ABSTRACT
Human papillomavirus (HPV) is the most prevalent sexually transmitted infection among teenagers and young adults. HPV vaccination and screening are vital preventive measures to reduce the incidence of HPV-related complications, including cervical cancer. Given the rising global incidence of cervical cancer, understanding the factors influencing awareness and knowledge among young adults in Saudi Arabia is essential for developing effective prevention strategies. This study investigates the levels of awareness, knowledge, and vaccine acceptability regarding HPV and cervical cancer among college students in Saudi Arabia. A cross-sectional study was conducted between May and September 2023 among 442 students in Saudi Arabia using a structured questionnaire to assess their knowledge and awareness of HPV, HPV vaccination, and cervical cancer. Multivariate logistic regression analysis was employed to examine the associations between predictor and dependent variables. Among participants, 54.1% were aware of HPV, and 66.5% had heard of cervical cancer. However, only 17% correctly identified HPV16 and HPV18 as high-risk genotypes for cervical cancer. Awareness of the HPV vaccine was reported by 36.2% of participants, with just 10% having received the vaccine. Female students exhibited significantly higher knowledge levels than males (p = .018). The primary barrier to vaccination was identified as a lack of education and awareness (80.1%). The study highlights a significant gap in knowledge and awareness regarding HPV, its vaccine, and cervical cancer among college students in Saudi Arabia. Targeted educational programs and awareness campaigns are essential to enhance understanding and promote preventive practices, including vaccination and regular screening.
KEYWORDS: HPV, cervical cancer, pap smear, Saudi Arabia, vaccination, knowledge
Introduction
The human papillomavirus (HPV) is a prevalent infection that is transmitted sexually. It can result in genital warts, cervical cancer, and other types of cancers.1 In Saudi Arabia, where HPV infection is widely spread, cervical cancer is the ninth most prevalent malignancy in Saudi women of all age ranges.2–4 Several studies conducted in Saudi Arabia have indicated that public knowledge and awareness of HPV remain low among the population.5–8
Currently, there are three prophylactic HPV vaccines available globally: the bivalent vaccine (Cervarix) targeting HPV types 16 and 18, the quadrivalent vaccine (Gardasil) targeting HPV types 6, 11, 16, and 18, and the nonavalent vaccine (Gardasil 9) covering nine HPV types including 6, 11, 16, 18, 31, 33, 45, 52, and 58. These vaccines have demonstrated high efficacy in preventing HPV infections and related cervical lesions when administered prior to exposure to the virus, typically recommended for preadolescents and young adults.9
In addition to vaccination, secondary prevention methods such as regular cervical screening through Pap smears and HPV DNA testing play a crucial role in early detection and management of precancerous lesions.10 Emerging studies have also explored the role of topical agents like carrageenan in preventing HPV transmission, suggesting potential as a microbicide due to its ability to inhibit HPV infection.11
Public attitudes toward STIs and preventive measures vary across different socio-demographic contexts. Studies have indicated that stigma, lack of awareness, and cultural factors significantly influence individuals’ willingness to engage in preventive practices and accept vaccination.12 Understanding these attitudes is essential for developing effective health education programs and interventions aimed at reducing the prevalence of HPV and associated diseases.
Although the HPV vaccine is available in Saudi Arabia, nothing is known about how well-informed college students in Riyadh are about the vaccine and cervical cancer. The fundamental factors that lead to cervical cancer development in women living across various regions of the globe are numerous determinants which are the prevalence of human papillomavirus, the absence of screening programs, the lack of access to health care, certain social environments, which promote certain behavioral factors, values, and beliefs about this disease.
Despite the Saudi MOH’s publication of HPV screening practice guidelines in 2014, a national screening program for the human papillomavirus (HPV) and cervical cancer has not yet been implemented in Saudi Arabia due to the reported low incidence of the disease and cost savings issues. Women in Saudi Arabia are projected to have a cervical cancer incidence of 2.2 per 100,000 age-standardized rates (ASR), according to the GLOBOCAN Report 2012. 84 (34.8%) out of a total of 241 women died from cervical cancer.13 In Saudi Arabia, the incidence of cervical cancer has shown a significant increase over the past decades, with recent statistics reporting approximately 358 new cases and 179 deaths annually.14 In addition, Saudi Arabia has a prevalence of as much as 96% HPV infection in aggressive cervical cancer, which is consistent with the 85–99% reported incidence globally. 43% of incidents of cancer to the cervix, in Saudi Arabia, are discovered at later stages, stages 3 and 4, in patients with this disease.15 While in other areas of the world, which operate and are knowledgeable about reliable screening programs percentages can be as low as 25%, such as in British Colombia.16 The most effective method to reduce the incidence of cervical cancer entails early detection through cervical cancer screening programs, as well as raising awareness and implementing educational initiatives. For the occurrence of cervical cancer to be kept to a minimum, the population’s degree of awareness and willingness to do the screening test and receive the vaccine is crucial.
Arguments against Saudi acceptance could be due to two factors which are the shortage of knowledge toward its benefits and social attitudes and culture that may discourage Saudis from accepting the HPV vaccine as a means of preventing cervical cancer. Such reluctance has important ramifications because lower vaccination rates would raise the financial strain on healthcare systems given the critical role vaccinations play in lowering hospitalization and death rates. Despite the paucity of information regarding the existence of the HPV virus in the region, young women in Saudi Arabia might gain an advantage from implementing a vaccine against human papillomavirus due to the expected rise in cervical cancer rates in the country.
The current study’s objective is to find out how well-informed college students in Riyadh are about HPV infection, the vaccine, and cervical cancer.
Materials and methods
Study design and participants
A cross-sectional study was conducted between May 2023 to September 2023 among students in Saudi Arabia. A total of 442 participants were recruited using convenience sampling through online platforms and university networks…
Survey instrument
Data were collected using a structured, self-administered questionnaire designed to assess knowledge and awareness of HPV, HPV vaccination, and cervical cancer. The questionnaire was developed based on a comprehensive review of existing literature and previously validated instruments used in similar studies.2,4,5,7 It comprised four sections: demographic information, knowledge about HPV, awareness and acceptability of HPV vaccination, and knowledge about cervical cancer and screening practices.
Validity and reliability
To ensure content validity, the questionnaire was reviewed by a panel of experts including epidemiologists, gynecologists, and public health professionals. A pilot study was conducted with 30 students to test the clarity, relevance, and reliability of the questions. The feedback obtained led to minor revisions for improved comprehension. The internal consistency of the knowledge sections was assessed using Cronbach’s alpha, yielding a value of 0.82, indicating good reliability. The results of the pilot study were excluded from the final analysis.
Data collection process
This study targeted college students in Riyadh, students from ages 18 years old to 25 years old. Data were collected using the English and Arabic language questionnaires that required acceptance by the participants. The final questionnaire was distributed electronically, and participation was voluntary. Informed consent was obtained from all participants prior to data collection.
Sampling procedure
The sample size proposed for this study was calculated to be 384 participants using http://www.raosoft.com/samplesize.html (accessed on 1 March 2023). This calculation was based on the prevalence of knowledge of 50% and a 95% confidence interval, with an error rate of less than 5% in a population of 7.6 million. However, to account for potential non-responses or incomplete surveys, the sample size was increased to 440.
Ethical considerations
The study was approved by the Alfaisal University Institutional Review Board (IRB log no. IRB-20240). The study was by the ethical guidelines of the Helsinki Declaration and the local guidelines of the National Committee of Bioethics, Saudi Arabia. A brief paragraph emphasizing the confidentiality of their responses and the option to withdraw from the survey at any time was written online. They were also informed of their right to withdraw from the study, without incurring any negative consequences. Written informed consent was obtained from the study participants before the study’s commencement. All collected data were securely housed, with exclusive access granted only to the research team, thereby ensuring protection against unauthorized use, access, or dissemination. The principal investigator guaranteed the confidentiality of the data. This manuscript has been reported in line with the STROCSS criteria.17
Statistical analysis
The data was analyzed using R programming language version 3.6.3. Categorical data were presented as frequencies and proportions and compared using the Chi-square test or Fischer’s exact t-test, as appropriate. Continuous data were presented as a median with an interquartile range and were compared using the Mann – Whitney U test. Multivariate logistic regression analysis was performed to determine the association between the predictor and dependent variables. A p value of < 0.05 was considered statistically significant.
Results
In this study, a total of 442 questionnaires were completed, with 392 (88.7%) belonging to college students and 50 (11.3%) from non-college students. The ages of the students had a median (interquartile range) of 20 [19–22] years, and out of the 442 participants, 82 (18.6%) were male. The majority of the students were unmarried and from the Central region, specifically Riyadh. A significant portion of the participants, 239 (54.1%), were aware of HPV, and 294 (66.5%) had knowledge of cervical cancer. Regarding the vaccine for cervical cancer, 160 (36.2%) participants reported awareness, while only 44 (10.0%) stated they had been vaccinated against HPV. Among the participants, a total of 198 (44.7%) were aware of the recommended age for receiving the HPV vaccine. Only 37 (8.4%) participants could correctly identify the available HPV vaccines. A significant majority of 326 (73.8%) participants were knowledgeable about the sexual transmission of HPV. The primary obstacle to receiving the HPV vaccine, as reported by 354 (80.1%) respondents, was a lack of education and awareness. However, 167 (37.8%) participants expressed their willingness to be vaccinated against HPV in the future, while 42 (9.5%) still had no plans for vaccination. Additionally, 97 (21.9%) participants recognized the need for regular screening after receiving the vaccine.
Table 1 presents a concise summary of the characteristics of the participants included in this study. Statistically, the male participants were found to be older than the female participants, with median ages of 21.00 [20.00–22.75] years for males and 20.00 [19.00–22.00] years for females (p-value = .003). It was observed that a greater number of males were aware that smoking is one of the causes of cervical cancer compared to females (p-value = .026). Conversely, more females identified Human Papillomavirus (HPV) as one of the causes of cervical cancer compared to males (p-value = .038).
Table 1.
Demographic data of the participants.
| Variable | Overall (n=442) | |
|---|---|---|
| Gender (%) | Female | 360 (81.4) |
| Male | 82 (18.6) | |
| Age (median [IQR]) | 20.00 [19.00, 22.00] | |
| Age Groups (%) | 18–26 years old | 432 (97.7) |
| More than 26 years old | 10 (2.3) | |
| Region (%) | Central region (Riyadh) | 345 (78.1) |
| Eastern Region | 31 (7.0) | |
| Northern region | 8 (1.8) | |
| Southern region | 9 (2.0) | |
| Western Region | 49 (11.1) | |
| Marital status (%) | Divorced | 2 (0.5) |
| Married | 5 (1.1) | |
| Single | 432 (97.7) | |
| Widow | 3 (0.7) | |
| Education (%) | Not college student | 50 (11.3) |
| College student | 392 (88.7) | |
| Do you know what cervical cancer is (%) | No | 148 (33.5) |
| Yes | 294 (66.5) | |
| What causes cervical cancer? | ||
| Smoking (%) | No | 326 (73.8) |
| Yes | 116 (26.2) | |
| Human papilloma virus (%) | No | 76 (17.2) |
| Yes | 366 (82.8) | |
| Oral contraceptives 10%) | No | 315 (71.3) |
| Yes | 127 (28.7) | |
| Bad diet (%) | No | 385 (87.1) |
| Yes | 57 (12.9) | |
| Alcohol (%) | No | 374 (84.6) |
| Yes | 68 (15.4) | |
| Is there a vaccine for cervical cancer (%) | I don’t know | 254 (57.5) |
| No | 28 (6.3) | |
| Yes | 160 (36.2) | |
| Have you heard about Human Papillomavirus HPV (%) | No | 203 (45.9) |
| Yes | 239 (54.1) | |
| Have you been vaccinated for HPV (%) | No | 398 (90.0) |
| Yes | 44 (10.0) | |
| Who is eligible for taking the HPV vaccine (%) | 27 years old and older | 43 (9.7) |
| 5 years-9 years old | 13 (2.9) | |
| 9 years-26 years old | 142 (32.1) | |
| I don’t know | 227 (51.4) | |
| Newborns | 17 (3.8) | |
| What are the different types of HPV that cause cancer (%) | HPV16 and HPV18 | 75 (17.0) |
| HPV16 AND HPV31 | 24 (5.4) | |
| HPV33 and HPV35 | 9 (2.0) | |
| I don’t know | 334 (75.6) | |
| Do you know what kinds of HPV vaccines are available (%) | No | 405 (91.6) |
| Yes | 37 (8.4) | |
| How can HPV get transmitted (%) | I don’t know | 173 (39.1) |
| Infectious Animal Disease | 3 (0.7) | |
| Inhalation (cough/sneeze.etc) | 11 (2.5) | |
| Sexually | 255 (57.7) | |
| Do you think that HPV can get transmitted sexually (%) | I don’t know | 101 (22.9) |
| No | 15 (3.4) | |
| Yes | 326 (73.8) | |
| What do you believe will be the primary barrier to receiving the HPV vaccine? | ||
| Lack of education and awareness (%) | No | 88 (19.9) |
| Yes | 354 (80.1) | |
| Fear or embarrassment (%) | No | 351 (79.4) |
| Yes | 91 (20.6) | |
| I don t believe in vaccinations (%) | No | 441 (99.8) |
| Yes | 1 (0.2) | |
| All of the above (%) | No | 440 (99.5) |
| Yes | 2 (0.5) | |
| Ignorance and shame (%) | No | 441 (99.8) |
| Yes | 1 (0.2) | |
| Don’t know (%) | No | 431 (97.5) |
| Yes | 11 (2.5) | |
| Busy (%) | No | 440 (99.5) |
| Yes | 2 (0.5) | |
| Poverty (%) | No | 441 (99.8) |
| Yes | 1 (0.2) | |
| If you have t received the HPV vaccine, do you think you will get vaccinated against HPV in the future (%) | I don’t know | 173 (39.1) |
| I have received the vaccine already | 25 (5.7) | |
| I need my parents’ approval | 35 (7.9) | |
| No | 42 (9.5) | |
| Yes | 167 (37.8) | |
| Have you ever heard of Pap test before (%) | No | 227 (51.4) |
| Yes | 215 (48.6) | |
| When should a woman have her first Pap test in your opinion (%) | 65 years old and older | 5 (1.1) |
| From age 10–19 years old | 74 (16.7) | |
| From age 20–65 years old | 261 (59.0) | |
| I don’t know | 102 (23.1) | |
| How regularly should a woman practice the Pap test in your opinion (%) | Every 1 year | 180 (40.7) |
| Every 3 months | 45 (10.2) | |
| Every 3 years | 97 (21.9) | |
| I don’t know | 120 (27.1) | |
| What might discourage you from getting Pap test practice? | ||
| Fear of discovering disease (%) | No | 356 (80.5) |
| Yes | 86 (19.5) | |
| Time (%) | No | 346 (78.3) |
| Yes | 96 (21.7) | |
| Lack of knowledge and awareness (%) | No | 181 (41.0) |
| Yes | 261 (59.0) | |
| Fear of discovering disease (%) | No | 356 (80.5) |
| Yes | 86 (19.5) | |
| Cultural reasons (%) | No | 440 (99.5) |
| Yes | 2 (0.5) | |
| I’m a male (%) | No | 378 (85.5) |
| Yes | 64 (14.5) | |
| Way of examination (%) | No | 440 (99.5) |
| Yes | 2 (0.5) | |
| I don’t know (%) | No | 435 (98.4) |
| Yes | 7 (1.6) | |
| Nothing (%) | No | 438 (99.1) |
| Yes | 4 (0.9) | |
| Discourage you from getting Pap test discomfort (%) | No | 441 (99.8) |
| Yes | 1 (0.2) | |
| Do Pap tests need to be performed on women who have received the HPV vaccine in your opinion (%) | I don’t know | 163 (36.9) |
| No | 51 (11.5) | |
| Yes | 228 (51.6) | |
| Clinical signs of cervical cancer include? | ||
| Pelvic pain (%) | No | 145 (32.8) |
| Yes | 297 (67.2) | |
| Bleeding (%) | No | 169 (38.2) |
| Yes | 273 (61.8) | |
| Vaginal discharge (%) | No | 175 (39.6) |
| Yes | 267 (60.4) | |
| Back pain (%) | No | 329 (74.4) |
| Yes | 113 (25.6) | |
| Weight loss (%) | No | 298 (67.4) |
| Yes | 144 (32.6) | |
| Dyspareunia (%) | No | 441 (99.8) |
| Yes | 1 (0.2) | |
| Risk factors of cervical cancer? | ||
| Smoking (%) | No | 318 (71.9) |
| Yes | 124 (28.1) | |
| Oral contraceptives (%) | No | 280 (63.3) |
| Yes | 162 (36.7) | |
| Age (%) | No | 319 (72.2) |
| Yes | 123 (27.8) | |
| Family history (%) | No | 179 (40.5) |
| Yes | 263 (59.5) | |
| Bad diet (%) | No | 367 (83.0) |
| Yes | 75 (17.0) | |
| Multiple sexual partners (%) | No | 114 (25.8) |
| Yes | 328 (74.2) | |
| Risk factors of cervical cancer I don t know (%) | No | 427 (96.6) |
| Yes | 15 (3.4) | |
| What are your sources of information and understanding regarding HPV vaccination (%) | Family and friends | 29 (6.6) |
| Friends | 1 (0.2) | |
| I don’t know | 153 (34.6) | |
| Medical experts, studies | 114 (25.8) | |
| School | 1 (0.2) | |
| Social media | 143 (32.4) | |
| web sites | 1 (0.2) | |
In Table 2, it is evident that the percentage of males (62.2%) who lacked knowledge about the different types of HPV vaccines was lower than the percentage of females (78.6%) (p-value = .018).
Table 2.
Baseline demographic characteristics of the male and female participants.
| level | Female | Male | P-value | |
|---|---|---|---|---|
| Age (median [IQR]) | 20.00 [19.00, 22.00] | 21.00 [20.00, 22.75] | .003*** | |
| Age Group (%) | 18–26 years old | 355 (98.6) | 77 (93.9) | .03*** |
| More than 26 years old | 5 (1.4) | 5 (6.1) | ||
| Region (%) | Central region (Riyadh) | 276 (76.7) | 69 (84.1) | .234 |
| Eastern Region | 29 (8.1) | 2 (2.4) | ||
| Northern region | 7 (1.9) | 1 (1.2) | ||
| Southern region | 6 (1.7) | 3 (3.7) | ||
| Western Region | 42 (11.7) | 7 (8.5) | ||
| Marital status (%) | divorced | 2 (0.6) | 0 (0.0) | .103 |
| Married | 5 (1.4) | 0 (0.0) | ||
| Single | 352 (97.8) | 80 (97.6) | ||
| widow | 1 (0.3) | 2 (2.4) | ||
| Education (%) | Not college student | 38 (10.6) | 12 (14.6) | .39 |
| College student | 322 (89.4) | 70 (85.4) | ||
| Do you know what cervical cancer is (%) | No | 117 (32.5) | 31 (37.8) | .43 |
| Yes | 243 (67.5) | 51 (62.2) | ||
| What causes cervical cancer? | ||||
| Smoking (%) | No | 274 (76.1) | 52 (63.4) | .026*** |
| Yes | 86 (23.9) | 30 (36.6) | ||
| Human papilloma virus (%) | No | 55 (15.3) | 21 (25.6) | .038*** |
| Yes | 305 (84.7) | 61 (74.4) | ||
| Oral contraceptives 10%) | No | 259 (71.9) | 56 (68.3) | .6 |
| Yes | 101 (28.1) | 26 (31.7) | ||
| Bad diet (%) | No | 314 (87.2) | 71 (86.6) | 1 |
| Yes | 46 (12.8) | 11 (13.4) | ||
| Alcohol (%) | No | 307 (85.3) | 67 (81.7) | .523 |
| Yes | 53 (14.7) | 15 (18.3) | ||
| Is there a vaccine for cervical cancer (%) | I don’t know | 206 (57.2) | 48 (58.5) | .295 |
| No | 20 (5.6) | 8 (9.8) | ||
| Yes | 134 (37.2) | 26 (31.7) | ||
| Have you heard about Human Papillomavirus HPV (%) | No | 171 (47.5) | 32 (39.0) | .205 |
| Yes | 189 (52.5) | 50 (61.0) | ||
| Have you been vaccinated for HPV (%) | No | 322 (89.4) | 76 (92.7) | .497 |
| Yes | 38 (10.6) | 6 (7.3) | ||
| Who is eligible for taking the HPV vaccine (%) | 27 years old and older | 37 (10.3) | 6 (7.3) | .735 |
| 5 years-9 years old | 10 (2.8) | 3 (3.7) | ||
| 9 years-26 years old | 119 (33.1) | 23 (28.0) | ||
| I don’t know | 180 (50.0) | 47 (57.3) | ||
| Newborns | 14 (3.9) | 3 (3.7) | ||
| What are the different types of HPV that cause cancer (%) | HPV16 and HPV18 | 53 (14.7) | 22 (26.8) | .018*** |
| HPV16 AND HPV31 | 18 (5.0) | 6 (7.3) | ||
| HPV33 and HPV35 | 6 (1.7) | 3 (3.7) | ||
| I don’t know | 283 (78.6) | 51 (62.2) | ||
| Do you know what kinds of HPV vaccines are available (%) | No | 332 (92.2) | 73 (89.0) | .47 |
| Yes | 28 (7.8) | 9 (11.0) | ||
| How can HPV get transmitted (%) | I don’t know | 132 (36.7) | 41 (50.0) | .124 |
| Infectious Animal Disease | 3 (0.8) | 0 (0.0) | ||
| Inhalation (cough/sneeze.etc) | 10 (2.8) | 1 (1.2) | ||
| Sexually | 215 (59.7) | 40 (48.8) | ||
| Do you think that HPV can get transmitted sexually (%) | I don’t know | 78 (21.7) | 23 (28.0) | .122 |
| No | 10 (2.8) | 5 (6.1) | ||
| Yes | 272 (75.6) | 54 (65.9) | ||
| What do you believe will be the primary barrier to receiving the HPV vaccine? | ||||
| Lack of education and awareness (%) | No | 66 (18.3) | 22 (26.8) | .113 |
| Yes | 294 (81.7) | 60 (73.2) | ||
| Fear or embarrassment (%) | No | 289 (80.3) | 62 (75.6) | .428 |
| Yes | 71 (19.7) | 20 (24.4) | ||
| I don t believe in vaccinations (%) | No | 359 (99.7) | 82 (100.0) | 1 |
| Yes | 1 (0.3) | 0 (0.0) | ||
| All of the above (%) | No | 359 (99.7) | 81 (98.8) | .814 |
| Yes | 1 (0.3) | 1 (1.2) | ||
| Ignorance and shame (%) | No | 359 (99.7) | 82 (100.0) | 1 |
| Yes | 1 (0.3) | 0 (0.0) | ||
| Don’t know (%) | No | 352 (97.8) | 79 (96.3) | .718 |
| Yes | 8 (2.2) | 3 (3.7) | ||
| Busy (%) | No | 358 (99.4) | 82 (100.0) | 1 |
| Yes | 2 (0.6) | 0 (0.0) | ||
| Poverty (%) | No | 360 (100.0) | 81 (98.8) | .418 |
| Yes | 0 (0.0) | 1 (1.2) | ||
| If you have t received the HPV vaccine, do you think you will get vaccinated against HPV in the future (%) | I don’t know | 129 (35.8) | 44 (53.7) | <.001*** |
| I have received the vaccine already | 23 (6.4) | 2 (2.4) | ||
| I need my parents’ approval | 33 (9.2) | 2 (2.4) | ||
| No | 26 (7.2) | 16 (19.5) | ||
| Yes | 149 (41.4) | 18 (22.0) | ||
| Have you ever heard of Pap test before (%) | No | 176 (48.9) | 51 (62.2) | .04*** |
| Yes | 184 (51.1) | 31 (37.8) | ||
| When should a woman have her first Pap test in your opinion (%) | 65 years old and older | 4 (1.1) | 1 (1.2) | <.001*** |
| From age 10–19 years old | 54 (15.0) | 20 (24.4) | ||
| From age 20–65 years old | 231 (64.2) | 30 (36.6) | ||
| I don’t know | 71 (19.7) | 31 (37.8) | ||
| How regularly should a woman practice the Pap test in your opinion (%) | Every 1 year | 158 (43.9) | 22 (26.8) | .002*** |
| Every 3 months | 41 (11.4) | 4 (4.9) | ||
| Every 3 years | 73 (20.3) | 24 (29.3) | ||
| I don’t know | 88 (24.4) | 32 (39.0) | ||
| What might discourage you from getting Pap test practice? | ||||
| Fear of discovering disease (%) | No | 280 (77.8) | 76 (92.7) | .003*** |
| Yes | 80 (22.2) | 6 (7.3) | ||
| Time (%) | No | 268 (74.4) | 78 (95.1) | <.001*** |
| Yes | 92 (25.6) | 4 (4.9) | ||
| Lack of knowledge and awareness (%) | No | 117 (32.5) | 64 (78.0) | <.001*** |
| Yes | 243 (67.5) | 18 (22.0) | ||
| Fear of discovering disease (%) | No | 280 (77.8) | 76 (92.7) | .003*** |
| Yes | 80 (22.2) | 6 (7.3) | ||
| Cultural reasons (%) | No | 358 (99.4) | 82 (100.0) | 1 |
| Yes | 2 (0.6) | 0 (0.0) | ||
| I’m a male (%) | No | 356 (98.9) | 22 (26.8) | <.001*** |
| Yes | 4 (1.1) | 60 (73.2) | ||
| Way of examination (%) | No | 358 (99.4) | 82 (100.0) | 1 |
| Yes | 2 (0.6) | 0 (0.0) | ||
| I don’t know (%) | No | 355 (98.6) | 80 (97.6) | .844 |
| Yes | 5 (1.4) | 2 (2.4) | ||
| Nothing (%) | No | 356 (98.9) | 82 (100.0) | .754 |
| Yes | 4 (1.1) | 0 (0.0) | ||
| Discourage you from getting Pap test discomfort (%) | No | 359 (99.7) | 82 (100.0) | 1 |
| Yes | 1 (0.3) | 0 (0.0) | ||
| Do Pap tests need to be performed on women who have received the HPV vaccine in your opinion (%) | I don’t know | 132 (36.7) | 31 (37.8) | .173 |
| No | 37 (10.3) | 14 (17.1) | ||
| Yes | 191 (53.1) | 37 (45.1) | ||
| Clinical signs of cervical cancer include? | ||||
| Pelvic pain (%) | No | 117 (32.5) | 28 (34.1) | .876 |
| Yes | 243 (67.5) | 54 (65.9) | ||
| Bleeding (%) | No | 131 (36.4) | 38 (46.3) | .122 |
| Yes | 229 (63.6) | 44 (53.7) | ||
| Vaginal discharge (%) | No | 147 (40.8) | 28 (34.1) | .321 |
| Yes | 213 (59.2) | 54 (65.9) | ||
| Back pain (%) | No | 268 (74.4) | 61 (74.4) | 1 |
| Yes | 92 (25.6) | 21 (25.6) | ||
| Weight loss (%) | No | 254 (70.6) | 44 (53.7) | .005 |
| Yes | 106 (29.4) | 38 (46.3) | ||
| Dyspareunia (%) | No | 360 (100.0) | 81 (98.8) | .418 |
| Yes | 0 (0.0) | 1 (1.2) | ||
| Risk factors of cervical cancer? | ||||
| Smoking (%) | No | 267 (74.2) | 51 (62.2) | .041 |
| Yes | 93 (25.8) | 31 (37.8) | ||
| Oral contraceptives (%) | No | 227 (63.1) | 53 (64.6) | .888 |
| Yes | 133 (36.9) | 29 (35.4) | ||
| Age (%) | No | 263 (73.1) | 56 (68.3) | .464 |
| Yes | 97 (26.9) | 26 (31.7) | ||
| Family history (%) | No | 144 (40.0) | 35 (42.7) | .747 |
| Yes | 216 (60.0) | 47 (57.3) | ||
| Bad diet (%) | No | 302 (83.9) | 65 (79.3) | .399 |
| Yes | 58 (16.1) | 17 (20.7) | ||
| Multiple sexual partners (%) | No | 92 (25.6) | 22 (26.8) | .922 |
| Yes | 268 (74.4) | 60 (73.2) | ||
| Risk factors of cervical cancer I don t know (%) | No | 347 (96.4) | 80 (97.6) | .848 |
| Yes | 13 (3.6) | 2 (2.4) | ||
| What are your sources of information and understanding regarding HPV vaccination (%) | Family and friends | 23 (6.4) | 6 (7.3) | .011*** |
| Friends | 0 (0.0) | 1 (1.2) | ||
| I don’t know | 122 (33.9) | 31 (37.8) | ||
| Medical experts, studies | 87 (24.2) | 27 (32.9) | ||
| School | 1 (0.3) | 0 (0.0) | ||
| Social media | 127 (35.3) | 16 (19.5) | ||
| web sites | 0 (0.0) | 1 (1.2) | ||
The p-values which have “***” after them are the significant p-values.
The participants who were enrolled in college exhibited a higher level of knowledge regarding the vaccine for cervical cancer when compared to non-college participants (p-value = .02). Furthermore, college students demonstrated a greater ability to identify different types of HPV in comparison to other participants (p-value = .015). These findings are summarized in Table 3.
Table 3.
Baseline demographic characteristics of college and not college students.
| level | Not college student | College | P-value | |
|---|---|---|---|---|
| Gender (%) | Female | 38 (76.0) | 322 (82.1) | .39 |
| Male | 12 (24.0) | 70 (17.9) | ||
| Age (median [IQR]) | 20.00 [18.00, 24.00] | 20.00 [19.00, 22.00] | .857 | |
| Age Group (%) | 18–26 years old | 42 (84.0) | 390 (99.5) | <.001*** |
| More than 26 years old | 8 (16.0) | 2 (0.5) | ||
| Region (%) | Central region (Riyadh) | 28 (56.0) | 317 (80.9) | <.001*** |
| Eastern Region | 3 (6.0) | 28 (7.1) | ||
| Northern Region | 1 (2.0) | 7 (1.8) | ||
| Southern Region | 6 (12.0) | 3 (0.8) | ||
| Western Region | 12 (24.0) | 37 (9.4) | ||
| Marital status (%) | divorced | 1 (2.0) | 1 (0.3) | .005*** |
| Married | 1 (2.0) | 4 (1.0) | ||
| Single | 46 (92.0) | 386 (98.5) | ||
| widow | 2 (4.0) | 1 (0.3) | ||
| Do you know what cervical cancer is (%) | No | 26 (52.0) | 122 (31.1) | .005*** |
| Yes | 24 (48.0) | 270 (68.9) | ||
| What causes cervical cancer? | ||||
| Smoking (%) | No | 35 (70.0) | 291 (74.2) | .638 |
| Yes | 15 (30.0) | 101 (25.8) | ||
| Human papilloma virus (%) | No | 11 (22.0) | 65 (16.6) | .449 |
| Yes | 39 (78.0) | 327 (83.4) | ||
| Oral contraceptives 10%) | No | 37 (74.0) | 278 (70.9) | .774 |
| Yes | 13 (26.0) | 114 (29.1) | ||
| Bad diet (%) | No | 43 (86.0) | 342 (87.2) | .981 |
| Yes | 7 (14.0) | 50 (12.8) | ||
| Alcohol (%) | No | 42 (84.0) | 332 (84.7) | 1 |
| Yes | 8 (16.0) | 60 (15.3) | ||
| Is there a vaccine for cervical cancer (%) | I don’t know | 37 (74.0) | 217 (55.4) | .02 |
| No | 0 (0.0) | 28 (7.1) | ||
| Yes | 13 (26.0) | 147 (37.5) | ||
| Have you heard about Human Papillomavirus HPV (%) | No | 25 (50.0) | 178 (45.4) | .643 |
| Yes | 25 (50.0) | 214 (54.6) | ||
| Have you been vaccinated for HPV (%) | No | 43 (86.0) | 355 (90.6) | .445 |
| Yes | 7 (14.0) | 37 (9.4) | ||
| Who is eligible for taking HPV vaccine (%) | 27 years old and older | 7 (14.0) | 36 (9.2) | .717 |
| 5 years-9 years old | 1 (2.0) | 12 (3.1) | ||
| 9 years-26 years old | 14 (28.0) | 128 (32.7) | ||
| I don’t know | 27 (54.0) | 200 (51.0) | ||
| Newborns | 1 (2.0) | 16 (4.1) | ||
| What are the different types of HPV that cause cancer (%) | HPV16 and HPV18 | 5 (10.0) | 70 (17.9) | .015*** |
| HPV16 AND HPV31 | 7 (14.0) | 17 (4.3) | ||
| HPV33 and HPV35 | 2 (4.0) | 7 (1.8) | ||
| I don’t know | 36 (72.0) | 298 (76.0) | ||
| Do you know what kinds of HPV vaccines are available (%) | No | 45 (90.0) | 360 (91.8) | .865 |
| Yes | 5 (10.0) | 32 (8.2) | ||
| How can HPV get transmitted (%) | I don’t know | 21 (42.0) | 152 (38.8) | .307 |
| Infectious Animal Disease | 0 (0.0) | 3 (0.8) | ||
| Inhalation (cough/sneeze.etc) | 3 (6.0) | 8 (2.0) | ||
| Sexually | 26 (52.0) | 229 (58.4) | ||
| Do you think that HPV can get transmitted sexually (%) | I don’t know | 13 (26.0) | 88 (22.4) | .001*** |
| No | 6 (12.0) | 9 (2.3) | ||
| Yes | 31 (62.0) | 295 (75.3) | ||
| What do you believe will be the primary barrier to receiving the HPV vaccine? | ||||
| Lack of education and awareness (%) | No | 6 (12.0) | 82 (20.9) | .194 |
| Yes | 44 (88.0) | 310 (79.1) | ||
| Fear or embarrassment (%) | No | 40 (80.0) | 311 (79.3) | 1 |
| Yes | 10 (20.0) | 81 (20.7) | ||
| I don t believe in vaccinations (%) | No | 50 (100.0) | 391 (99.7) | 1 |
| Yes | 0 (0.0) | 1 (0.3) | ||
| All of the above (%) | No | 50 (100.0) | 390 (99.5) | 1 |
| Yes | 0 (0.0) | 2 (0.5) | ||
| Ignorance and shame (%) | No | 50 (100.0) | 391 (99.7) | 1 |
| Yes | 0 (0.0) | 1 (0.3) | ||
| Don’t know (%) | No | 48 (96.0) | 383 (97.7) | .805 |
| Yes | 2 (4.0) | 9 (2.3) | ||
| Busy (%) | No | 50 (100.0) | 390 (99.5) | 1 |
| Yes | 0 (0.0) | 2 (0.5) | ||
| Poverty (%) | No | 49 (98.0) | 392 (100.0) | .221 |
| Yes | 1 (2.0) | 0 (0.0) | ||
| If you haven t received HPV vaccine, do you think you will get vaccinated against HPV in the future (%) | I don’t know | 20 (40.0) | 153 (39.0) | .318 |
| I have received the vaccine already | 2 (4.0) | 23 (5.9) | ||
| I need my parents’ approval | 7 (14.0) | 28 (7.1) | ||
| No | 2 (4.0) | 40 (10.2) | ||
| Yes | 19 (38.0) | 148 (37.8) | ||
| Have you ever heard of Pap test before (%) | No | 32 (64.0) | 195 (49.7) | .08 |
| Yes | 18 (36.0) | 197 (50.3) | ||
| When should a woman have her first Pap test in your opinion (%) | 65 years old and older | 1 (2.0) | 4 (1.0) | .001*** |
| From age 10–19 years old | 18 (36.0) | 56 (14.3) | ||
| From age 20–65 years old | 21 (42.0) | 240 (61.2) | ||
| I don’t know | 10 (20.0) | 92 (23.5) | ||
| How regularly should a woman practice the Pap test in your opinion (%) | Every 1 year | 24 (48.0) | 156 (39.8) | .338 |
| Every 3 months | 7 (14.0) | 38 (9.7) | ||
| Every 3 years | 7 (14.0) | 90 (23.0) | ||
| I don’t know | 12 (24.0) | 108 (27.6) | ||
| What might discourage you from getting Pap test practice? | ||||
| Fear of discovering disease (%) | No | 41 (82.0) | 315 (80.4) | .931 |
| Yes | 9 (18.0) | 77 (19.6) | ||
| Time (%) | No | 37 (74.0) | 309 (78.8) | .55 |
| Yes | 13 (26.0) | 83 (21.2) | ||
| Lack of knowledge and awareness (%) | No | 21 (42.0) | 160 (40.8) | .994 |
| Yes | 29 (58.0) | 232 (59.2) | ||
| Fear of discovering disease (%) | No | 41 (82.0) | 315 (80.4) | .931 |
| Yes | 9 (18.0) | 77 (19.6) | ||
| Cultural reasons (%) | No | 50 (100.0) | 390 (99.5) | 1 |
| Yes | 0 (0.0) | 2 (0.5) | ||
| I’m a male (%) | No | 40 (80.0) | 338 (86.2) | .335 |
| Yes | 10 (20.0) | 54 (13.8) | ||
| Way of examination (%) | No | 50 (100.0) | 390 (99.5) | 1 |
| Yes | 0 (0.0) | 2 (0.5) | ||
| I don’t know (%) | No | 50 (100.0) | 385 (98.2) | .726 |
| Yes | 0 (0.0) | 7 (1.8) | ||
| Nothing (%) | No | 50 (100.0) | 388 (99.0) | 1 |
| Yes | 0 (0.0) | 4 (1.0) | ||
| Discourage you from getting Pap test discomfort (%) | No | 50 (100.0) | 391 (99.7) | 1 |
| Yes | 0 (0.0) | 1 (0.3) | ||
| Do Pap tests need to be performed on women who have received the HPV vaccine in your opinion (%) | I don’t know | 21 (42.0) | 142 (36.2) | .72 |
| No | 5 (10.0) | 46 (11.7) | ||
| Yes | 24 (48.0) | 204 (52.0) | ||
| Clinical signs of cervical cancer include? | ||||
| Pelvic pain (%) | No | 25 (50.0) | 120 (30.6) | .01*** |
| Yes | 25 (50.0) | 272 (69.4) | ||
| Bleeding (%) | No | 20 (40.0) | 149 (38.0) | .906 |
| Yes | 30 (60.0) | 243 (62.0) | ||
| Vaginal discharge (%) | No | 28 (56.0) | 147 (37.5) | .018 |
| Yes | 22 (44.0) | 245 (62.5) | ||
| Back pain (%) | No | 37 (74.0) | 292 (74.5) | 1 |
| Yes | 13 (26.0) | 100 (25.5) | ||
| Weight loss (%) | No | 38 (76.0) | 260 (66.3) | .225 |
| Yes | 12 (24.0) | 132 (33.7) | ||
| Dyspareunia (%) | No | 50 (100.0) | 391 (99.7) | 1 |
| Yes | 0 (0.0) | 1 (0.3) | ||
| Risk factors of cervical cancer? | ||||
| Smoking (%) | No | 37 (74.0) | 281 (71.7) | .86 |
| Yes | 13 (26.0) | 111 (28.3) | ||
| Oral contraceptives (%) | No | 33 (66.0) | 247 (63.0) | .797 |
| Yes | 17 (34.0) | 145 (37.0) | ||
| Age (%) | No | 40 (80.0) | 279 (71.2) | .253 |
| Yes | 10 (20.0) | 113 (28.8) | ||
| Family history (%) | No | 24 (48.0) | 155 (39.5) | .32 |
| Yes | 26 (52.0) | 237 (60.5) | ||
| Bad diet (%) | No | 43 (86.0) | 324 (82.7) | .694 |
| Yes | 7 (14.0) | 68 (17.3) | ||
| Multiple sexual partners (%) | No | 17 (34.0) | 97 (24.7) | .216 |
| Yes | 33 (66.0) | 295 (75.3) | ||
| Risk factors of cervical cancer I don t know (%) | No | 46 (92.0) | 381 (97.2) | .135 |
| Yes | 4 (8.0) | 11 (2.8) | ||
| What are your sources of information and understanding regarding HPV vaccination (%) | Family and friends | 4 (8.0) | 25 (6.4) | <.001*** |
| Friends | 1 (2.0) | 0 (0.0) | ||
| I don’t know | 16 (32.0) | 137 (34.9) | ||
| Medical experts, studies | 5 (10.0) | 109 (27.8) | ||
| School | 0 (0.0) | 1 (0.3) | ||
| Social media | 23 (46.0) | 120 (30.6) | ||
| web sites | 1 (2.0) | 0 (0.0) | ||
The p-values which have “***” after them are the significant p-values.
In the logistic regression model, being a college student was found to be associated with a higher level of knowledge regarding cervical cancer (odds ratio [OR]: 2.44, p = .004), the appropriate timing for women to have their first Pap test (OR: 2.44, p = .004), and clinical signs of cervical cancer (OR: 2.44, p = .004). Male participants displayed lower knowledge and awareness regarding the causes of cervical cancer, the appropriate timing for women to have their first Pap test, and HPV transmission compared to females. However, males exhibited greater knowledge and awareness regarding the different types of HPV that can cause cancer. Additionally, older participants demonstrated greater knowledge and awareness regarding vaccine eligibility, HPV transmission, the appropriate timing for women to have their first Pap test, and the appropriate timing for women to have their first Pap test compared to younger participants. The relevant statistical data is presented in Table 4.
Table 4.
Knowledge about cervical cancer and HPV.
| Variable | Knowledge about cervical cancer | Knowledge about Causes cervical cancer | Knowledge about there is a vaccine for cervical cancer | Hearing about Human Papillomavirus (HPV) | Knowledge about eligibility for vaccine | Knowledge about different types of HPV that cause cancer | Knowledge about HPV transmission | Knowledge about HPV sexually transmitted | Knowledge about appropriate time for woman to have her first Pap test | Knowledge about pap smear Follow up time | Knowledge about pap smear for Vaccinated women | Knowledge about Clinical signs of cervical cancer | Knowledge about Risk factors of cervical cancer |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| OR (95% CI) p-value | OR (95% CI) p-value | OR (95% CI) p-value | OR (95% CI) p-value | OR (95% CI) p-value | OR (95% CI) p-value | OR (95% CI) p-value | OR (95% CI) p-value | OR (95% CI) p-value | OR (95% CI) p-value | OR (95% CI) p-value | OR (95% CI) p-value | OR (95% CI) p-value | |
| Gender | |||||||||||||
| Female | — | — | — | — | — | — | — | — | — | — | — | — | — |
| Male | 0.8(0.48, 1.34) 0.4 | 0.34 (0.12, 1.04) 0.046*** | 0.77 (0.45, 1.28) 0.3 | 1.36 (0.83, 2.25) 0.2 | 0.67 (0.40, 1.10) 0.12 | 2.06(1.21, 3.46) 0.007*** | 0.58 (0.35, 0.94) 0.029*** | 0.66(0.39, 1.12) 0.12 | 0.28 (0.16, 0.47) <0.001*** | 1.47 (0.83, 2.54) 0.2 | 0.74(0.45, 1.21)0.2 | 0.53(0.22, 1.37) 0.2 | 1.71(0.43, 11.9) 0.5 |
| Age | 1.02 (0.95, 1.08) 0.6 | 1.06 (0.92, 1.31) 0.6 | 1.03 (0.96, 1.10) 0.4 | 1.04 (0.97, 1.11) 0.3 | 1.08(1.01, 1.17) 0.029*** | 1.06 (0.99, 1.14) 0.13 | 1.09(1.02, 1.18) 0.023*** | 0.98(0.92, 1.05) 0.6 | 1.11(1.04, 1.20) 0.006*** | 1.11 (1.03, 1.21) 0.01*** | 0.99(0.93, 1.05) 0.7 | 1.02 (0.93, 1.14) 0.7 | 0.98 (0.88, 1.14) 0.8 |
| Education | |||||||||||||
| Not college student | — | — | — | — | — | — | — | — | — | — | — | — | — |
| College student | 2.44 (1.33, 4.51) 0.004*** | 1.16 (0.18, 4.41) 0.8 | 1.78 (0.92, 3.67) 0.1 | 1.3 (0.71, 2.40) 0.4 | 1.17 (0.63, 2.19) 0.6 | 0.98 (0.49, 2.06) >0.9 | 1.44 (0.78, 2.67) 0.2 | 1.76 (0.92, 3.28) 0.081 | 2.52(1.35, 4.84) 0.004*** | 2.85 (1.17, 8.56) 0.036 | 1.13 (0.62, 2.07) 0.7 | 3.74 (1.43, 8.98) 0.004*** | 2.99 (0.77, 9.39) 0.077 |
The p-values which have “***” after them are the significant p-values.
Male participants exhibited lower awareness regarding the availability of Pap tests, while older participants and college students demonstrated higher awareness of Pap test availability. This information is summarized in Table 5.
Table 5.
Association of awareness about cervical cancer and HPV.
| Variable | HPV vaccine availability awareness | Pap test availability awareness |
|---|---|---|
| OR (95% CI) p-value | OR (95% CI) p-value | |
| Gender | ||
| Female | — | — |
| Male | 1.33 (0.55, 2.90) 0.5 | 0.52 (0.31, 0.86) 0.012*** |
| Age | 1.05 (0.95, 1.14) 0.3 | 1.09 (1.02, 1.18) 0.013*** |
| Education | ||
| Not college student | — | — |
| College student | 0.96 (0.36, 3.25) >0.9 | 2.08 (1.11, 4.06) 0.026*** |
The p-values which have “***” after them are the significant p-values.
Additionally, males had lower odds of considering a lack of education and awareness as a barrier compared to females (odds ratio [OR]: 0.55, p = .041). On the other hand, older participants had higher odds of considering religion and culture as a barrier compared to younger participants. These results can be found in Table 6.
Table 6.
Association of primary barrier to receiving the HPV vaccine.
| Variable | Lack of education and awareness | Fear or embarrassment | Religion and culture |
|---|---|---|---|
| OR (95% CI) p-value | OR (95% CI) p-value | OR (95% CI) p-value | |
| Gender | |||
| Female | — | — | — |
| Male | 0.55 (0.31, 0.99) 0.041*** | 1.2 (0.66, 2.12) 0.5 | 1.02 (0.51, 1.91) >0.9 |
| Age | 1.08 (0.98, 1.21) 0.15 | 1.06 (0.99, 1.15) 0.1 | 1.08 (1.01, 1.18) 0.043*** |
| Education | |||
| Not college student | — | — | — |
| College student | 0.54 (0.20, 1.23) 0.2 | 1.25 (0.59, 2.93) 0.6 | 0.81 (0.39, 1.88) 0.6 |
The p-values which have “***” after them are the significant p-values.
Moreover, male participants were less likely than females to perceive factors such as fear of discovering disease, time constraints, and lack of knowledge and awareness as discouraging reasons for women to undergo Pap tests. On the other hand, older participants had higher odds of considering time constraints as a discouragement from getting Pap tests. These findings are presented in Table 7.
Table 7.
Association of factors that discourage from getting pap test practice.
| Variable | Fear of discovering disease | Time | Lack of knowledge and awareness |
|---|---|---|---|
| OR (95% CI) p-value | OR (95% CI) p-value | OR (95% CI) p-value | |
| Gender | |||
| Female | — | — | — |
| Male | 0.25 (0.09, 0.57) 0.003*** | 0.1 (0.03, 0.29) <0.001*** | 0.14 (0.08, 0.24) <0.001*** |
| Age | 1.05 (0.96, 1.13) 0.2 | 1.1 (1.03, 1.19) 0.007*** | 0.98 (0.91, 1.05) 0.6 |
| Education | |||
| Not college student | — | — | — |
| College student | 1.13 (0.53, 2.66) 0.8 | 0.81 (0.40, 1.75) | 0.9 (0.45, 1.72) 0.7 |
The p-values which have “***” after them are the significant p-values.
Discussion
The purpose of this study is to understand, analyze, and compare the level of knowledge and awareness of Cervical cancer and Human papillomavirus among college students in Riyadh. HPV is a frequent cause of genital warts and cervical cancer and is a common STD.1 One of the main risk factors for HPV infection and eventually cervical cancer is having multiple sexual partners. Due to Saudi Arabia’s traditional culture, it is difficult to investigate this health issue in sufficient depth because people are hesitant to discuss their sexual lives or believe that the risk factors for HPV or the sexual behaviors. HPV vaccination and screening are crucial preventive steps to lower the incidence of HPV and its related consequences. Consequently, Saudi Arabia approved the prophylactic HPV vaccine for females aged 11 to 26 to reduce the prevalence of HPV. The HPV vaccine has been a part of Saudi Arabia’s modified National Immunization Schedule for girls since 2010. Yet research on healthcare coverage, vaccine efficacy, and cervical cancer screening is scarce. A few studies conducted in Saudi Arabia’s central and western regions revealed a lack of awareness of HPV and its related complications2,4–7
The current study found that a significant portion of the study participants (54.1%) were aware of HPV. This is higher than a study conducted in Pretoria, South Africa where 73.8% of the participants did not know what HPV is.18 Another study in Northern China} regarding HPV knowledge showed that 77% of respondents had no knowledge of HPV.19 A high level of HPV (Human Papillomavirus) awareness in Saudi Arabia can be explained by the Ministry of Health’s coordinated efforts in putting out extensive awareness campaigns.
However, poor knowledge about HPV was evident among participants; only 17% correctly identified HPV16 and HPV18 genotypes as the primary causes of cervical cancer, which is notably lower compared to a previous study in Riyadh where 57.23% of participants recognized these genotypes as associated with cervical cancer.20
Furthermore, 66.5% of the participants had heard of cervical cancer which was similar to a study conducted among parents in Sharjah, UAE in which awareness was reported at 66.2%.21
When asked about the clinical signs of cervical cancer, 67.2% of the participants considered pelvic pain to be one of the major signs, 61.8% thought bleeding to be a clinical presentation of cervical cancer, and 60.4% believed vaginal discharge to be one. In another study carried out in Qassim, Saudi Arabia, found that, noncyclic bleeding was the most common clinical sign.22 Also, a greater number of males were aware that smoking is one of the causes of cervical cancer compared to females (p = .026) (Table 2). Conversely, more females identified HPV as one of the causes of cervical cancer compared to males (p = .038) (Table 2).
A Pap smear, commonly referred to as the Pap test, is considered an essential cervical cancer screening technique that has saved many lives. It plays a pivotal role in promoting women’s health and well-being, yet only 48.8% of the participants had heard of it. 60% of them didn’t know or weren’t aware of its significance. Fear of finding a sickness (20%), and culturally unacceptable (12.3%) were the most common reasons for not taking the test. Most participants were eager to undergo screening once they were made aware of it. Studies have shown the low rate of cervical screening is due to a lack of knowledge regarding pap smears.22,23
However, the majority of participants in the current study (58%) believed that women should have their first pap test performed between the ages of 20 and 65. Nevertheless, there was no question to support this, so they might have mistaken it for a vaginal swab. 50% of the participants correctly identified that women who have got the HPV vaccine require the pap test to be done. Only 20% of the participants, or a minority, knew that the pap smear should be done every three years, whereas 40%believed it should be repeated every year and 26% were unsure.
Thus, HPV awareness campaigns need to be tailored to raise knowledge and awareness concurrently for comprehensive public health outcomes. Acquiring knowledge enables people to comprehend the potential complications linked to HPV infections, how the virus spreads, and ways to avoid the disease by getting vaccinated and being screened frequently. Conversely, awareness makes sure people understand the importance of this knowledge and take proactive measures to safeguard their communities and themselves. Campaigns covering both have better public health results.
Although cervical cancer burden and mortality are reduced with HPV vaccination alone or in combination with screening in a variety of settings, only 160 (36.2%) participants reported awareness, while only 44 (10.0%) stated they had been vaccinated against HPV, despite the vaccine being incorporated into females’ routine immunization schedules in the national immunization schedule in Saudi Arabia24,25. Conversely, the most often mentioned barrier to vaccination uptake was a lack of education and awareness (80.1%). These results highlight the necessity of stepping up educational initiatives to address the concerns and promote vaccination uptake. Also, the authors believe a comprehensive strategy involving both parents and providers can be adopted to boost the HPV vaccination. Parent-focused educational campaigns resonate with our suggestions for leveraging multiple stakeholders in HPV vaccination campaigns as a study done in Qassim, Saudi Arabia, showed that 70.8% of mothers were willing to provide the HPV vaccine to their daughters.22 Another study done in Oman showed 47.1% of participants were willing toward vaccinating their daughters.23
The results of this study highlight two important factors associated with the level of HPV vaccine awareness and knowledge in society. Firstly, our study found a significant relationship between gender and knowledge of the HPV vaccine (p = .018). males (62.2%) had lower knowledge regarding the different types of HPV vaccines compared to females (78.6%). This finding is similar to a study done among Male Medical Students in Saudi Arabia in which only 42% had heard of the HPV vaccine, with poor knowledge scores regarding HPV and its vaccine.26 This can be attributed to the fact male HPV vaccination is still elective, and only few articles have examined males’ perception and knowledge of the HPV vaccine. Therefore, we think it’s imperative to increase both male and female students’ awareness of HPV, particularly for those enrolled in medical schools who will eventually work as healthcare providers. Furthermore, the introduction of Gender-Neutral HPV Vaccination Programs can be a huge step in combating the prevalence of HPV and its related diseases. Recent publications advocate for including boys in vaccination programs to accelerate the reduction in HPV prevalence and associated cancers, supporting our study’s suggestions for broader epidemiological impact as it promotes herd immunity.27 Also, these campaigns support the idea that avoiding diseases linked to HPV is a collective responsibility and helps to demolish stigmas around the virus.
Secondly, as predicted, education level remains a significant factor in awareness and knowledge of HPV vaccine (p = .02). The participants who were enrolled in college exhibited a higher level of knowledge regarding the vaccine when compared to non-college participants. This conclusion is similar to studies conducted in Saudi Arabia in which better knowledge was related to a higher level of education.13,20,22
The findings of this study have significant implications for the Saudi Arabian healthcare system. The low levels of awareness and knowledge regarding HPV and its vaccine suggest a need for structured and culturally sensitive educational initiatives. Healthcare providers should be trained to effectively communicate information about HPV, its potential health consequences, and the importance of vaccination and regular screening. Incorporating HPV education into primary healthcare services and utilizing mass media campaigns can enhance public understanding.
Policymakers can leverage these insights to develop national strategies that prioritize HPV education and integrate vaccination programs into routine immunization schedules for both genders, considering the benefits of gender-neutral vaccination policies in achieving herd immunity. Collaborations between educational institutions, healthcare organizations, and community leaders can facilitate widespread dissemination of information and address cultural barriers that may hinder acceptance. Additionally, implementing school-based vaccination programs and offering free or subsidized vaccines can improve accessibility and uptake among young adults.
However, this study has several limitations that should be considered when interpreting the results. Firstly, the sample size of 442 participants, while adequate for preliminary insights, may not be fully representative of the entire college student population in Saudi Arabia, potentially limiting the generalizability of the findings. The use of convenience sampling and an online self-administered questionnaire may introduce selection and response biases, as individuals with internet access and particular interests or awareness levels may have been more likely to participate. Additionally, self-reported data are subject to social desirability and recall biases, which could affect the accuracy of the responses. Future studies should aim for larger, randomized samples and consider employing mixed-method approaches, including interviews and focus groups, to gain a more comprehensive understanding of the factors influencing HPV awareness and vaccine acceptability. Despite these limitations, the study provides valuable insights into current knowledge gaps and can inform targeted educational and policy interventions.
Conclusion
HPV is a prevalent cause of genital warts and cervical cancer, both of which are largely preventable through vaccination and regular screening practices such as Pap smears. This study highlights a significant deficiency in awareness and knowledge regarding HPV infection, the HPV vaccine, and cervical cancer among college students in Saudi Arabia. To address this gap, comprehensive health education programs should be implemented, focusing on increasing awareness about HPV transmission, associated risks, and the benefits of vaccination and early detection through screening. Future research should explore effective strategies for integrating HPV education into academic curricula and assessing the impact of targeted awareness campaigns on vaccination uptake rates. Additionally, longitudinal studies could provide insights into changing perceptions and knowledge levels over time, informing policymakers and healthcare providers in developing and refining public health interventions aimed at reducing the burden of HPV-related diseases in Saudi Arabia.
Acknowledgments
We thank the researchers supporting project number RSP 2024 R47, King Saud University, Riyadh, Saudi Arabia.
Biographies
Dr. Abdul Rehman Zia Zaidi is a Senior Lecturer in the Department of Family and Community Medicine at Alfaisal University, Riyadh, Saudi Arabia. His research interests include community medicine, healthcare management, medical education, and public health.
Prof. Sultan Ayoub Meo is a Professor in the Department of Physiology at King Saud University, Riyadh, Saudi Arabia. His research focuses on respiratory physiology, environmental health, and medical education.
Dr. Baraa Alghalyini is the Vice Dean, College of Medicine and Head of the Department of Family and Community Medicine at Alfaisal University, Riyadh, Saudi Arabia. Her research focuses on family medicine, public health, and social determinants of health.
Funding Statement
King Saud University, Riyadh, Saudi Arabia [RSP 2024 R47].
Disclosure statement
No potential conflict of interest was reported by the author(s).
Author contributions
B.A. and A.R.Z.Z.; Conceptualization, methodology, software, formal analysis, H.T.; validation, investigation, Y.Y.A, S.A.A, S.A.A.A.; resources, data curation, H.A.A, M.R, S.S.A.; S.A.M review and editing.
Data availability statement
The data presented in this study are available on request from the corresponding author.
Informed consent statement
Informed consent was obtained from all subjects involved in the study.
Institutional review board statement
The study was conducted in accordance with the Declaration of Helsinki and approved by the Institutional Review Board of Alfaisal University (IRB-20240 on 29 May 2023).
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The data presented in this study are available on request from the corresponding author.