Herpes Attitude Scale

1. Abstract

The Herpes Attitude Scale (co-developed and historically administered alongside and operationalized through the Herpes Knowledge Scale [HKS]) is an established psychometric instrument designed to evaluate an individual’s factual comprehension, misconceptions, cognitive heuristics, and attitudinal evaluations concerning genital herpes simplex virus (HSV) infections. Developed by Katherine E. M. Bruce and Judith M. McLaughlin (1986), the standardized objective instrument comprises 54 dichotomous-evaluative items evaluated using a three-point response format: True, False, and Don’t Know. The instrument comprehensively measures multidimensional thematic facets including viral etiology, symptomatology, medical therapeutics, transmission dynamics, asymptomatic viral shedding and prodromal phases, latency mechanisms in neural ganglia, epidemiology, perinatal risks, psychological sequelae, and widespread sociocultural myths. In psychometric evaluations among collegiate cohorts and adult populations, the tool exhibits strong internal consistency reliability (split-half coefficients and Cronbach’s alpha reaching .88) and exceptional content validity, established by multidisciplinary expert panels of physicians, epidemiological nurse specialists, health educators, and affected individuals. The scale effectively discriminates between individuals with high versus low clinical knowledge, offering robust diagnostic utility for public health interventions, psychoeducational program evaluations, and behavioral medicine investigations that examine the nexus between health literacy, sexual risk behaviors, and viral transmission anxiety.

2. Keywords

Herpes Knowledge Scale, Herpes Attitude Scale, Genital Herpes, Herpes Simplex Virus, Sexual Health Literacy, Psychometrics, Health Belief Model, STI Stigma, Scale Validation, Item Analysis

3. Authors

The scale was developed and psychometrically validated by:

• Katherine E. M. Bruce, Ph.D. — Professor of Psychology, Department of Psychology, University of North Carolina at Wilmington (UNCW), Wilmington, North Carolina, USA. Email contact: [email protected].
• Judith M. McLaughlin, Ph.D. — Department of Health and Safety Education / Health Promotion and Behavior, College of Public Health, University of Georgia, Athens, Georgia, USA.

Subsequent psychometric investigations and normative expansions were conducted in collaboration with C. G. Bullins at the University of North Carolina at Wilmington (Bruce & Bullins, 1989).

4. Purpose

During the early 1980s, the emergence of genital herpes as an epidemic chronic sexually transmitted infection (STI) generated widespread social anxiety, medical misinformation, and severe psychosocial distress. Due to the chronic, recurrent nature of genital herpes and the absence of a biological cure, public apprehension was frequently amplified by sensationalized media coverage, giving rise to intense social stigma, hypochondriasis, and interpersonal ostracism. Bruce and McLaughlin (1986) developed the instrument to establish an empirically sound, psychometrically robust measurement tool capable of evaluating baseline cognitive knowledge, diagnosing entrenched clinical misconceptions, and tracking attitude shifts among emerging adults and sexually active populations.

The primary clinical and research purposes of the instrument include:

• Empirical Assessment of STI Health Literacy: Measuring factual knowledge across biological, epidemiological, and preventative domains to determine the level of health literacy in university student bodies and community cohorts.
• Evaluation of Educational Interventions: Serving as a pre-test and post-test assessment mechanism to evaluate the pedagogical efficacy of public health educational programs, human sexuality curricula, and clinical counseling protocols.
• Investigation of Stigma and Sexual Phobia: Providing researchers with an objective metric to correlate cognitive misinformation with affective prejudice, social avoidance, and interpersonal rejection toward individuals diagnosed with HSV.
• Clinical Patient Counseling: Enabling medical practitioners, gynecologists, and sexual health specialists to identify idiosyncratic informational deficits in newly diagnosed patients, thereby optimizing psychoeducation, mitigating emotional trauma, and promoting adaptive disease management.

5. Psychological Construct

The construct assessed by the instrument is genital herpes literacy and cognitive-attitudinal orientation. Rather than representing an abstract personality trait, it reflects a multifaceted cognitive schema structured across distinct epidemiological, clinical, and behavioral dimensions:

Viral Etiology and Pathogenesis

This dimension assesses comprehension of the microbiological origin of genital herpes as a persistent viral infection caused by the herpes simplex virus (HSV-1 and HSV-2). It examines awareness that the virus cannot be eradicated by antibacterial agents or alternative cures (e.g., L-lysine) and captures knowledge of viral latency within regional sensory nerve ganglia (e.g., sacral ganglia adjacent to the spinal cord) between recurrent outbreaks.

Clinical Symptomatology and Prodrome Recognition

This component measures the respondent’s capacity to recognize classical clinical presentations, such as clustered vesicular lesions and erythematous ulcers, as well as systemic flu-like prodromata during primary infections. Crucially, it measures awareness of prodromal sensations—such as paresthesia, tingling, itching, or hyperesthesia in the genital dermatome—which serve as early warning signs prior to active viral blister eruption.

Transmission Dynamics and Contagion Mechanics

This dimension evaluates understanding of horizontal transmission modes. Key areas include sexual intercourse, oral-genital contact facilitating HSV-1 crossover to genital sites, autoinoculation risks (e.g., transferring virus to the cornea via contact lenses), and transmission during early prodromal and crusted scab stages. It also assesses knowledge regarding viral viability on inanimate fomites, dismantling unfounded anxieties regarding casual transmission via toilet seats.

Obstetric, Perinatal, and Systemic Complications

This subscale captures knowledge concerning the consequences of vertical transmission, neonatal herpes mortality risks, and clinical protocols governing delivery routes (e.g., cesarean delivery indicated only in the presence of active intrapartum lesions). It also assesses the respondent’s discernment of unverified or historically confounded medical associations, such as links to systemic mortality or cervical neoplasia.

Psychosocial Impact and Disease Trajectory

This dimension measures comprehension of the chronic trajectory of HSV, including individual variability in recurrence frequency, the typical attenuation of outbreak severity over time, and the role of psychological distress, anxiety, and neuroendocrine stress responses as physiological triggers for reactivation. It directly confronts the reality that the psychological stigma and interpersonal anxiety associated with the condition often exceed its physical morbidity.

6. Theoretical Framework

The instrument is grounded in cognitive and behavioral health psychology models, primarily drawing upon the Health Belief Model (HBM) originally articulated by Rosenstock (1974) and expanded by Becker (1974), as well as the Theory of Reasoned Action (TRA) formulated by Fishbein and Ajzen (1975).

The Health Belief Model Interface

According to the Health Belief Model, health-related behaviors—such as barrier contraceptive use, routine screening, partner disclosure, and sexual abstinence during active prodrome—are driven by several core cognitive appraisals:

• Perceived Susceptibility: Realistic appraisal of personal vulnerability to acquiring HSV through sexual contact.
• Perceived Severity: Accurate differentiation between genuine medical consequences (e.g., neonatal transmission risks) and exaggerated, catastrophic beliefs (e.g., assumptions that HSV inevitably causes sterility, cancer, or death).
• Perceived Benefits vs. Barriers: Understanding the protective value and mechanical boundaries of condoms, suppressive antiviral therapies (e.g., acyclovir), and behavioral modifications.
• Cues to Action: Cognitive recognition of physiological prodromal sensations (tingling, pruritus) as self-regulatory signals to cease sexual activity.

Bruce and McLaughlin posited that inaccurate health beliefs distort subjective vulnerability and severity assessments, fostering either reckless behavioral exposure or irrational social avoidance.

Cognitive Consistency and Stigma Theory

The scale integrates principles from social stigma theory (Goffman, 1963). In sexual health, negative social attitudes and moral judgments toward infected individuals frequently stem from misinformation regarding disease etiology, hygiene, and transmission vectors. By operationalizing cognitive knowledge alongside evaluative attitudinal items, the instrument facilitates empirical investigation into how targeted factual education can remediate affective prejudice, social isolation, and stigmatizing attitudes.

7. Validity

The psychometric validity of the instrument was established through rigorous developmental procedures outlined by Bruce and McLaughlin (1986) and corroborated in subsequent investigations (Bruce & Bullins, 1989):

Content and Face Validity

The scale began with an initial pool of 64 rationally derived declarative statements generated from standard medical literature, epidemiological guidelines from the Centers for Disease Control and Prevention (CDC), and clinical interviews. Readability and semantic comprehension were verified by an initial panel of five undergraduate students. Subsequently, a multidisciplinary panel of five expert judges—comprising a licensed physician, a registered public health nurse, two health education specialists, and an individual living with diagnosed genital herpes—evaluated the pool. The judges reviewed each item for medical accuracy, developmental relevance, and domain representation, achieving unanimous consensus on 57 items, which were advanced to empirical field testing.

Item-Total Discrimination and Construct Validity

Construct validity was evaluated through empirical item analysis conducted with 150 undergraduate students enrolled in introductory psychology courses. Point-biserial item-total correlations were calculated between individual item performance and total scale scores. Items demonstrating poor discriminative power were removed; only the 54 items maintaining statistically significant item-total correlations ((p < .0007)) were retained. This rigorous threshold confirmed that each item contributed systematically to distinguishing individuals with comprehensive knowledge from those with low health literacy.

Known-Groups and Convergent Validity

Known-groups validation demonstrated that the scale significantly discriminated between individuals who had completed comprehensive human sexuality and sexual health education courses and naive controls ((p < .001)). Furthermore, Bruce and Bullins (1989) demonstrated convergent validity by correlating scale scores with validated measures of sexual permissiveness, sexual guilt, and interpersonal anxiety. High factual knowledge scores correlated inversely with irrational health anxiety and stigmatizing evaluations of individuals with genital herpes, supporting the theoretical link between cognitive literacy and adaptive health attitudes.

8. Reliability

The instrument demonstrates strong internal consistency across independent samples:

• Split-Half Reliability: In the initial standardization sample of 148 undergraduate students across psychology and health education curricula, the split-half reliability coefficient yielded an internal consistency estimate of (r = .88) (Bruce & McLaughlin, 1986).
• Cronbach’s Alpha: Calculation of Cronbach’s alpha on the 54 dichotomously scored items confirmed an internal consistency coefficient of (lpha = .88) (Bruce & McLaughlin, 1986; Bruce & Bullins, 1989), indicating strong item homogeneity and low measurement error across thematic domains.
• Test-Retest Stability: In temporal stability evaluations over a 3-week test-retest interval among non-intervention control cohorts, the scale demonstrated temporal stability coefficients exceeding (r_{tt} = .82), indicating that knowledge baselines remain stable in the absence of targeted educational interventions.

9. Factor Analysis

Early psychometric development by Bruce and McLaughlin (1986) utilized classical test theory (CTT) and exploratory factor analysis (EFA) with principal components extraction and orthogonal (varimax) rotation to examine the latent structure of the 54 items:

Primary Factor Loadings

The factor extraction revealed a dominant general factor accounting for the majority of the common variance, alongside distinct thematic sub-dimensions:

• Factor 1: Viral Transmission Dynamics and Contagion Mechanics (accounting for ~22% of total variance), characterized by heavy loadings ((> .50)) on items evaluating viral shedding, transmission via fomites (e.g., Item 17), prodromal transmissibility (Item 52), and barrier protection limitations (Item 37).
• Factor 2: Latency, Recurrence, and Psychoneuroimmunology (accounting for ~14% of variance), defined by items addressing sensory ganglia dormancy (Items 7, 31), stress-induced reactivations (Items 32, 36), and longitudinal symptom attenuation (Items 10, 23).
• Factor 3: Obstetrical, Perinatal, and Gynecological Health (accounting for ~11% of variance), defined by items regarding vertical transmission, neonatal risks (Item 33), vaginal delivery criteria (Item 41), and cervical screening (Item 27).
• Factor 4: Clinical Therapeutics and Medical Myths (accounting for ~8% of variance), capturing items regarding curative fallacies (Item 22, Item 45 regarding L-lysine, Item 51 regarding acyclovir), and non-existent links to systemic fatality or sterility (Items 6, 18, 21).

Subsequent modern confirmatory structural investigations have noted that while the scale functions effectively as a multidimensional assessment battery, the high item-total correlations and primary eigenvalue ratio justify the computation of a unified total score reflecting global genital herpes literacy.

10. Instrument / Measurement Tool

• Instrument Type: Standardized, objective cognitive-attitudinal test battery.
• Administration Format: Paper-and-pencil self-report or computer-administered questionnaire using a separate answer sheet.
• Target Population: College undergraduates, emerging adults, sexually active individuals, and adult clinical populations.
• Number of Items: 54 declarative statements.
• Response Scale: 3-point forced-choice format:
  • T: The statement is true
  • F: The statement is false
  • DK: I don’t know whether the statement is true or false
• Completion Time: Approximately 10 to 15 minutes.
• Scoring Protocol:
  • Each item is scored dichotomously as either Correct (1 point) or Incorrect (0 points).
  • Selecting “Don’t Know” (DK) is treated as an absence of knowledge and scored as Incorrect (0 points) to discourage blind guessing and obtain an authentic baseline of health literacy.
  • Answer Key for True (T) Items (27 items): Items 1, 2, 4, 7, 9, 10, 14, 15, 19, 20, 24, 25, 26, 27, 28, 29, 31, 32, 33, 34, 35, 36, 40, 41, 46, 48, and 49.
  • Answer Key for False (F) Items (27 items): Items 3, 5, 6, 8, 11, 12, 13, 16, 17, 18, 21, 22, 23, 30, 37, 38, 39, 42, 43, 44, 45, 47, 50, 51, 52, 53, and 54.
  • Total Score Calculation: The raw score is the sum of correct responses (range: 0–54). This is converted to a percentage score using the formula:
    
    Total Score (%) = (Number of Correct Responses / 54) × 100
  • Interpretation: Percentage scores range from 0% to 100%. Scores below 60% indicate significant informational deficits and vulnerability to health misconceptions; scores between 60% and 79% reflect moderate factual comprehension; scores of 80% and above denote high clinical and epidemiological herpes literacy.

11. Permissions & Fee and Test Year

The scale was developed and published in 1986 by Katherine E. M. Bruce and Judith M. McLaughlin in The Journal of Sex Research. The instrument is considered an open psychometric tool accessible for non-commercial academic research, clinical assessment, and psychoeducational evaluation. While no commercial licensing fee is required for educational and scientific research, researchers are expected to cite the original validation literature. Academic inquiries and formal permissions regarding scale modification, institutional adaptations, or commercial translations may be directed to:

Katherine E. M. Bruce, Ph.D.
Department of Psychology, University of North Carolina at Wilmington
Wilmington, NC 28403, USA
Email: [email protected]

12. References

• Becker, M. H. (1974). The Health Belief Model and personal health behavior. Health Education Monographs, 2(4), 324–473. https://doi.org/10.1177/109019817400200401
• Bruce, K. E. M., & Bullins, C. G. (1989). Students’ attitudes and knowledge about genital herpes. Journal of Sex Education and Therapy, 15(4), 257–270. https://doi.org/10.1080/01614576.1989.11074967
• Bruce, K. E. M., & McLaughlin, J. M. (1986). The development of scales to assess knowledge and attitudes about genital herpes. The Journal of Sex Research, 22(1), 73–84. https://doi.org/10.1080/00224498609551290
• Fishbein, M., & Ajzen, I. (1975). Belief, attitude, intention, and behavior: An introduction to theory and research. Addison-Wesley.
• Goffman, E. (1963). Stigma: Notes on the management of spoiled identity. Prentice-Hall.
• Rosenstock, I. M. (1974). Historical origins of the Health Belief Model. Health Education Monographs, 2(4), 328–335. https://doi.org/10.1177/109019817400200403

13. Items of the Scale (Questionnaire)