visit:
Positive – The test results say I have HPV
Negative – The test results say I do not have HPV
Not sure
Decline to answer

2. Do you have any symptoms of HPV now?
Not sure
Decline to answer

3. Have you ever had any symptoms such as genital warts or bumps that would make you think that you
have had HPV?
Not sure
Decline to answer

                         PART 2: KNOWLEDGE

HPV Knowledge Items (Response Categories = True, False, Not Sure, Declined to Answer)

1. There are many types of HPV.
2. You can always tell when someone else has HPV.
3. You can have HPV without knowing it.
4. You can transmit HPV even if you do not see a wart.
5. Most HPV infections clear up within a short time.
6. Some types of HPV cause cervical cancer.
7. HPV can be passed to a newborn at birth.
8. HPV is a bacterial infection.
9. HPV causes genital warts.
10. HPV causes herpes.
11. HPV causes an abnormal Pap test in women.
12. HPV causes HIV/AIDS.
13. HPV is a virus.
14. HPV can affect a woman’s ability to get pregnant.
15. You can get/transmit HPV through sexual contact with another person.
16. Only men get HPV.
17. Antibiotics can cure HPV.
18. There is a vaccine for women that prevents certain types of HPV.
19. Using a condom will decrease the chance of transmitting HPV.


These questions ask you about your beliefs and attitudes about HPV. Please answer the following
questions by putting a check in the box that best describes your reactions regarding your most recent HPV
test result. HPV Knowledge Items (Response Categories = Strongly Agree, Agree,
Moderately Agree, Moderately Disagree, Disagree, or Strongly Disagree). Participants may decline to answer any item.

1. I feel that I can tell my partner my most recent HPV test result.
2. I feel that I can suggest that my partner get a Pap test.
3. I feel that I can ask my partner if she has gotten a Pap test.
4. I feel that I can use condoms every time I have sex to prevent getting or spreading HPV.
5. I feel that I can be monogamous (have one sex partner at a time).
6. I feel that I am able to practice safe sex by getting tested for sexually transmitted infections.
7. I feel that I will get the vaccine when it becomes available for men.
8. Suggesting that my partner have a Pap test helps prevent her from getting cervical cancer.
9. By using condoms I could reduce the risk of getting/spreading HPV.
10. Using condoms could reduce my partner’s risk of getting HPV.
11. Having a fewer number of sexual partners could reduce the risk of getting/spreading HPV.
12. By getting vaccinated against HPV when it becomes available for men I could reduce the risk of my sexual partner getting HPV.
13. I am concerned that I will get genital warts.
14. I am concerned that my partner will get genital warts.
15. I believe that genital warts would be a serious threat to my health.
16. I believe that genital warts would be a serious threat to my partner’s health.
17. In the time since I have received my HPV test result, I have been concerned about giving a sexually transmitted infection to my sex partner.
18. It is likely my partner will have an abnormal Pap test.
19. Having an abnormal Pap test is a serious threat to my partner’s health.

      Thank you for taking the time to fill out this survey.


1. Walboomers JM, Jacobs MV, Manos MM, et al. Human papillomavirus is a necessary cause of invasive cervical cancer worldwide. J Pathol. 1999;189(1):12–19. [PubMed]
2. Bosch FX, Lorincz A, Munoz N, et al. The causal relation between human papillomavirus and cervical cancer. J Clin Pathol. 2002;55(4):244–265. [PMC free article] [PubMed]
3. World Health Organization. [Accessed September 12, 2008];Comprehensive Cervical Cancer Control: A Guide to Essential Practice. Available at: http://www2.alliancehpsr.org/reproductive-health/publications/cervical_cancer_gep/text.pdf.
4. Parkin DM, Bray F. Chapter 2: The burden of HPV-related cancers. Vaccine. 2006;24(Suppl 3):S11–S25. [PubMed]
5. Ullrich A, Garwood P, Claeys P. WHO’s Action Plan Against Cervical Cancer. [Accessed September 15, 2006];The European Magazine for Sexual and Reproductive Health. 2007 64:4–6. Available at: http://www.euro.who.int/document/ens/en64.pdf.
6. World Health Organization. [Accessed September 12, 2008];Human Papillomavirus and HPV Vaccines: Technical Information for Policy-makers and Health Professionals. Available at: http:// www.who.int/reproductive-health/publications/hpvvaccines_techinfo/hpvtechinfo_nocover.pdf.
7. Cates W., Jr. Estimates of the incidence and prevalence of sexually transmitted diseases in the United States. American Social Health Association Panel. Sex Transm Dis. 1999;26(4 Suppl):S2–S7. [PubMed]
8. Dunne E, Nielson C, Stone K, et al. Prevalence of HPV Infection among men: a systematic review of the literature. J Infect Dis. 2006:1044–1057. [PubMed]
9. Weinstock H, Berman S, Cates W., Jr Sexually transmitted diseases among American youth: incidence and prevalence estimates, 2000. Perspect Sex Reprod Health. 2004;36(1):6–10. [PubMed]
10. American Cancer Society. [Accessed May 9, 2008];Cancer Facts & Figures 2008. Available at: http://www.cancer.org/downloads/STT/2008CAFFfinalsecured.pdf.
11. Centers for Disease Control. [Accessed February 6, 2008];Genital HPV infection. Available at: http://www.cdc.gov/std/HPV/hpv.pdf.
12. Agarwal SS, Sehgal A, Sardana S, et al. Role of male behavior in cervical carcinogenesis among women with one lifetime sexual partner. Cancer. 1993;72(5):1666–1669. [PubMed]
13. Buckley JD, Harris RW, Doll R, et al. Casecontrol study of the husbands of women with dysplasia or carcinoma of the cervix uteri. Lancet. 1981;2(8254):1010–1015. [PubMed]
14. Thomas DB, Ray RM, Pardthaisong T, et al. Prostitution, condom use, and invasive squamous cell cervical cancer in Thailand. Am J Epidemiol. 1996;143(8):779–786. [PubMed]
15. Zunzunegui MV, King MC, Coria CF, et al. Male influences on cervical cancer risk. Am J Epidemiol. 1986;123(2):302–307. [PubMed]
16. Castellsague X, Bosch FX, Munoz N, et al. Male circumcision, penile human papillomavirus infection, and cervical cancer in female partners. N Engl J Med. 2002;346(15):1105–1112. [PubMed]
17. Shah KV. Human papillomaviruses and anogenital cancers. N Engl J Med. 1997;337(19):1386–1388. [PubMed]
18. Waller J, McCaffery KJ, Forrest S, et al. Human papillomavirus and cervical cancer: issues for biobehavioral and psychosocial research. Ann Behav Med. 2004;27(1):68–79. [PubMed]
19. Perrin KK, Daley EM, Naoom SF, et al. Women’s reactions to HPV diagnosis: insights from indepth interviews. Women Health. 2006;43(2):93–110. [PubMed]
20. Baer H, Allen S, Braun L. Knowledge of human papillomavirus infection among young adult men and women: implications for health education and research. J Community Health. 2000;25(1):67–78. [PubMed]
21. Daley EM, Perrin KK, Vamos C, et al. HPV knowledge among HPV+ Women. Am J Health Behav. 2008;32(5):477–487. [PubMed]
22. Dell DL, Chen H, Ahmad F, et al. Knowledge about human papillomavirus among adolescents. Obstet Gynecol. 2000;96(5 Pt 1):653–656. [PubMed]
23. Holcomb B, Bailey JM, Crawford K, et al. Adults’ knowledge and behaviors related to human papillomavirus infection. J Am Board Fam Pract. 2004;17(1):26–31. [PubMed]
24. Lambert EC. College students’ knowledge of human papillomavirus and effectiveness of a brief educational intervention. J Am Board Fam Pract. 2001;14(3):178–183. [PubMed]
25. McCaffery K, Waller J, Nazroo J, et al. Social and psychological impact of HPV testing in cervical screening: a qualitative study. Sex Transm Infect. 2006;82(2):169–174. [PMC free article] [PubMed]
26. Pitts M, Clarke T. Human papillomavirus infections and risks of cervical cancer: what do women know? Health Educ Res. 2002;17(6):706–714. [PubMed]
27. Yacobi E, Tennant C, Ferrante J, et al. University students’ knowledge and awareness of HPV. Prev Med. 1999;28(6):535–541. [PubMed]
28. McPartland TS, Weaver BA, Lee SK, et al. Men’s perceptions and knowledge of human papillomavirus (HPV) infection and cervical cancer. J Am Coll Health. 2005;53(5):225–230. [PubMed]
29. Pitts MK, Fox C, Willis J, et al. What do gay men know about human papillomavirus? Australian gay men’s knowledge and experience of anal cancer screening and human papillomavirus. Sex Transm Dis. 2007;34(3):170–173. [PubMed]
30. Tider DS, Parsons JT, Bimbi DS. Knowledge of human papillomavirus and effects on sexual behaviour of gay/bisexual men: a brief report. Int J STD AIDS. 2005;16(10):707–708. [PubMed]
31. Verhoeven V, Baay M, Colliers A, et al. The male factor in cervical carcinogenesis: a questionnaire study of men’s awareness in primary care. Prev Med. 2006;43(5):389–393. [PubMed]
32. D’Urso J, Thompson-Robinson M, Chandler S. HPV knowledge and behaviors of black college students at a historically black university. J Am Coll Health. 2007;56(2):159–163. [PubMed]
33. Gorbach PM, Hoa DTK, Eng E, Tsui AO. The meaning of RTI symptoms to women in Vietnam, a qualitative study of illness representation: collaboration or self regulation? Health Educ Behav. 1997;24(6):773–785. [PubMed]
34. Mullens AB, McCaul KD, Erickson SC, et al. Coping after cancer: risk perceptions, worry, and health behaviors among colorectal cancer survivors. Psychooncology. 2004;13(6):367–376. [PubMed]
35. Smalec JL, Klingle RS. Bulimia interventions via interpersonal influence: the role of threat and efficacy in persuading bulimics to seek help. J Behav Med. 2000;23(1):37–57. [PubMed]
36. Taylor SD, Bagozzi RP, Gaither CA. Gender differences in the self-regulation of hypertension. J Behav Med. 2001;24(5):469–487. [PubMed]
37. Leventhal H. Fear appeals and persuasion: the differentiation of a motivational construct. Am J Public Health. 1971;61(6):1208–1224. [PMC free article] [PubMed]
38. Witte K. Putting the fear back into fear appeals: the Extended Parallel Process Model. Communication Monographs. 1992;59:329–349.
39. Witte K. [Accessed August 27, 2008];Theory-based interventions and evaluations of outreach efforts. Available at: http://nnlm.gov/evaluation/pub/witte/
40. Brissette I, Leventhal E, Leventhal H. The common-sense model. In: Cameron L, Leventhal H, editors. The Self-regulation of Health and Illness Behavior. London and New York: Routledge; 2003. pp. 49–50.
41. Weller SC, Romney AK. Systematic Data Collection. London: Sage Publications; 1988.
42. Giuliano AR, Nielson CM, Flores R, et al. The optimal anatomic sites for sampling heterosexual men for human papillomavirus (HPV) detection: the HPV detection in men study. J Infect Dis. 2007;196(8):1146–1152. [PMC free article] [PubMed]
43. Nielson CM, Flores R, Harris RB, et al. Human papillomavirus prevalence and type distribution in male anogenital sites and semen. Cancer Epidemiol Biomarkers Prev. 2007;16(6):1107–1114. [PubMed]
44. Nielson CM, Harris RB, Dunne EF, et al. Risk factors for anogenital human papillomavirus infection in men. J Infect Dis. 2007;196(8):1137–1145. [PMC free article] [PubMed]
45. Prezza Technologies Inc. Ultimate Survey EnterpriseNET Version 304. 2005
46. Muthén LK, Muthén BO. Mplus User’s Guide. Los Angeles, CA: Muthén & Muthén; 2007.
47. Buhi ER, Goodson P, Neilands TB. Out of sight, not out of mind: strategies for handling missing data. Am J Health Behav. 2008;32(1):83–92. [PubMed]
48. Flora DB, Curran PJ. An empirical evaluation of alternative methods of estimation for confirmatory factor analysis with ordinal data. Psychol Methods. 2004;9:466–491. [PMC free article] [PubMed]
49. Buhi ER, Goodson P, Neilands TB. Structural equation modeling: a primer for health behavior researchers. Am J Health Behav. 2007;31(1):74–85. [PubMed]
50. Raubenheimer JE. An item selection procedure to maximize scale reliability and validity. South African Journal of Industrial Psychology. 2004;30(4):59–64.
51. Yu C. Evaluating cutoff criteria of model fit indices for latent variable models with binary and continuous outcomes. Los Angeles: University of California; [Accessed August 27, 2008]. Available at: http://www.statmodel.com/download/Yudissertation.pdf.
52. Thompson B. Score reliability: Contemporary thinking on reliability issues. Thousand Oaks, CA: Sage; 2003.
53. Nunnally JC, Bernstein IH. Psychometric Theory. New York: McGraw-Hill; 1994.
54. Muthén LK. [Accessed March 26, 2008];Mplus discussion > Confirmatory factor analysis > skewness. Available at: http://www.statmodel.com/discussion/messages/9/352.html.
55. Anastasi A. Psychological Testing. New York: Macmillan; 1997.
56. Leventhal H. A perceptual-motor theory of emotion. In: Berkowitz L, editor. Advances in Experimental Social Psychology. Vol. 17. Orlando: Academic Press, Inc; 1984. p. 126.
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