Adolescent Knowledge About Sexually Transmitted Diseases

LIANA R. CLARK, MD, MALAKA JACKSON, MD, AND LYNNE ALLEN-TAYLOR, PHD

From The Childrens Hospital of Philadelphia, University of

Pennsylvania School of Medicine, Center for Excellence for
Minority Health, Philadelphia, Pennsylvania

Background: Adolescents learn about sexually transmitted

diseases (STDs) from many sources, yet little is known about
how well these educational sources are teaching them about
STDs.
Goal: The goal was to assess basic knowledge about STDs
and their prevalence, to determine the correlates of high STD
knowledge levels, and to explore whether self-perceptions of
STD knowledge correlated with knowledge test scores.
Study Design: A convenience sample of adolescents from
waiting areas in an urban childrens hospital were asked by
peer educators about their STD education, the sources of this
education, and their self-perception of their STD knowledge.
They then were given a short assessment testing their knowledge of major, incurable, and curable STDs.
Results: In the 393 surveys collected from adolescents aged
12 to 21 years (mean [SD] age, 16.9 1.8 years), 97%
self-reported having been educated about STDs, and the reported major sources were school (70%), parents (52%), and
friends (31%). Only 7 (2%) correctly named all 8 major STDs,
35 (9%) named the 4 curable STDs, and 13 (3%) named the 4
incurable STDs. HIV was the mostly commonly named of the
8 major STDs (91%), followed by gonorrhea (77%) and syphilis (65%). Trichomonas infection (22%), human papillomavirus infection (22%), and hepatitis B (15%) were the leastnamed STDs. Forty-six percent thought HIV was the most
common STD in the Philadelphia area. The participants mean
total STD knowledge score was 3.5 1.9 (maximum possible
score, 8). There were fair correlations between knowledge
scores and age (correlation coefficient [r] 0.31; P < 0.0001),
as well as between knowledge score and self-perception of STD
knowledge (r 0.23; P < 0.0001). Adolescents educated by
parents, school, other relatives, and friends performed better
than those educated by other sources. Those educated by
multiple sources outperformed those educated by one source.
Conclusions: Adolescents specific knowledge about nonHIV STDs is only cursory, despite their reports of having
received education about STDs. We must attempt to improve
and balance our STD education so that adolescents receive and
retain detailed age-appropriate STD information that is consistent with their risk for disease.

ONE OF THE PRIMARY GOALS of sexuality education is

to provide accurate information about human sexuality. The
Guidelines for Comprehensive Sexuality Education, published by the Sexuality Information and Education Council
of the United States (SIECUS), were created in 1991 by a
multidisciplinary task force comprising representatives
from many national health and educational organizations.
These organizations included Planned Parenthood, the National School Boards Association, and the American Medical Association. The SIECUS guidelines recommend that
sexuality education include instruction about sexually transmitted diseases (STDs).1 The content of this STD education
should be based on the developmental levels of the children
or adolescents.
The SIECUS guidelines propose four levels of educational content. Level 1 knowledge is for children aged 5 to
8 years. Children this age should learn that STDs and HIV
are caused by small organisms such as bacteria and viruses.
They should know that they need not worry about getting an
STD or HIV and that a person cannot become infected with
HIV by being around or touching someone who is
HIV-positive.1
Level 2 knowledge is for the preadolescent, between the
ages of 9 and 12 years. In addition to understanding level 1
knowledge, children this age should be familiar with the
different types of STDs. Level 3 knowledge is for early
adolescents aged 12 to 15 years. Teens this age should have
more information on STD transmission, symptoms, diagnosis, treatment, and cure. Level 4 knowledge is for middle
adolescents aged 15 to 18 years. These teens should have a
full understanding of STDs/HIV and should be able to serve
as accurate sources of STD/HIV information.1
Little is known about how well sexuality education resources are meeting these educational objectives. To our
knowledge, there are no data on whether adolescents have a
good awareness and understanding of all the STD risks of
unprotected sexual intercourse. This is important to know

The authors thank William C. Holmes, MD, MSCE, and Christine Forke,
BA, for their valuable feedback in the development of the manuscript.
Reprint requests: Liana R. Clark, MD, CraigDalsimer Division of
Adolescent Medicine, The Childrens Hospital of Philadelphia, 324 South
34th Street, Philadelphia, PA 19104. E-mail: clark@email.chop.edu
Received for publication July 31, 2001, revised November 15, 2001, and
accepted November 20, 2001.

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ADOLESCENT KNOWLEDGE ABOUT STDs

Vol. 29 No. 8

since such knowledge is an essential precursor of sexual risk

reduction.
The study objectives were (1) to assess SIECUS level 2
and partial level 3 knowledge about STDs in a group of
adolescents; (2) to determine the correlates of high STD
knowledge levels in adolescents; (3) to explore whether
self-perceptions of STD knowledge correlated with STD
knowledge test scores; and (4) to assess adolescents perceptions of STD prevalence in their community.
We hypothesized that overall, adolescents would demonstrate good basic knowledge about STDs, as evidenced by
their being able to name the majority of STDs, and that age
would be a major correlate of high STD knowledge (i.e.,
older adolescents STD knowledge would be greater than
that of younger adolescents). We also hypothesized that
adolescents self-perceptions of STD knowledge would correlate with actual knowledge scores.
Methods
Participants
Between April 1996 and February 1998, adolescent peer
sexuality education counselors canvassed waiting rooms at
an urban childrens hospital for adolescents to participate in
this study. The adolescents found in these waiting areas
were asked to participate in a short (5-minute) STD
knowledge assessment. Agreement to participate was taken
as verbal consent. The adolescent did not have to be a
patient at the hospital to participate in this study. Questionnaires were completed by 393 respondents who were between the target ages of 12 and 21 years. The waiting areas
visited included three adolescent medicine practice sites and
the hospital emergency department waiting area. These sites
are traditionally visited by peer educators during the course
of their educational rounds. This study was approved by the
Institutional Review Board of The Childrens Hospital of
Philadelphia.
Interviewers
The Childrens Hospital of Philadelphia Department of
Social Work manages the adolescent peer education program. On an annual basis, adolescent applicants are selected
and then trained to provide sexuality education to teens in a
broad variety of settings, from schools to youth detention
facilities. As part of their training, they are educated about
STDs and related diseases.
Data Collection
Our peer educators conducted structured interviews with
adolescents who agreed to participate. Peer educators were
instructed to read the questionnaire to participants verbatim,
without deviation. Participants were asked to provide basic

437

demographic information, after which the study questions

were read. Participants were asked whether they had been
educated about STDs and, if so, to enumerate all sources
of this education. Next, participants were asked about
self-perceptions of STD knowledge, rated according to a
4-point scale (a lot, average, a little, or nothing). Participants then were asked to name as many of the eight
major STDs as they could. Peer educators were instructed
to give credit for mispronounced or partial answers, such
as gono-something.
After the participants named all STDs that they knew,
they were asked which ones were curable (i.e., could get
rid of with medicine) and which ones were incurable (i.e.,
could not get rid of with medicine). Last, participants
were asked which STD they believed to be most common in
both teens and adults in the Philadelphia area.
We defined the major STDs according to those identified
as such in the United States by the Centers for Disease
Control and Prevention (Atlanta).2,3 These were Neisseria
gonorrhoeae, Chlamydia trachomatis, and Trichomonas
vaginalis infections, syphilis, HIV infection, genital herpes,
human papilloma virus (HPV) genital infection, and hepatitis B virus (HBV) infection. Of these, N gonorrhoeae, C
trachomatis, and Trichomonas vaginalis infections and
syphilis were defined further as curable STDs; genital herpes and infections with HIV, HPV, and HBV were defined
as incurable STDs.
After completing the questionnaire, peer educators provided both written and oral review of the correct responses
for the participants. Any additional information that the
adolescent requested was also provided, including information about contraception or about obtaining confidential
health care services.
Statistical Analysis
We computed raw scores for the number of major, curable, and incurable STDs correctly named by each participant. In addition, in order to factor in the effect of incorrect
answers on these raw scores, we calculated knowledge
scores as follows: the number of the eight major STDs
correctly named minus the number of incorrectly named
infections (e.g., yeast infection, bacterial vaginosis) (total
knowledge score); the curable STDs correctly named minus
incorrect answers (curable STD knowledge score); and the
incurable STDs correctly named minus incorrect answers
(incurable STD knowledge score).
To evaluate the participants performance by age, we
categorized them by stage of adolescence: those aged 1215
years were early adolescents, those aged 16 18 years were
middle adolescents, and those aged 18 years were late
adolescents.
Descriptive statistics were used for demographic information, knowledge scores, and the one STD prevalence

438
TABLE 1.

CLARK ET AL

Sexually Transmitted Diseases

August 2002

Demographic Characteristics of the Study Population

Variable
Number (%)
Age in years: mean SD
Race: no. (%)
Black
Asian

Male

Female

All

144 (37)
17.15 1.73

247 (63)
16.73 1.75

NS

391*
16.88 1.75

119 (38)
2

198 (62)
0

14 (31)
4 (31)
4 (31)

31 (69)
9 (69)
9 (69)

317
2
NS

White
Latino
Other

45
13
13

*Sex not given for two respondents.

NS not significant.

question. Chi-square analyses, t tests, and analysis of variance (ANOVA) F tests with a critical value of 0.05 were
used for comparisons of STD knowledge scores between
groups. Post hoc Scheffe tests for multiple comparisons
were completed for the multigroup comparisons that were
significant by ANOVA F tests. To examine the relationship
between age and STD knowledge, as well as the relationship
between knowledge score and self-perception of STD
knowledge, pairwise correlations and linear regression analysis were performed. In addition, a multiple linear regression model including all independent variables to predict
knowledge score was used to determine which variables
best predicted high levels of STD knowledge. Analyses
were conducted using STATA 6 for Windows (Stata Corporation, College Station, TX)4 and SPSS for Windows
(SPSS Incorporated, Chicago, IL).5
Results
Questionnaires were collected from 393 adolescents aged
12 to 21 years; 144 (37%) were male and 247 (63%) were
female (sex data were missing for 2 respondents). The mean
age was 17.2 1.7 years for the males and 16.7 1.8 years
for the females (P NS; Table 1). The majority (81%) of
the respondents were black. Forty-four percent reported
having Medicaid insurance (Table 2).
Almost every respondent reported having been educated
about STDs (97%), and the major sources of this education
were school (70%), parents (52%), friends (31%), doctors/
health professionals (22%), and other relatives (21%). Only
seven respondents (2%) correctly named all eight major
STDs.
Thirty-five respondents (9%) correctly identified the four
curable STDs, and 13 (3%) correctly identified the four
incurable STDs. Only two people (0.5%) correctly identified all eight major STDs, all four curable STDs, and all
four incurable STDs. When asked to name the eight major
STDs, 91% of the respondents included HIV; 77%, gonorrhea; 65%, syphilis; 58%, genital herpes; 53%, chlamydial
infection; 22%, HPV infection; 22%, trichomonas infection;

and 15%, HBV infection. Incorrect infections named were

lice (36%), vaginal candidiasis (8%), and bacterial vaginosis (3%). When asked which STD was most common in
adolescents and adults in Philadelphia, the answer most
commonly given was HIV (46%). Other responses included
gonorrhea (18%), chlamydia (10%), genital herpes (7%),
and syphilis (5%).
Of the 393 adolescents who attempted to name the eight
major STDs, the mean total raw score was 4.03 1.93
(range, 0 8). The raw curable and incurable scores were
1.54 1.30 (range, 0 4) and 1.59 0.89 (range, 0 4),
respectively. When we deducted the incorrect answers from
these raw scores, the mean total knowledge score was 3.50
1.86 (range, 1 to 8), the mean curable STD knowledge
score was 1.27 1.38 (range, 3 to 4), and the mean
incurable STD knowledge score was 1.17 1.17 (range,
3 to 4). These adjusted STD knowledge scores were used
for the remainder of the analyses.
Subgroup comparisons for total, curable, and incurable
STD knowledge scores are presented in Table 2. There were
no statistically significant differences in the total, incurable,
and curable STD knowledge scores when evaluated by sex
and ethnicity. Adolescents with Medicaid insurance had
higher total knowledge scores than those who did not know
their source of health insurance (Table 2).
Age was somewhat correlated with both total knowledge
score (r 0.31; P 0.0001) and curable STD knowledge
score (r 0.26; P 0.0001). Age and incurable STD
knowledge score were minimally correlated (r 0.16; P
0.002). Ten percent of the variance in total knowledge, 7%
of the variance in curable STD knowledge, and 3% of the
variance in incurable STD knowledge was explained by age.
Total knowledge score increased by 0.33 points per additional year of age; the curable STD knowledge score, by
0.21 points per additional year of age; and incurable STD
knowledge score, by only 0.11 points per additional year of
age.
Early adolescents had lower scores than middle and/or
late adolescents (Table 2). Late adolescents performed better on total knowledge score than did the middle adoles-

TABLE 2.

439

ADOLESCENT KNOWLEDGE ABOUT STDs

Vol. 29 No. 8

Subgroup Comparisons of Sexually Transmitted Disease (STD) Knowledge Scores

Total Knowledge Score

Variable

No. (%) of
Participants

Mean SD

Range

Sex
Male

144 (37)

3.33 1.87

08

Female
Ethnicity
Black
White
Latino/a
Other
Insurance type
Private
Medicaid
Self-pay
Dont know
Missing data
Stage of
adolescence
(years)
Early (1215)
Middle (16 or 17)
Late (18)
STD knowledge
A lot
Average
A little
Nothing

247(63)

3.60 1.86

18

319 (81)
45 (12)

3.56 1.85
3.38 1.95

18
07

13 (3)
17 (4)

3.15 1.28
3.00 2.19

15
06

122 (31)
172 (44)
7 (2)
50 (13)
42 (11)

3.51 1.74
3.77 1.89
4.57 0.98
2.82 1.88
3.02 1.93

57 (15)
236 (60)
100 (25)
103 (25)
219 (56)
64 (17)
6 (2)

P Value

NS

Curable STD Knowledge Score

Mean SD

Range

1.16 1.20

24

P Value

NS

Incurable STD Knowledge

Score
Mean SD

Range

1.08 1.10

34

1.23 1.21

34

1.21 1.14
1.27 1.36

34
34

P Value

NS

1.34 1.48

34

1.34 1.37
0.98 1.50

34
24

1.08 1.44
0.75 1.06

04
03

0.46 1.33
0.63 0.81

22
03

17
08
36 0.05*
08
08

1.21 1.35
1.44 1.43
1.14 1.77
1.10 1.36
0.93 1.22

14
34
14
24
14

1.17 1.15
1.13 1.20
1.71 1.25
1.14 1.16
1.26 1.17

34
34
13
24
24

NS

2.23 1.46
3.59 1.85
4.16 1.71

06
18 0.0001
08

0.27 0.80
1.40 1.43
1.62 1.38

13
34 0.0001
14

0.71 0.94
1.15 1.14
1.49 1.31

33
34
24

0.002

3.88 1.82
3.64 1.87
2.61 1.53
1.83 1.94

07
18 0.001
06
05

1.50 1.47
1.31 1.38
0.83 1.18
0.50 1.23

14
34 0.009
14
12

1.41 1.27
1.19 1.11
0.75 1.17
0.67 0.82

24
24
34
02

0.004

NS

NS

NS

NS

*Medicaid scored higher than dont know.

Early scored lower than middle and late; middle scored lower than late.

Early scored lower than middle and late.

Early scored lower than late.

A little scored lower than a lot and average.

A little scored lower than a lot.

NS not significant.

cents, but their curability STD knowledge scores did not

differ significantly.
Total knowledge scores differed somewhat on the basis
of self-perception of STD knowledge; the perceived levels
were a lot (26%), average (56%), a little (16%), and
nothing (1.5%) (Table 2). Those reporting a little STD
knowledge performed worse than those reporting a lot and
average STD knowledge (Table 2).
When we evaluated the relationship between mean total
knowledge scores and self-perception of STD knowledge by
sex, we found performance differences only in females
(females, a lot versus a little, P 0.003; average
versus a little, P 0.03). No significant differences were
found for females in curable and incurable STD knowledge
scores. For males, there were no differences between the
mean total, curable, and incurable STD knowledge scores of
those reporting a lot, average, and a little STD
knowledge.
Perceived STD knowledge level was somewhat correlated with total knowledge score (r 0.23; P 0.0001).
The correlations between self-perceptions of knowledge and

curable (r 0.16; P 0.002) and incurable (r 0.18; P

0.0004) STD knowledge were less.
Participants who reported being educated by multiple
sources had higher total knowledge scores than those who
listed only one source for their STD education (3.8 versus
3.0; P 0.0004). In addition, there was a moderate correlation between the number of sources of education listed by
an adolescent and his or her total knowledge score (r
0.34; P 0.0001). Those adolescents educated by their
parents, friends, relatives, school, or other sources (such as
books or television) had higher total knowledge scores
(mean score range, 3.7 4.4) than those who did not receive
education from these sources (range, 3.23.5; all P values
0.05). Moreover, those educated by physicians (3.8) did
no better than those who did not receive such education
(3.5; P NS) (Table 3).
In constructing models to predict the correlates of high
STD knowledge in our sample, we included all independent
variables (age, race, sex, insurance, self-perception of STD
knowledge, and all sources of STD education). The final
model predicting total knowledge score included age (

440
TABLE 3.

CLARK ET AL

Sexually Transmitted Diseases

August 2002

Knowledge Scores, by Sources of Education About Sexually Transmitted Diseases (STDs)

Total Knowledge Score

Sources of STD
Education

No. (%) of
Participants

Mean SD

Range

82 (22)

3.81 1.84

08

Physician
Yes
No
Parent
Yes

298 (78)

3.46 1.87

18

198 (48)

3.81 1.87

08

No
Relative
Yes

182 (52)

3.23 1.81

18

78 (21)

4.37 1.89

08

No
Friend
Yes

302 (79)

3.31 1.80

18

119 (31)

4.12 1.95

08

261 (69)

3.26 1.76

18

45 (12)

3.89 1.84

17

No
Peer Educator
Yes
No
School
Yes
No
Other Training
Yes
No
Other Sources
Yes
No

3.48 1.87

08

267 (70)

3.66 1.91

18

113 (30)

3.22 1.72

07

22 (6)

4.05 1.76

17

358 (94)

3.5 1.87

18

51 (13)

4.08 1.92

07

3.45 1.84

NS

0.003

0.0001

0.0001

NS

335 (88)

329 (87)

P Value

18

0.04

NS

0.03

Curable STD
Knowledge Score
Mean SD

Range

1.43 1.56

24

1.24 1.35

34

1.37 1.41

24

1.18 1.37

34

1.64 1.68

34

1.19 1.30

24

1.64 1.51

34

1.12 1.31

24

1.42 1.76

14

1.26 1.34

34

1.31 1.4

34

1.21 1.37

24

1.50 1.47

14

1.27 1.39

34

1.57 1.22

14

1.23 1.42

34

Incurable STD
Knowledge Score

P Value

NS

NS

0.01

0.0007

NS

NS

NS

NS

Mean SD

Range

1.15 1.16

24

1.20 1.13

34

1.14 1.14

24

1.23 1.13

34

1.45 1.38

24

1.12 1.06

34

1.41 1.26

24

1.00 1.06

34

1.4 1.45

24

1.16 1.09

34

1.22 1.23

34

1.11 0.88

23

1.32 1.25

14

1.18 1.13

34

1.22 0.86

03

1.18 1.18

34

P Value

NS

NS

0.03

0.009

NS

NS

NS

NS

NS not significant.

0.27; P 0.0001), self-perception of STD knowledge (

0.41; P 0.005), and education by a relative ( 0.97;
P 0.05) or other source ( 1.0; P 0.05) as significant
variables. However, the models R2 was small at 0.24. In
prediction of curable STD knowledge score, only age (
0.19; P 0.0001) was significant, and in the model predicting incurable STD knowledge score, age ( 0.09; P
0.02), self-perception of STD knowledge ( 0.19; P
0.05), and race ( 0.20; P 0.004) were significant.
Again, the R2 values were quite small (curable STD knowledge, 0.13; incurable STD knowledge, 0.09), indicating
there are other unmeasured factors explaining STD knowledge scores.
Discussion
Results of this survey suggest that adolescents have low
total knowledge scores, indicating an unacceptably low
level of SIECUS level 2 (preadolescent) knowledge. Moreover, their knowledge about curability appears to be even
worse, demonstrating poor SIECUS level 3 (early adoles-

cent) STD knowledge. These findings were true even for

adolescents older than age 16 years, who should demonstrate level 4 STD knowledge. Our findings mirror those of
previous studies,6 8 although our study is the first to assess
knowledge within the context of formal knowledge
guidelines.
Although 90% of our respondents named HIV disease as
one of the major STDs, fewer than one quarter identified
trichomonas infection or HPV infection. The annual incidence of trichomonas infection is second only to that of
chlamydial infection in the United States.2 HPV infection
rates are also quite high, as improvements in our diagnostic ability have shown.9 12 Trichomonas and HPV
infections are among the most common curable and incurable STDs, respectively, in the adolescent population.
It appears that our participants seem to have little knowledge about the STDs that they are at most risk of contracting. Other authors have suggested that adolescent
misconceptions and lack of knowledge about the major
non-HIV STDs put them more at risk for consequences of
their sexual behaviors.13 Perhaps we are putting too much

Vol. 29 No. 8

ADOLESCENT KNOWLEDGE ABOUT STDs

emphasis on HIV infection, to the exclusion of educating

about the other STDs.
Forty-six percent of our subjects incorrectly identified
HIV infection as the most common STD in the Philadelphia
area. These findings are similar to those in a study by
Mellanby et al,14 in which 53% of adolescents believed that
HIV infection was the most common STD. According to
recently reported data from the Centers for Disease Control
and Prevention, C trachomatis infection is the most commonly reported STD in our region.3
These results indicate the hegemony that HIV infection
has held in the STD education arena. Because HIV infection
has the most dire consequences, we spend the bulk of our
resources educating people about how to avoid contracting
this illness. It was believed that if teens saw themselves as
potentially vulnerable to HIV, they would be motivated to
either abstain from intercourse or use barrier methods faithfully to avoid infection. However, perceptions of vulnerability to HIV infection are usually quite low in the adolescent and young adult population.1517 As described by van
der Velde et al,18 teens seem to have the optimistic belief
that their partners would not have such an infection. When
this low perception of vulnerability is added to the relative
rarity of HIV infection in the adolescent population in
comparison with infections such as those due to Chlamydia
or Trichomonas,2 teens may feel somewhat invulnerable to
such a disease. Thus, it is easy for the adolescent to demonstrate high levels of HIV knowledge but have low levels
of knowledge about the other more common STDs to which
they are more vulnerableand consequently still practice
unsafe sexual behaviors.
Other authors have assessed adolescents perceived vulnerability to STDs.16,19 22 Adolescents seem to rate their
vulnerability to STDs as being similar to that of their friends
but less than that of adolescents in general.20,22,23 Thus, they
may have social network optimistic bias (perceiving their
and their friends risk as being lower than the general risk to
all adolescents) rather than personal optimistic bias (perceiving their personal risk as being lower than that of their
friends).
The majority of the teens in this study were unaware of
the most common STDs, and this ignorance affects their
perceptions of STD prevalence. If they can name only three
or four STDs and do not know which are curable and which
are not, they do not have the necessary information to make
a valid assessment of their risk of STD infection. Although
accurate knowledge alone is insufficient to produce changes
in attitude and behavior, it is a necessary component toward
an adolescents developing the motivation to change his or
her behavior.23,24 Moreover, if perceived vulnerability is
thought of as a function of the prevalence of STDs in the
adolescents social network and of social network optimistic
bias, better educating the adolescent about the more prevalent STDs might reduce the optimistic bias and increase

441

perceptions of vulnerability to infection. We have not yet

seen whether improving overall STD knowledgenot just
HIV knowledgemight move teens toward sexual risk
reduction.
Adolescents have difficulty understanding the potential
for asymptomatic STD infection.6,23 Although a person may
be asymptomatically infected with any STD, HSV and HPV
infections are extremely likely to be transmitted asymptomatically.2529 This illustrates a potential two-level knowledge deficit. The adolescents may not be aware of genital
herpes or genital wart infections. In fact, in our study, 42%
did not list HSV and 78% did not list HPV. Furthermore,
even if they are aware of these infections, they are unlikely
to understand the potential for asymptomatic infection with
these organisms. Compounding this potential problem is the
fact that health care providers rarely screen for HSV or HPV
infection during routine sexual health care visits.30 This
combination of knowledge deficit and lack of routine
screening may make teens believe that having routine sexual health visits is enough to ensure that they are not at risk
for or have not contracted an STD. This is an area for future
research.
Consistent with our hypothesis, the older adolescents
performed better on the knowledge assessment than did the
younger adolescents. However, the increase in knowledge
as a function of age was minimal. This may indicate a lack
of further learning by the late adolescents, or perhaps the
educational resources have not covered the details about the
non-HIV STDs that they need to know.
Other factors may explain the better performance of our
middle and late adolescents as compared to our younger
teens. Older teens are more likely to be sexually active and
thus more likely to have had an STD than are younger
teens.6,31,32 Thus, the age-related increase in STD knowledge may be unrelated to education; knowledge level may
be due experiential factors (e.g., having contracted an STD)
rather than routine sexuality education.
Self-perception of STD knowledge was only minimally
correlated with the knowledge scores in this study. Interestingly, another study comparing self-perception of HIV
knowledge to scores on an HIV knowledge assessment
found that males who reported high HIV knowledge scored
lower on the assessment than those who reported moderate
knowledge of HIV. This situation was reversed among the
adolescent females.33 Although we did not find a similar
pattern between males and females in our study, we did find
that there were no differences in mean total knowledge
scores between males in the four STD knowledge categories. Only our female subjects had a significant difference in
mean total knowledge scores between those knowing a lot
or having average knowledge and those knowing a little.
The reason for this difference is not clear. It may be that
males are more likely to overrepresent their level of STD
knowledge. Stevenson suggests that this tendency may be a

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CLARK ET AL

male overconfidence or pseudo-confidence in their sexuality knowledge that relates to male sexual socialization.33
The majority of our sample had been educated about
STDs via one or more sources, most often school and
parents. This observation differs from other studies, in
which health professionals, friends, and television were the
more common sources of STD education and information.14,34 Our results showed that those educated by their
parents, other relatives, friends, and school performed better
than those educated by other sources, including physicians.
This may be related to time of exposure to the STD messages. Physicians have much less time with the adolescent
to teach about STDs than do parents, friends, or even school
instructors.
The associations between the independent variables and
our adolescents STD knowledge scores were quite small.
Other unexplored variables seem to be responsible for the
majority of variance in our models predicting STD knowledge. Future work should be done to help identify variables
more highly correlated to adolescent STD knowledge.
There are several limitations to this study. Our method of
knowledge assessment may have more accurately tested
respondent recall of STD information than recognition. Recall assessments tend to be more difficult than those relying
on recognition.35 It is possible that if we had chosen a
recognition assessment, the STD knowledge scores would
have been higher. When teens are weighing the risks and
benefits of having unprotected sex, however, their knowledge component of the decision-making process is based on
recall and not recognition. If they cannot procure STD
knowledge from memory, they will not be able to make an
accurate risk assessment. In addition, we did not obtain any
information about the respondents sexual behaviors and
STD history. As has been seen in other studies,6,32 adolescents who are sexually active and those who have had STDs
appear to be more knowledgeable than those who are not
sexually active. This lack of information may mask other
important correlates of adolescent STD knowledge.
Another potential limitation is our decision to not assess
all SIECUS level 3 knowledge (which would have involved
assessing knowledge about transmission, symptomatology,
diagnostic methods, and curability of STDs). We chose to
assess the simplest area of level 3 knowledge by testing
knowledge of only STD curability. Our finding of limited
curability knowledge suggests that more highly specified
STD informationsuch as about transmission, symptomatology, and diagnostic methodswould not have been
known.
We did not test interrater reliability in our adolescent peer
educators. However, we were very clear (in instructing them
about the assessment questionnaires) about what answers to
consider correct and incorrect. We also did not record the
number or characteristics of adolescents who declined to
participate in this study. Our study sample, then, may differ

Sexually Transmitted Diseases

August 2002

in some unmeasured way from those teens who opted not to

take the assessment. In addition, setting this study within a
health care complex may have led to a sample that is not
generalizable to other non-health-seeking adolescents.
These constraints, however, probably led to an overestimation of general adolescent STD knowledge, because healthseeking teens who agree to participate in a study of STD
knowledge are more likely to have greater knowledge than
those who have no contact with healthcare professionals or
are unwilling to have their knowledge tested (because of
embarrassment at their lack of knowledge).
Last, the response options for the question assessing
self-perception of STD knowledge may have been imprecise in design. Adolescents perceptions of their knowledge
level may be, in some measure, dependent on their assessment of their peers level of STD knowledge. If they perceive their friends as having average levels of STD
knowledge, then they may believe that their knowledge
level is equivalent and may choose average as their response as well. However, if their peers STD knowledge
level is actually very good, they might inadvertently lower
their self-perception of STD knowledge level. Some caution
must be exercised, then, in the interpretation of the relation
between self-perception of STD knowledge and knowledge
scores in this study.
This study illustrates that overall adolescent knowledge
of STDs is minimal. Middle and late adolescents, for example, did not reach proficiency even with SIECUS level 2
(preadolescent) knowledge. Current STD education may be
overemphasizing HIV infection at the expense of other
STDs for which teens are at greater risk. These data suggest
that educational efforts may be failing adolescents in either
design or execution. Future studies should evaluate the
content, sources, and retention of STD knowledge in similar
populations of adolescents.
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