
==== Front
Hum Vaccin Immunother
Hum Vaccin Immunother
Human Vaccines & Immunotherapeutics
2164-5515
2164-554X
Taylor & Francis

39219415
10.1080/21645515.2024.2395086
2395086
Version of Record
Research Article
HPV
Assessing Saudi women’s awareness about human papillomavirus (HPV) and their susceptibility to receive the vaccine
S. S. ALQARNI ET AL.
HUMAN VACCINES & IMMUNOTHERAPEUTICS
Alqarni Sana S. a *
Alshehri Samiyah M. b *
Alkhateeb Mariam A. c
Alsudias Lama S. d
a Department of Clinical Laboratory Science, College of Applied Medical Science, King Saud University , Riyadh, Saudi Arabia
b Department of Pharmacology and Toxicology College of Pharmacy, King Saud University, Riyadh , Saudi Arabia
c Department of Biology, College of Science, Princess Nourah Bint Abdulrahman University , Riyadh, Saudi Arabia
d Department of Information Technology, College of Computer and Information Sciences, King Saud University , Riyadh, Saudi ‎Arabia
CONTACT Sana S. Alqarni saalqarni@ksu.edu.sa Department of Clinical Laboratory Science, College of Applied Medical Sciences, King Saud University , P. BOX 145111, ZIP 4545, Riyadh 11451, Saudi Arabia.
* These authors contributed equally to this work.

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© 2024 The Author(s). Published with license by Taylor & Francis Group, LLC.
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The Author(s)
https://creativecommons.org/licenses/by-nc/4.0/ This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial License (http://creativecommons.org/licenses/by-nc/4.0/), which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. The terms on which this article has been published allow the posting of the Accepted Manuscript in a repository by the author(s) or with their consent.

ABSTRACT

Cervical cancer is a significant health concern for women worldwide, with human papillomavirus (HPV) being the primary cause. This study aimed to assess Saudi women’s awareness and knowledge of HPV, determine their information sources, and evaluate their intention to receive the HPV vaccine. A questionnaire-based survey was conducted among 654 Saudi females aged 18 to 60 years from January to May 2023. The results revealed that 60.85% of the participants had heard about HPV, but only 8.25% had received the HPV vaccination. Despite the low vaccination rate, 71.11% of the respondents expressed willingness to receive the vaccine. Educational level was the significant predictor of the vaccine awareness and acceptance. The internet and social media were the most prevalent sources of information about HPV. The study highlights the need for additional education about HPV-related diseases and vaccination among Saudi women. Although there is a high level of HPV vaccine acceptance, the lack of knowledge suggests that targeted educational interventions are necessary to increase awareness and promote vaccination uptake. These findings can inform public health strategies to reduce the burden of cervical cancer in Saudi Arabia through improved HPV vaccination coverage and education.

KEYWORDS

Human papillomavirus
vaccine
Papanicolaou
prophylactic
cervical
and cancer
Princess Nourah bint Abdulrahman University 10.13039/501100004242 PNURSP2024R294 Princess Nourah bint Abdulrahman University 10.13039/501100004242 Princess Nourah bint Abdulrahman University researchers Supporting Project number [PNURSP2024R294], Princess Nourah bint Abdulrahman University, Riyadh, Saudi Arabia.
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pmcIntroduction

Cervical cancer is the fourth-most common cancer among women worldwide. It is one of the top three cancers affecting women younger than 45 years.1,2 Epidemiological investigations report 445,000 new cases of cervical cancer and 236,000 deaths annually.3 In Saudi Arabia, cervical cancer is the eighth most common cancer among Saudi women of all ages.4,5 Patients often do not exhibit obvious symptoms or signs in the early stages of cervical cancer, leading to the disease’s frequent neglect and misdiagnosis.6 Over the past several decades, the detection and treatment of cervical cancer and its precursors have improved considerably.7 People primarily use cervical cytologic screening to detect cervical cancer and premalignant lesions, with early diagnosis and appropriate treatment reducing cancer mortality risk.6 Researchers have discovered that microorganisms may play a crucial role in cervical cancer development.8 Infection with high-risk human papillomavirus (HR-HPV) is believed to be the major cause of cervical cancer.9

Vaccination is the most practical and cost-effective method for HPV prevention. Approved prophylactic HPV vaccines offer strong protection against HPV infection and some HPV-related cancers.10 These vaccines protect against up to nine HPV genotypes. The three vaccines are named Gardasil, Cervarix, and Gardasil-9.11,12 The United States Food and Drug Administration (FDA) approved the first prophylactic vaccine, Gardasil, also known as the quadrivalent HPV vaccine, in 2006.13 It targets HPV6 and 11, which cause about 90% of genital warts, in addition to targeting HPV16 and 18, the most common oncogenic HPV genotypes.14 The second prophylactic vaccine, Cervarix, also called the HPV bivalent vaccine, was approved by the European Medicines Agency (EMA) in September 2007 and by the FDA in October 2009. It targets HPV16 and HPV18.15 The third prophylactic vaccine, Gardasil-9, also called the HPV 9-valent vaccine, was licensed by the FDA in 2014. It targets HPV 6, 11, 16, 18, 31, 33, 45, 53, and 58. Researchers linked the five additional HPVs to an additional 20% of cervical cancer incidences. Consequently, Gardasil 9 has the potential to prevent almost 90% of cervical cancers.16

Since the innovation of the HPV vaccine, several countries have introduced it to children’s immunization schedules. However, national HPV programs typically cover only 30% of the global target population, and full-dose coverage remains inadequate in many areas.17 In Saudi Arabia, the HPV vaccine was recently included in the children’s immunization schedule. According to the Saudi Ministry of Health website, the HPV vaccine policy in Saudi Arabia is for females only. Girls at the age of 11 can have three doses: the first dose at 0, the second dose after 1 to 2 months, and the third dose after 6 months. Women aged 15 to 26 can have the first dose and catch-up immunization. Furthermore, as a protection policy in Saudi Arabia, women between the ages of 21 and 29 should have a cervical test every three years, in addition to the use of cytology-based Papanicolaou (pap) tests. Women between the ages of 30 and 65 should have a pap test every five years, in addition to an HPV test.4

Previous studies on knowledge and attitudes toward the HPV vaccine in Saudi Arabia revealed a variety of flaws and gaps, primarily in knowledge about HPV infection and its role in cancer, as well as the availability of the HPV vaccine.18–23 In 2021, Akkour conducted his study to evaluate the awareness of cervical cancer, HPV infection, and HPV vaccines across various regions of Saudi Arabia. The study showed only 17.7% of participants heard about the HPV vaccine, and only 2.0% of them received it, despite the fact that 54.1% of them expressed a willingness to do so after learning about it.20 In 2022, researchers conducted two studies in Eastern Province and Jazan Province. Both studies showed an inadequate level of knowledge regarding HPV infection and its vaccine.21,22 In line with this, previous studies consistently reveal a lack of awareness and knowledge about HPV infection and the HPV vaccine across various regions of Saudi Arabia. Despite the low levels of initial awareness, there is a significant willingness among participants to receive the vaccine once informed, indicating a potential area for public health education and intervention.23–28

Despite extensive research on HPV awareness and vaccine uptake among women in Saudi Arabia, significant gaps remain that require attention. In fact, previous research on national awareness and HPV prevalence in Saudi Arabia has primarily focused on regional areas, making it difficult to generalize their findings globally, particularly in rural areas (19,21-23,27,28). Furthermore, these reports typically target certain populations, for example, doctors or students studying in health-related educational institutions, without considering a wider population.26,27 Additionally, one study reported small sample sizes with females aged 11–26,19 so their results may not be completely representative of the population. Another study failed to assess gender variations across different regions of Saudi Arabia.22 While, Jazan Province conducted the only study to examine how education affects HPV knowledge.21 Thus, this study aims to identify HPV awareness and knowledge, as well as their information sources, the proportion of Saudi women who have gotten the HPV vaccination, and their intentions toward having HPV vaccinations in Saudi women nationwide depending on their education level.

Materials and method

Study design

We conducted a cross-sectional study using an online self-administered questionnaire in accordance with Checklist for Reporting Results of Internet E-Surveys (CHERRIES) to gather nationwide data from female population of Saudi Arabia from January 2023 to May 2023.

Data collection tool

Data was collected through a self-administered questionnaire which was designed following a review of relevant previous studies addressing HPV knowledge and attitudes related to HPV vaccination.21,29 The questionnaire contained closed-ended questions. It was composed of six sections as follows: The first introductory section included a short summary of the study aims. In the second section, participants were required to indicate their agreement to participate in this study The third section designed to assess the demographic characteristics of the participants (gender, age, nationality, job status and education level). A fourth section assesses HPV knowledge, including an introductory item that asks whether the participant has heard of HPV previously, with a request not to complete the survey in case the answer is no. This was followed by seven items (yes, no or I don’t know) assessing HPV knowledge, with a request to answer based on the participant’s prior knowledge as follows: (a) the infection with HPV is rare; (b) the infection with HPV is sexually transmitted; (c) Genital warts are caused by HPV; (d) HPV can cause cervical cancer; (e) Men cannot be infected by HPV; (f) Individuals can be infected with HPV for years without knowing; and (g) HPV can be treated with antibiotics. The final section comprised five questions about the HPV vaccine and the ability to obtain it. This was followed by six items as follows: (a) awareness of HPV vaccines availability in Saudi Arabia; (b) whether they are vaccinated against HPV; (c) are HPV vaccines are safe and effective at preventing cervical cancer; (d) are you willing to obtain the vaccine if it is provided free of charge? For those who answered no to the previous question, what are your primary reasons for refusing it? (e) Do you intend to pay for the HPV vaccination? and (f) From which sources did you obtain your knowledge of HPV?

The validity of each item in the questionnaire was checked by the first and second authors before conducting the pilot test. Then a pilot test was conducted with three Saudi female respondents who did not participate in the final analysis. Following the pilot test, the questionnaire undergoes a few adjustments.

Sampling size calculation

The minimum required sample size was determined using the Check-Market online sample size calculator.29 Assuming 15 million Saudi female population in Saudi Arabia according to SAUDI ARABIA (KSA) population statistics 2023,30 with a 5% margin of error and a 95% confidence interval, the minimum sample size was 385. Convenience sampling strategy was utilized to meet the required sample size.

Data collection

This is an online self-administered a questionnaire-based study targeting Saudi population women aged from 18 to 60 years old with all different education levels and job status. The survey was designed by Google Forms to collect data. The survey link was distributed online via e-mail, social media platforms, and via WhatsApp. The distribution of the survey was conducted from January to May 2023 with no incentives provided to encourage participants to participate. The survey was designed and presented simultaneously to participants in Arabic and English. The population of our study was determined according to the inclusion and exclusion criteria. The inclusion criteria for this study are Saudi females in the age group of 18 to 60 years with all different education levels and job status. The exclusion criteria are non-Saudi females, men, and anyone who refused to participate. A total of 685 participants answered the questionnaire. About 678 participants continued the survey (99%), however 7 participants declined to participate. Around 678 participants continued the survey, 670 (98.8%) were females, and 8 (1.2%) participants were males. Non-Saudi females participated in the study with total number of 16 (2.4%). All participants who met the inclusion and exclusion criteria were included in this study. The sample size included for this study is 654 participants with response rate of 95.5%. All participants were anonymous and not given rewards to participate.

Data analysis

Data were analyzed using Statistical Package for the Social Sciences (SPSS version, 2020). Descriptive statistics (mean and standard deviation (SD) were used to describe the scale variables (HPV knowledge score). The association between categorical variables were evaluated using the chi-squared test (χ2). The p value of 0.050 was assumed as the statistical significance cutoff. Covariates associated with HPV knowledge (employment status, education, and age) were examined using linear regression analysis, where the dependent variable of each model was a standardized composite score for overall knowledge regarding HPV and independent variables included all other covariates. Adjusted beta estimates, with 95% confidence intervals are presented for each independent variable. The chosen demographic and clinical variables were evidence-based predictors in previous literature.

Study ethics

The ethical approval to conduct the project was granted from King Saud University, Vice Rectorate for Graduate Studies and Scientific Research, Research Ethics Committee (no. KSU-HE-23-176). All collected data were kept confidential and used for only the purpose of research. Also, the questionnaires did not include participants’ personal information or any other identification methods.

Results

Participants’ demographic characteristics

A total of 654 Saudi females’ participants were included in this study. Table 1 describes the study participants’ age, education level, employment, and vaccination status. The participants’ ages ranged from 18 to 60 years old. Most of the participants were 18 to 30 years old (n = 319, 48.78%). Also, half of the participants were employed (n = 332, 50.77%). The bachelor’s degree is the commonly completed or current education in the participants are graduate level (n = 376, 57.4%), followed by a postgraduate (n = 224, 34.2), while the lowest number of participants were undergraduate (n = 52, 7.9%) and uneducated (n = 2, 0.31%).Table 1. General characteristics of the study participants n = 654.

Variable	Category	Frequency (N)	Percent (%)	
Age	18-30	319	48.8	
 	31-40	195	29.8	
 	41-50	114	17.4	
 	51-60	26	3.97	
 	Total	654	100	
Employment status	Student	248	37.9	
 	Employed	332	50.76	
 	Un-employed	45	6.88	
 	Others	29	4.4	
 	Total	654	100	
Education Level	Uneducated	2	0.3	
 	Undergraduate	52	7.95	
 	Graduate	376	57.5	
 	Postgraduate	224	34.3	
 	Total	654	100	

HPV knowledge among the study participants

To determine whether participants had heard of HPV prior to the survey, one item was mandatory: Have you heard about HPV infection? with a request not to complete the survey if the answer is no. Among the participants, only 398 (60.85%) reported having previous awareness of HPV. Participants were grouped by education level to determine whether participants’ education levels influenced their previous awareness of the virus. Participants who have graduated showed the highest prior awareness of HPV (n = 207) followed by postgraduate (n = 173) and undergraduates (n = 18). Although, the uneducated participants have no previous awareness of HPV (p < .001, χ2 = 48.673) (Figure 1). Figure 1. Awareness about HPV awareness in women with different education level (n = 398).

Knowledge about HPV and its related diseases among Saudi women’s study participants based on prior knowledge of HPV

To assessing HPV knowledge, with a request to answer based on the participant’s prior knowledge seven items were used by choosing (yes, no, I don’t know) such as Is HPV infections are rare? Is HPV being sexually transmitted? Are Genital warts caused by HPV? Can HPV cause cervical cancer? Can men get HPV? Can individuals be infected by HPV for years without knowing? Can HPV cure by antibiotics?

Participants who had heard about HPV before this study, based on their responses (398 participants, 60.85%) are included in this section to assess their general level of knowledge regarding HPV disease. Most participants responded to knowledge questions about HPV and its related diseases by I Don’t know (63.6% to 45%); see (Figure 2). Only 10.8% of respondents agreed that HPV infection is rare. Nearly 12.7% of participants agreed that HPV patients can be treated with antibiotics. Approximately 29% of participants believed men could be infected with HPV. According to 34% of participants, HPV causes genital warts. About 45% of respondents reported that HPV infections are transmitted sexually. A similar percentage of participants (44%) believed that individuals could be infected with HPV for many years without knowing it. More than half of the participants (54%) believed that HPV causes cervical cancer (Figure 2). Figure 2. Saudi women’s participants’ general level of knowledge of HPV based on their prior awareness of HPV vaccine (n = 398).

Knowledge about HPV and its related diseases among Saudi women’s study participants based on education level

We then investigated the level of knowledge and awareness about human papillomavirus (HPV) among undergraduate (UE), graduate (G), and postgraduate (PG) participants. On the question of whether HPV infection is rare, many of them did not know across all the three groups, but highest inconsistency was noted among graduates with a total sum of 262 people who were uncertain. Therefore, chi-square analysis showed that there were significant differences between these two variables (χ2 = 33.059, p < .001). Among respondents who knew about sexual transmission of HPV, most graduates correctly answered it at number 133 followed by postgraduates at number148 showing education levels to be significantly associated with this variable (χ2 = 74.627; p < .001). It was also found that more students gave correct answers regarding whether genital warts are caused by HPV or if they can cause cervical cancer as well as other cancers such as anal and oral cancers; both questions showed variation by education level (χ2 = 49.109, χ2 = 94.818; both df = 28, p < .001). This research also discovered that there were substantial differences in knowledge related to the fact that men could contract HPV (χ2 = 23.012, p = .001) and persons could have HPV for years without knowing it (χ2 = 19.333, p = .004). Lastly, there was a significant difference in the knowledge that HPV cannot be treated with antibiotics (χ2 = 19.381, p = .004), with many participants across all education levels showing a lack of knowledge on this point (Table 2).Table 2. Saudi women’s participants’ general level of knowledge of HPV based on their prior awareness of HPV vaccine.

HPV Knowledge Items	Response	Education Level	χ2	p-value	
UE	UG	G	PG	
Have you heard of human papillomavirus?	Yes	0	18	207	173	48.673	<.001*	
No	2	34	169	51	
Is infection with papillomavirus rare?	Yes	0	11	36	23,	33.059	<.001*	
No	1	6	78	84	
Don’t know	1	35,	262	117	
Is infection with papillomavirus sexually transmitted?	Yes	1	13	133	148	74.627	<.001*	
No	1	9	29,	7	
Don’t know	0	30	214	69	
Are genital warts caused by the human papilloma virus	Yes	1	10	106	107	49.109	<.001*	
No	1	3,	8	7,	
Don’t know	0	39	262	110	
Can human papillomavirus cause cervical cancer?	Yes	1	23	163	165	94.818	<.001*	
No	1	1	6	0	
Don’t know	0	28	207	59	
Does human papillomavirus infect men?	Yes	1,	11	90	86	23.012	.001*	
No	1	8	65	44	
Don’t know	0	33	221	94	
Can individuals be infected with HPV for years without
knowing?	Yes	0	20	147	122	19.333	.004*,b,c	
No	0	0	6	0	
Don’t know	2	32,	223	102	
Can human papilloma virus be treated with antibiotics?	Yes	0	11	45	28	19.381	.004*,b,c	
No	1	5	77	71	
Don’t know	1	36	254	125	
UE: uneducated; UG: undergraduate; G: graduate; PG: postgraduate. *The Chi-square statistic is significant at the .05 level. bMore than 20% of cells in this subtable have expected cell counts less than 5. cThe minimum expected cell count in this subtable is less than one.

We further performed regression analysis to examine factors that affect the knowledge related to human papillomavirus (HPV). Significantly across most items, education level seemed as a persistent predictor, confirming the importance of education in improving knowledge related to HPV. Age and employment status were significant less frequently indicating that these elements do not have much influence on HPV awareness and knowledge (Table 3). However, for the question “Can human papillomavirus be treated with antibiotics?,” no significant relationship was established between any of the variables (education level, employment status, and age) highlighting the general lack of knowledge across all groups regarding the treatment of HPV.Table 3. Linear regression analysis of HPV awareness and attitudes.

HPV Items	 	B	Std Error	95.0% CI	t	Sig.	
Is infection with papillomavirus rare?	(Constant)	2.781	0.118	(2.548, 3.014)	23.471	0.000	
Education level	−0.090	0.045	(−0.179, −0.002)	−2.003	0.046*	
Employment Status	−0.049	0.039	(−0.124, 0.027)	−1.261	0.208	
Age	0.021	0.034	(−0.047, 0.088)	0.605	0.545	
Have you heard of human papillomavirus?	(Constant)	1.845	0.082	(1.684, 2.006)	22.531	0.000	
Education level	−0.231	0.031	(−0.292, −0.17)	−7.415	0.000*	
Employment Status	0.001	0.027	(−0.051, 0.054)	0.053	0.958	
Age	0.036	0.024	(−0.01, 0.083)	1.534	0.125	
Is infection with papillomavirus sexually transmitted?	(Constant)	2.895	0.162	(2.577, 3.214)	17.846	0.000	
Education level	−0.438	0.062	(−0.559, −0.317)	−7.112	0.000*	
Employment Status	−0.025	0.053	(−0.129, 0.078)	−0.481	0.630	
Age	0.094	0.047	(0.002,0.187)	2.008	0.045*	
Are genital warts caused by the human papilloma virus	(Constant)	3.032	0.162	(2.715, 3.349)	18.765	0.000	
Education level	−0.305	0.061	(−0.426, −0.185)	−4.974	0.000*	
Employment Status	−0.059	0.053	(−0.163, 0.044)	−1.129	0.259	
Age	0.028	0.047	(−0.064, 0.119)	0.589	0.556	
Can human papillomavirus cause cervical cancer?	(Constant)	2.802	0.168	(2.473, 3.132)	16.689	0.000	
Education level	−0.399	0.064	(−0.525, −0.274)	−6.261	0.000*	
Employment Status	−0.025	0.055	(−0.132, 0.083)	−0.452	0.651	
Age	0.031	0.049	(−0.065, 0.126)	0.632	0.528	
Does human papillomavirus infect men?	(Constant)	2.670	0.150	(2.375,2.965)	17.785	0.000	
Education level	−0.245	0.057	(−0.357, −0.133)	−4.297	0.000*	
Employment Status	−0.006	0.049	(−0.102, 0.09)	−0.117	0.907	
Age	0.078	0.043	(−0.007, 0.163)	1.798	0.073	
Can individuals be infected with HPV for years without knowing?	(Constant)	2.592	0.171	(2.255, 2.928)	15.132	0.000	
Education level	−0.234	0.065	(−0.362, −0.107)	−3.603	0.000*	
Employment Status	−0.008	0.056	(−0.118, 0.101)	−0.149	0.882	
Age	0.033	0.050	(−0.064, 0.131)	0.675	0.500	
Can human papilloma virus be treated with antibiotics	(Constant)	2.674	0.124	(2.43, 2.917)	21.520	0.000	
Education level	−0.061	0.047	(−0.154, 0.031)	−1.297	0.195	
Employment Status	−0.010	0.040	(−0.089, 0.07)	−0.244	0.807	
Age	−0.006	0.036	(−0.076, 0.065)	−0.159	0.874	
*The Chi-square statistic is significant at the .05 level.

The attitude of Saudi women’s study participants toward HPV vaccines

To assess the Saudi women’s study participants attitude toward HPV vaccines, four items were used by choosing (yes, no, I don’t know) such as Are you aware of the availability of HPV vaccines? Have you received the HPV vaccination? Given that HPV vaccines are safe and effective to protect against infection by the most common HPV types associated with cervical cancer, are you willing to get the HPV vaccine? Are you willing to pay for HPV vaccine?

Participants who had heard about HPV before this study, based on their responses (398 participants, 60.85%) are included in this section to evaluate their general level of knowledge and attitude toward vaccines against HPV. The majority of study participants (79.5%) know Saudi Arabia administers HPV vaccinations. However, just 8.29% of study participants have received an HPV vaccination. Most of the respondents (71.11%) are willing to receive HPV vaccines, whereas only 44.97% are willing to pay for them if they are not free (Figure 3). Figure 3. The knowledge and attitude regarding the HPV vaccines among Saudi women’s study participants who are aware of HPV.

The attitude of Saudi women’s study participants toward HPV vaccines based on education level

Next, we aimed to investigate the knowledge and perception of HPV vaccine among participants with different educational levels such as Undergraduate (UE), Graduate (G) and Postgraduate (PG). There were significant differences in several aspects. In postgraduates and graduates, greater awareness of the availability of HPV vaccine in Saudi Arabia was observed, compared to undergraduates (χ2 = 68.811, p < .001). Very few participants had been vaccinated as shown by vaccination status, with the highest numbers among postgraduates (n = 14) and graduates (n = 18) (χ2 = 51.155, p < .001). Those who agreed that they would get the HPV vaccine when available had a higher number of graduates (n = 122) followed by postgraduates (n = 148); while undergraduates showed least interest with only 18 undergraduates showing interest in getting vaccinated (χ2 = 59.656, p < .001). Also, willingness to pay for HPV vaccine showed a similar trend. (χ2 = 57 .991, p < 0.001). Beliefs about fabricated safety and efficacy data on vaccines, whether Pharmaceuticals hide dangers associated with vaccines or not; and vaccines do not appear linked to autism spectrum disorder all differed significantly from one another (p < .001 for each), but general awareness were more pronounced in graduates than in undergraduates (Table 4).Table 4. Knowledge and attitude regarding the HPV vaccines among Saudi women’s study participants who are aware of HPV based on their education level.

HPV Vaccine Items	Response	Education Level	χ2	p-value	
UE	UG	G	PG	
Are you aware of the availability of HPV vaccines in Saudi Arabia?	 	2	34	169	51	68.811	<0.001*	
Yes	0	12	151	154	
No	0	4,	31	7	
I don’t know	0	2	25	12	
Have you ever been vaccinated against human papillomavirus?	 	2	34	169	51	51.155	<0.001*	
Yes	0	1	18	14	
No	0	17	179	155	
I don’t know	0	01	10	4	
Given that HPV vaccines are safe and effective for protecting against infection with the most common types of HPV associated with cervical cancer, are you ready to get the HPV vaccine	 	2	34	169	51	59.656	<0.001*	
Yes	0	13	148	122	
No	0	2	27	38	
I don’t know	0	3	32	13	
Are you willing to pay for the HPV vaccine	 	2	34	169	51	57.991	<0.001*	
Yes	0	8	90	81	
No	0	5	73	73	
Don’t know	0	5	44	19	
Vaccine safety data is often fabricated	 	2	34	169	51	53.630	<0.001*	
Strongly disagree	0	5	37	31	
disagree	0	4	53	54	
neutral	0	9	93	68	
agree	0	01	15	15	
Strongly agree	0	01	9	5	
Immunizing children is harmful, and this fact is covered up.	 	21	34	169	51	54.125	<0.001*	
Strongly disagree	0	6	80	68	
Disagree	0	3	65,	52	
Neutral	0	6	49	37	
agree	0	2	11	10	
Strongly agree	0	1	2	6	
Pharmaceutical companies cover up the dangers of vaccines	 	2	34	169	51	51.877	<0.001*	
Strongly disagree	0	5	27	24	
Disagree	0	1	47,	41	
Neutral	0	6	70	58	
Agree	0	4	46	36	
Strongly agree	0	2	17	14	
Vaccine efficacy data is often fabricated.	 	2	34	169	51	53.734	<0.001*	
Strongly disagree	0	6	39	30	
Disagree	0	5	62	61	
Neutral	0	4	75,	63	
Agree	0	2	23	12	
Strongly agree	0	1	8	7	
International organizations trying to cover up the link between vaccines and autism.	 	2	34	169	51	51.232	<0.001*	
Strongly Disagree	0	4	59	43	
Disagree	0	4	46	42	
Neutral	0	6	80,	66	
Agree	0	3	14	13	
Strongly agree	0	1	8	9	
UE: Uneducated, UG: Undergraduate; G: Graduate; PG: Postgraduate. *The Chi-square statistic is significant at the .05 level.

The regression analysis further examined the influence of sociodemographic variables (education level, employment status, and age) on participants’ awareness and beliefs regarding the HPV vaccine (Table 5). For awareness of HPV vaccine availability in Saudi Arabia, education level had a significant negative effect (B = −0.165, p = .006), while employment status and age were not significant predictors. Regarding HPV vaccination status, none of the sociodemographic variables showed significant effects. Willingness to pay for the HPV vaccine was marginally influenced by education level (B = −0.126, p = .071), with no significant effects from employment status and age. Education level positively influenced the main source of knowledge about HPV (B = 0.271, p = .059), while age had a significant positive effect (B = 0.224, p = .039), and employment status was not significant. Belief in the fabrication of vaccine safety data was not significantly influenced by any sociodemographic variables. For the belief that immunizing children is harmful and covered up, education level had a significant negative effect (B = −0.200, p = .034), and age had a significant positive effect (B = 0.312, p < .001). Employment status was not significant. Belief in pharmaceutical companies covering up vaccine dangers showed no significant effects from any sociodemographic variables. Similarly, the belief that vaccine efficacy data is fabricated was not significantly influenced by education level or employment status, but age showed a marginal positive effect (B = 0.142, p = .052). Finally, the belief that international organizations cover up the link between vaccines and autism was significantly influenced by age (B = 0.237, p = .002), with no significant effects from education level or employment status.Table 5. Linear regression analysis of HPV vaccine awareness and attitudes.

HPV Vaccine Items	Sociodemographic variable	B	Std. Error	95% CI	t	Sig.	
Are you aware of the availability of HPV vaccines in Saudi Arabia?	(Constant)	1.649	0.149	(1.356, 1.942)	11.068	0.000	
Education level	−0.165	0.059	(−0.281, −0.049)	−2.787	0.006	
Employment Status	0.082	0.047	(−0.011, 0.175)	1.742	0.082	
Age	−0.056	0.045	(−0.143, 0.032)	−1.245	0.214	
Have you ever been vaccinated against human papillomavirus?	(Constant)	2.038	0.080	(1.88, 2.196)	25.338	0.000	
Education level	0.009	0.032	(−0.054, 0.072)	0.283	0.777	
Employment Status	−0.028	0.025	(−0.078, 0.022)	−1.092	0.276	
Age	−0.033	0.024	(−0.081, 0.014)	−1.379	0.169	
Are you willing to pay for the HPV vaccine	(Constant)	2.021	0.174	(1.678, 2.364)	11.583	0.000	
Education level	−0.126	0.069	(−0.262, 0.011)	−1.811	0.071	
Employment Status	−0.013	0.055	(−0.121, 0.096)	−0.230	0.818	
Age	0.013	0.052	(−0.09, 0.116)	0.245	0.806	
What is your main source of knowledge about HPV	(Constant)	3.322	0.360	(2.614, 4.031)	9.226	0.000	
Education level	0.271	0.143	(−0.01, 0.552)	1.893	0.059	
Employment Status	0.034	0.114	(−0.19, 0.257)	0.297	0.767	
Age	0.224	0.108	(0.012, 0.437)	2.076	0.039	
Vaccine safety data is often fabricated	(Constant)	2.391	0.235	(1.929, 2.853)	10.176	0.000	
Education level	−0.019	0.093	(−0.203, 0.164)	−0.204	0.838	
Employment Status	0.060	0.074	(−0.085, 0.206)	0.815	0.416	
Age	0.027	0.070	(−0.111, 0.166)	0.384	0.701	
Immunizing children is harmful, and this fact is covered up.	(Constant)	1.883	0.237	(1.418, 2.348)	7.954	0.000	
Education level	−0.200	0.094	(−0.385, −0.015)	−2.128	0.034	
Employment Status	0.042	0.075	(−0.105, 0.189)	0.556	0.579	
Age	0.312	0.071	(0.172, 0.451)	4.387	0.000	
Pharmaceutical companies cover up the dangers of vaccines	(Constant)	2.958	0.273	(2.421, 3.495)	10.834	0.000	
Education level	−0.041	0.108	(−0.255, 0.172)	−0.382	0.703	
Employment Status	−0.037	0.086	(−0.207, 0.132)	−0.433	0.665	
Age	0.048	0.082	(−0.113, 0.209)	0.580	0.562	
Vaccine efficacy data is often fabricated.	(Constant)	2.360	0.242	(1.883, 2.836)	9.731	0.000	
Education level	−0.083	0.096	(−0.273, 0.106)	−0.866	0.387	
Employment Status	0.036	0.077	(−0.114, 0.187)	0.476	0.634	
Age	0.142	0.073	(−0.001, 0.285)	1.951	0.052	
International organizations trying to cover up the link between vaccines and autism.	(Constant)	2.214	0.256	(1.71, 2.718)	8.635	0.000	
Education level	−0.103	0.102	(−0.304, 0.097)	−1.014	0.311	
Employment Status	0.010	0.081	(−0.15, 0.169)	0.120	0.904	
Age	0.237	0.077	(0.085, 0.388)	3.076	0.002	

The reasons for the unwillingness of Saudi women’s study participants to get the HPV vaccine.

To determine the reasons for the unwillingness of Saudi women study participants to receive the HPV vaccine, each participant was given multiple options. What is/are the primary reason(s) for your refusal to receive the HPV vaccine? The options are: I consider these vaccines unsafe. I consider these vaccines ineffective. I do not consider myself at risk of HPV infection. I do not consider HPV as a common infection in Saudi. For me, it is inconvenient to be vaccinated. Visiting the doctor makes me feel uncomfortable, which keeps me from being vaccinated. I had severe side effect after having COVID-19 vaccine. Participants were also allowed to write any other reasons that influenced their decision to obtain the vaccine.

Saudi females’ study participants whos’ unwilling or hesitant to receive the HPV vaccine are (25%, n = 100) were asked to justify their reasons. Most of participants whos’ unwilling or hesitant to receive the HPV vaccine were justify their reasons as they don’t consider themself at risk of HPV (34%). The second reason was they consider these vaccines unsafe (17%). Third reason was they had severed side effect after receiving the corona virus vaccine (15%). While (13%) of participants were state other reasons such as (I do not have sexual relations, Muslims are not exposed to this virus, I don’t know where I can get the vaccine, the effectiveness of the vaccine decreases with age, I need more information about the vaccine. Other reasons that were provided by participants included the fact that they do not think HPV to be a widespread disease in Saudi Arabia (8%) or that it is not proper for them to be vaccinated for medical, personal, or religious reasons (7%). Less popular causes were that going to the doctor makes them feel uncomfortable (4%) or that they do not believe in the vaccine’s efficacy (2%) (Figure 4) Figure 4. Reasons for the unwillingness of Saudi women’s study participants to get the HPV vaccine.

Sources of HPV knowledge among Saudi female participants

The internet and social media were the most prevalent sources of information that participants claimed they used to gain knowledge about HPV (47.24%). Followed by studies in the university (21.11%), then health care providers (11.56%), then communication with family and friends (8.79%), scientific journals and articles (7.04%), TV, radio, and newspapers (3.02%), and lastly, studies in schools (1.26%) (Figure 5) Figure 5. Source of knowledge among study participants (n = 358).

Discussion

HPV is a common sexually transmitted disease and a significant cause of cervical cancer and genital warts.31 Saudi Arabia has approved the prophylactic HPV vaccine for females aged 11 to 26 to reduce HPV prevalence.32 The Ministry of Health (MoH) has called for giving girls the HPV vaccine at an early age33 and is responsible for its administration and enforcement. This study’s sociodemographic characteristics revealed a relatively young sample, with most participants aged 18–30. It is particularly important to vaccinate this age group against HPV because it falls within the recommended vaccination age range (11–26 years old).34,35

Early investigations into HPV vaccine knowledge and attitudes in Saudi Arabia revealed wide gaps. These gaps were specific to knowledge about HPV infection, its role in cancer, and HPV vaccine availability. Therefore, the primary aims of this study are to evaluate Saudi women’s overall knowledge of HPV infection and HPV-related cancers. To do so, we determined whether participants had heard of HPV before the survey. One item was mandatory: Have you heard about HPV infections? Our study revealed that 60.85% (n = 398) of Saudi women had heard about HPV before this study, based on their responses. In our study, the high percentage of HPV awareness is likely to be attributed to the fact that the majority of our study participants have a bachelor’s degree (46.99%), followed by master’s degree participants (25.38%), and PhD degree participants (18.09%). This comes in agreement with a previous study conducted at King Saud University, which found that about 60% of health college students were aware of HPV.36 Moreover, our study is in line with a previous study conducted in the United States by McBride et al.. (2018), which showed 59.72% of women reported hearing of the disease.37 In addition, our findings are supported by a study indicating that higher education level is a significant factor positively correlated with HPV awareness.37 However, other previous studies in the literature, such as the study by Chen et al.. (2021), showed only 38.5% of the women had heard of HPV.37

Further, to assess HPV knowledge, seven items were used, such as: Is HPV infection rare? Is HPV being sexually transmitted? Does HPV cause genital warts? Can HPV cause cervical cancer? Can men get HPV? Can individuals be infected with HPV for years without knowing it? Can antibiotics cure HPV infections? However, most participants responded to the knowledge questions about HPV by saying they didn’t know (63.6% to 45%), which means there is a lack of knowledge among Saudi women participating in the study about HPV.

To make informed decisions and take preventive measures, it is essential to have knowledge of HPV and its associated risks. In our study, more than half of the participants (54%) believed that HPV causes cervical cancer. These findings are in line with a study conducted in the Makkah region of Saudi Arabia, which showed that a substantial number of participants (41.6%) were aware that HPV can cause cervical cancer.38 Despite this, it should be noted that many participants were unaware of this risk. This clearly shows that comprehensive educational campaigns are necessary to improve knowledge.

We calculated the percentage of Saudi women who have received the vaccination. To assess Saudi women’s willingness to receive HPV vaccines, four items were used, such as Do you know that HPV vaccines are available? Have you gotten the HPV vaccine? Are you willing to get the HPV vaccine? Are you willing to pay for the HPV vaccine?

The study’s major finding is that the majority of Saudi women participating (79.5%) are aware that Saudi Arabia administers HPV vaccinations. However, this is inconsistent with previous and recent studies. A previous study by Akkour’s et al.. (2021) to assess the awareness of cervical cancer, HPV infection, and HPV vaccines in different regions of Saudi Arabia showed only 17.7% of participants heard about the HPV vaccine.5 A recent study by Rezq et al.. (2023) in Saudi Arabia showed 31.1% of the participants had heard of the HPV vaccine and around 11% had received it.38 The reason behind this variation in our study could be that most of our study participants are educated. As mentioned above, the highest number of participants (46.99%) had a bachelor’s degree, followed by master’s degree participants (25.38%) and PhD degree participants (18.09%). Therefore, our findings suggest that education plays a vital role in shaping individuals’ attitudes toward HPV vaccination. The percentage of Saudi women who have received the vaccination in our study is only 8.25%. This finding is consistent with a previous finding by Akkour’s 2021, which showed that only 2.0% of Saudi women received the HPV vaccine.5 This is also consistent with a recent finding by Khulud et al.. (2023) that showed only 10.9% had received the HPV vaccine.39 This highlighted the significance of raising awareness among Saudi women about the importance of vaccines for their protection against cervical cancer and HPV-related diseases. Moreover, recent systematic reviews have shown that healthcare providers should be encouraged, and narrative education regarding HPV vaccine benefits can encourage HPV vaccination uptake.40,41

In terms of HPV vaccine acceptance, a high percentage of Saudi women participating in this study (71.11%) accepted it. This is consistent with several previous studies, such as Sallam et al.’s (2021) study, which revealed that 75% of people would be open to receiving the HPV vaccine (30), and Akkour’s study in 2021, which also showed that 54.1% of Saudi women expressed a willingness to get the HPV vaccine after learning about it (5, 20). Furthermore, educated Saudi female study participants with graduate and postgraduate degrees showed the highest level of HPV vaccine acceptance. This finding suggests that HPV vaccination has a positive effect on vaccination attitudes. However, it is necessary to address concerns such as the participants’ belief that they are not at risk of HPV (34%), vaccines are unsafe (17%), feel uncomfortable (4%), and do not believe the vaccine is effective (2%), which have been reported as barriers to vaccine uptake. Previous studies have reported similar concerns, emphasizing the need for targeted interventions to address these obstacles.41–43 Rezq et al., (2023) also discovered comparable perceptions toward HPV vaccination and screening, demonstrating entrenched fallacies and a lack of awareness as major hurdles.38 Increased exposure to vaccine conspiracy beliefs in the media has been shown by Alshehri and Sallam to be correlated with worsened perceptions of vaccination, possibly amplifying hesitancy.41 Furthermore, Abdelaliem et al. highlighted the concerns, awareness, and attitudes toward HPV among nursing students, which might propose potential educational strategies focusing on both misconceptions regarding vaccination and vaccine acceptance rates.44

To the best of our knowledge, this is the first study to report that 15% of Saudi women participants believed they hesitated to get the HPV vaccine because they experienced severe side effects following the COVID vaccine. Because of the side effects associated with the COVID vaccine, many questions need to be answered regarding the potential for hesitancy spillover effects across vaccines, including the HPV vaccine. In addition, previous studies also reported that COVID vaccine attitudes may influence the uptake of other vaccines, based on scholarly and public concerns.44

In our study, the internet and social media were the primary sources of information on HPV and vaccination for 48.24% of respondents. These results are in accordance with a recent study done by Turki et al.. (2023), who demonstrated that the internet and social media were the most prevalent sources of information about HPV infection and vaccines (48.4%).45 As a result of this trend, online platforms are increasingly influential in the distribution of health information.43 Saudi health care can use this method to educate the Saudi population more about HPV and vaccination. However, this also highlights the risk of misinformation and disinformation and the need to provide accurate and reliable information to the public.

This study’s limitations included the fact that most study participants (female students who are well-educated) are expected to have a higher level of knowledge than the general population. Furthermore, the study did not collect the marital status or geographical location of the participants. Thus, the results of the current study may not be representative of the level of HPV knowledge and attitude toward HPV vaccination among the entire population in Saudi Arabia. It would be beneficial to conduct a study to investigate such an objective. Furthermore, the possibility of careless or inaccurate responses in survey studies cannot be excluded. Furthermore, because participation in this study was voluntary, respondents who showed interest may be more health aware. In this scenario, selection bias may have been introduced, resulting in an overestimation of our results. Additionally, using self-administered online surveys may limit researchers’ ability to explore participants’ responses in depth or address potential ambiguities that may arise. Despite these limitations, our study sheds light on the level of HPV vaccine acceptance among the Saudi women who participated in it. Furthermore, the study consistently includes a larger number of participants than other similar research studies, which is a significant strength of the study. Our study highlighted the urgent need to increase HPV awareness and knowledge among Saudi women. To achieve this, HPV education campaigns must be implemented to increase awareness and knowledge of HPV and related diseases. Further studies are therefore needed to present a more comprehensive study that is representative of the Saudi women’s population from diverse sociodemographic backgrounds. Longitudinal qualitative research should be conducted to gain a deeper insight into Saudi women’s knowledge, attitudes, and beliefs regarding HPV infection and vaccination through in-depth interviews or focus group discussions. Such an approach would help uncover additional cultural, social, and psychological factors that contribute to perceptions of the HPV vaccine in this population, which could be used by interventionists (public health workers) to design tailored campaigns with specific educational messages aimed at raising awareness about cervical cancer prevention and other HPV-related diseases and thus improving uptake among Saudi women.

Conclusions

The study revealed a lack of knowledge about HPV among the Saudi women participating in the study, with 60.85% of them having heard about it prior to the study. However, majority of Saudi women participating in this study (71.11%) accepted the HPV vaccine. Still, only 8.25% of Saudi women have received the vaccination. We determined several reasons for the participants’ unwillingness to receive the HPV vaccine, including their belief that they are not at risk of HPV (34%), and their belief that vaccines are unsafe (17%). Also, this is the first study to report that 15% of Saudi women participants believed they hesitated to get the HPV vaccine because they experienced severe side effects following the COVID vaccine. The internet and social media were the primary sources of HPV and vaccination information for Saudi women (48.24%). Our findings highlighted the critical need to raise HPV awareness and knowledge among Saudi women. To accomplish this, HPV education movements must be implemented to raise awareness and knowledge about HPV and related diseases. As online platforms become more influential in the distribution of health information, Saudi health care can use this method to educate the Saudi public about HPV and vaccination.

Supplementary Material

JMIG_CHERRIES.docx

Sana S. Alqarni, PhD. I am currently an assistant professor of cancer molecular genetics in the Clinical Laboratory Science Department in the College of Applied Medical Science at King Saud University in Saudi Arabia. My responsibilities include teaching at the university level, promoting learning by involving students in their learning environment, encouraging higher-order self-learning and critical thinking skills, and assisting students in analyzing, evaluating, and critically reflecting on their own experiences rather than simply transferring knowledge. Another important aspect of my job is that I am a researcher, collaborating on a variety of projects with undergraduate and postgraduate students. My research seeks to identify molecular pathways involved in the development of cancer, genetics, and inherited diseases in Saudi Arabian patients. The goal is to apply this knowledge to better understand disease mechanisms. My research seeks to identify molecular pathways involved in the development of cancer, genetics, and inherited diseases in Saudi Arabian patients. The goal is to apply this knowledge to better understand disease mechanisms and develop new diagnostic markers. This research could aid in the development of new treatment strategies for this type of illness.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Author contributions

Conceptualization, S.A. and S.A.; methodology, S.A.; software, L.A.; validation, S.A. and S.A.; formal analysis, L.A.; investigation, S.A. and S.A.; resources, S.A.; data curation, S.A.; writing – original draft preparation, S.A. and S.A.; writing – review and editing, M.A; visualization, M.A.; supervision, S.A. and S.A.; project administration, S.A; funding acquisition, M.A. All authors have read and agreed to the published version of the manuscript.

Data availability statement

All data related to this study are available from the corresponding author on upon request.

Institutional review board statement

The ethical approval to conduct the project was granted from King Saud University, Vice Rectorate for Graduate Studies and Scientific Research, Research Ethics Committee (no. KSU-HE-23-176).

Informed consent statement

Informed consent was obtained from all subjects involved in the study.

Supplementary material

Supplemental data for this article can be accessed on the publisher’s website at https://doi.org/10.1080/21645515.2024.2395086
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