Introduction: The most common sexually transmitted infection worldwide is the human papillomavirus (HPV) infection. It is believed that over 80% of sexually active women have contracted the virus at some point in their lives. About 11 million women in Saudi Arabia who are aged 15 to 44 years are at risk of having HPV-related cervical cancer.

Aim: To assess the awareness and knowledge of undergraduate medical students (males and females) about the human papilloma virus (HPV) vaccination and to pinpoint the major factors influencing their attitudes towards it.

Subjects and methods: A prospective, cross-sectional online survey included 411 undergraduate medical students (males and females) across different grades during three months, from January 1^st to March 31st, 2024, at the Batterjee Medical College, Jeddah City, Saudi Arabia. We statistically analyzed the collected data using Microsoft Office^®, Excel^® 2016, and IBM's Statistical Package for Social Studies (SPSS^®) version 26.0. IBM is located in Chicago, Illinois, USA.

Results: The majority of participating students were of young age, 20–25 years old (233, 56.69%), female (393, 95.62%), and of Saudi nationality (260, 63.26%). The most common recruited students were from the preparatory year (124, 30.17%), while the fewest were from the M6 grade (6, 1.46%). We implemented "Kamel's scoring system for students' awareness", which yielded the following scores: not acceptable (124, 30.17%), fairly acceptable (101, 24.57%), moderately acceptable (95, 23.11%), acceptable (71, 17.27%), and highly acceptable (20, 4.87%). Next, we implemented "Kamel's scoring system for students' knowledge", which yielded the following scores: very low (130, 31.63%), low (110, 26.76%), moderate (90, 21.90%), high (50, 12.17%), and very high (31, 7.54%). We implemented "Kamel's scoring system for students' attitude" to assess the students' attitude towards HPV vaccine utilization. We interpreted the calculated scores as inadequate or poor (136, 33.09%), reasonable or fair (100, 24.33%), sufficient or good (80, 19.46%), remarkable or very good (70, 17.03%), and outstanding or excellent (25, 6.08%). results were of statistical significance (the P-value is <0.00001).

Conclusion: The estimated degree of awareness and knowledge about the HPV vaccination among undergraduate medical students at the Batterjee Medical College (BMC) was poor. This results in low motivation and utilization of the available vaccine.

Keywords: awareness and knowledge of HPV vaccination, attitude towards HPV vaccination, prevention of cervical cancer, and medical students in Saudi Arabia

In the USA and Europe, cervical cancer ranks as the third most common female genital tract malignancy (after ovarian and endometrial carcinomas). Therefore, for Saudi women during their reproductive years, cervical cancer ranks as the second most prevalent cancer (after endometrial carcinoma). Saudi women have an estimated cervical cancer incidence of 1.9 per 100,000 at the age-standardized rate.¹

Many factors, such as lack of education or knowledge about HPV infection, absence or negligence of routine screening programmes, and the difficulty encountered in accessing healthcare facilities, have been linked to cervical cancer in women living in various parts of the world.²

Human papillomavirus (HPV), with high-risk serotypes 16 and 18, is the primary cause of cervical cancer and accounts for about 70% of cancer cases. Whereas, HPV of low-risk serotypes 6 and 11 is regarded as a cause of ano-genital warts (Condyloma Accuminata) that mostly do not progress into cancer. There is poor information about HPV’s genotypes and its prevalence in Saudi Arabia.^1,2

Teenagers in Saudi Arabia (males and females) may benefit from the HPV vaccination despite the lack of information regarding the virus frequency, as there may be a rise in HPV infection among young people who are sexually active nationwide.² The estimated number of new cervical cancer cases and deaths in the year 2024 is 358 and 179, respectively.³

High-risk women for cancer cervix include infection with human papillomavirus (serotypes 16 and 18), early sexual activity, multiple sexual partners, early age at first vaginal delivery, and grand-multiparity. Also, women with immunosuppressive illnesses such as diabetes mellitus or HIV infection, co-infection with other sexually transmitted infections (such as herpes simplex), heavy cigarette smoking and excess alcohol intake, long-term use (> 5 years) of combined oral contraceptive pills, oestrogen-only HRT, low socio-economic status, a lack of screening (a Pap-smear of HPV-DNA testing), as well as women with morbid obesity.^1–3

Three types of HPV vaccine have been developed to prevent not only cervical cancer but also other HPV-related vulvar, vaginal, anal, and oropharyngeal diseases. A bivalent (Cervarix^®) vaccine that protects against HPV 16 and 18, a quadrivalent (Gardasil^®) vaccine that is effective against HPV serotypes 6, 11, 16, and 18, and a nine-valent (Gardasil-9^®) vaccine that protects against HPV serotypes 16, 18, 31, 33, 45, 52, and 58. The recommended age for vaccination in both sexes is from 9 to 45 years old in a 2- or 3-dose schedule (at 0, 2 months, and 6 months). People who are pregnant or have a yeast hypersensitivity should not take it. The first dose of HPV vaccine listed in the compulsory Saudi national immunisation schedule is at the age of 11- years -old.

It is unknown how many Saudi women have had HPV vaccinations. However, a number of surveys have indicated a low uptake. Only 2% of Saudi females received the HPV vaccine in 2020. Whereas, it was just 4% of the participants in a different local study in Eastern Province who had had the vaccination.⁵ Furthermore, a Riyadh-based survey in Saudi Arabia revealed that 89.5% of Saudi parents have not received HPV vaccination.⁶ It is interesting to note that medical students (males and females) also reported poor HPV vaccine uptake.^7–9

The HPV vaccine may not be accepted by the Saudi population as a means of preventing cervical cancer for a variety of reasons, including cultural beliefs and values, religious and moral reasons,⁹ public media content, vaccine hesitancy (due to low belief in its safety and efficacy or for its possible side effects), and personal education disparities.⁸ Globally, vaccine hesitancy has been found to be the primary cause of low vaccination uptake and coverage rates.

Although cancer of the of the cervix is preventable, most women in developing countries, including Saudi Arabia, are clinically presented at advanced stages that require extensive surgical and chemotherapy/radiotherapy treatment with a reduced survival rate. The World Health Organisation (WHO) estimates that the HPV vaccine will be able to save more than 4 million women’s lives in low- and middle-income countries over the next decade.⁹ Thus, understanding cervical cancer and the role of HPV infection is the most predictive factor for positive HPV vaccination behaviour.

The HPV vaccination rate in Saudi Arabia is lagging behind other countries. Most educational interventions were primarily directed at the female population and parents rather than healthcare providers, despite evidence that provider recommendation is a key determinant of vaccine uptake.¹⁰ The HPV vaccine is available in Saudi Arabia (approved by the Saudi Food and Drug Administration in 2010) and is expected to protect against two-thirds of cervical cancer cases.¹¹

Aims of the study (objectives)

1. To measure the degree of awareness and knowledge about HPV vaccination among undergraduate medical students at the Batterjee Medical College (BMC), Jeddah City, Saudi Arabia.
2. To trace the impact of students’ awareness and knowledge on their attitudes towards HPV vaccine utilization and recommendation.
3. To reduce the gap between medical knowledge and utilization rate of the HPV vaccination among medical students.

Proposed study questions

1. What is the degree of awareness and knowledge among undergraduate medical students at the BMC about the HPV vaccine?
2. What is the impact of students’ awareness and knowledge on their potential attitude towards the perception and utilization of the HPV vaccine? Is there a significant correlation between students’ background awareness and knowledge and their potential attitude towards HPV vaccine utilization and recommendation? The null hypothesis (H0) assumes no correlation, while the real hypothesis (H1) assumes the existence of a strong correlation between the two variables.

This is a prospective, online, cross-sectional KAP study that carried out (by a confidential invitation link distributed to BMC medical students with varying academic studying years). In an effort to reach as many students as possible, the questionnaire was distributed "anonymously" on several social media sites that are popular in Saudi Arabia, including Facebook^®, Messenger^®, WhatsApp^®, Twitter^®, Instagram^®, Telegram^®, Snapchat^®, and Tick-Tok^®. The duration of the questionnaire phase was three months, from January 1st to March 31st, 2024, with a six-month study period.

Selecting and excluding criteria

The selection criteria included all undergraduate students of the preparatory year as well as medical students (males and females) from different medical grades (from M1 to M6) who are assigned to the General Medicine Practice program and still affiliated with the Batterjee Medical College (BMC), Jeddah City, Saudi Arabia. The recruited students, as they are living in different districts and villages related geographically to the city of Jeddah, would symbolize the whole city.

The exclusion criteria involved all undergraduate and postgraduate medical students (males and females) who are studying at, and affiliated with other medical colleges, other than the BMC, either in the city of Jeddah or in any other city in Saudi Arabia or worldwide.

Sample size calculation

The minimal sample size required for a valid study is 384 students, which was calculated in two ways: online at www.calculator.net, and then confirmed by using the following mathematical equation, considering the level of confidence is 95% with an expected prevalence of 50% and precision of 0.05 (margin of error):

$n= \frac{z^{2 }X p \left(1-p\right)}{{\epsilon }^2}$ (1)

$n= \frac{{1.96}^{2 }X 0.5 \left(1-0.5\right)}{{0.05}^2}=384.16$ (2)

Where

n: is the sample size.

z: is the z-score of 95% confidence level (1.96).

p: is the expected population proportion (50%).

ε: is the margin of error (5%)

Since our population was known as 1551 total students (797 students of the preparatory year and 754 students of the different 6 grades of medical school for the academic year 2023-2024), we used the following correction formula:

$fn= \frac{\text{P}}{1+\text{P}/\text{n }}$ (1)

$fn= \frac{1551}{1+1551/384.16}=309$ (2)

Where:

n: minimal sample size.

fn: corrected sample size.

P: known population (1551 students).

We initially planned to recruit 400 participants to increase the statistical validity and reliability of the study. We received a total of 436 answer sheets (the initial 20 students’ responses were used for the questionnaire validation process, and then 416 students’ responses). After the process of filtration, the final number of participants was 411, with five responses excluded due to incomplete sheets. The high number of participating students increases the significant power of the study and lowers the margin of error to 4.15%.

Study tools

For every medical student who fulfilled the study’s inclusion criteria and agreed to participate freely in the current trial (signed an informed consent online), the entire data listed in the questionnaire was collected.

The information was gathered through an online electronic survey, and the co-authors used a Google Form (Google LLC, Mountain View, California, United States) to record the participating students’ responses in an anonymous manner. A structurally coherent set of four sets of essential questions related to HPV- vaccination were developed. 

(https://docs.google.com/forms/d/e/1FAIpQLSev12_JV6wh_SrULXs62lgJs6aV97V

IrZt29VhP3Asl5RH_HQ/viewform).

There were four sections on the questionnaire. The first section (composed of 16 questions) covered the socio-demographic details of the recruited students, such as age, sex, nationality, and educational level. Awareness about the HPV vaccine was covered in the second section (30 questions). The third section (10 questions) was about the students’ knowledge of the HPV vaccine. The last fourth section (composed of nine questions) covered the students’ attitudes towards HPV vaccination.

The questionnaire validation process has been completed using a representative sample of twenty students from the targeted study’s population (a pilot study), which has demonstrated satisfactory reliability (Pearson’s correlation coefficient = 0.86) and validity (Cronbach’s α coefficient = 0.84). Of course, the result of the pilot study was excluded from the final analysis.

The collected data was statistically analysed using Microsoft Office, Excel^® 2016, and IBM's Statistical Package for Social Studies (SPSS^®) version 26.0., Chicago, Illinois, USA. The Pearson Chi-square test and Fisher's exact test are used for categorical variables, while the Student's t-test is used for continuous variables. The significance cut-off value was 0.05, and it was used as the p-value. The survey’s results are presented in graphs and by using numbers, percentages, mean values, and standard deviations.

For previous studies, the literature was searched mainly for the keywords at the Bristol University Library online (MetaLib^®), in addition to the pertinent online medical journals and magazines. Additionally, we looked for articles that were indexed in CINAHL Plus, MEDLINE, PubMed, EMBASE, the Cochrane Methodology Register, and MEDLINE. Since proximity searches were not possible in PubMed, Ovid used to search MEDLINE.

Ethical considerations

Approval was obtained at the start of the study from the institutional research board (IRB) of the Batterjee Medical College, Jeddah, Saudi Arabia. All procedures were consistent with the ethical and scientific research committee standards and with the Helsinki Declaration of 1964 and its later modifications.

Informed consent has been obtained from all students who agreed to participate “freely” in our study. Data was collected anonymously, and the confidentiality of participants’ data was guaranteed. The collected data was kept safely as a soft copy without sharing any, except if it was requested by the BMC research unit for verification.

The total number of undergraduate medical students recruited for statistical analysis in the current study was 411 male and female students (out of a total 1551 students, with a percentage of 26.50%). The sociodemographic characteristics of the participating students are shown in (Table 1). The main age group of the involved students (Figure 1) was between 20 and 25- years -old (233, 56.69%). Female students prevailed over male students (393 females and 18 males), with a dominant Saudi nationality of Arabic ethnicity (260, 63.26%, and 344, 83.70%, respectively).

Figure 1 Age groups of participating students.

The invited students were from the preparatory year and the five medical grades (M1 to M5), in addition to M6 students (medical interns or House-officers). The main participating students were from the preparatory year (Figure 2) and the lesser were from the M6 year. As the parents’ education level plays an important role in tutoring their children (Figure 3), we found that the majority have a university degree (212, 51.58%).

Figure 2 Studying grades of participating students.

Figure 3 Parents' education levels of participating students.

Most of the participating students were single (381, 92.70%), living in Jeddah City, Saudi Arabia (396, 96.35%), with low-average family income (261, 63.50%), devoid of any medical illness (324, 78.83%), and without habits of medical importance (348, 84.67%). All the above-mentioned data are of statistical significance (the P-value is <0.00001).

For assessment of students’ awareness about the HPV vaccine, we postulated 30 pre-structured questions (Table 2). The students have to answer these by either “True”, “False”, or “I don’t know”. Each “true” answer is calculated as "1," and the other two answers are considered "0." “Kamel’s scoring system for students’ awareness” was implemented (Table 3), and the calculated scores were interpreted as: not acceptable (0–6), fairly acceptable (7–12), moderately acceptable (13–18), acceptable (19–24), and highly acceptable (25–30). The majority of participating students had an unacceptable level of awareness (124, 30.17%) with statistical significance (P-value <0.00001).

For assessment of students’ knowledge about the HPV vaccine, we postulated 8 pre-structured questions (Table 4). The students have to answer these by checking the correct answer, "√," according to their background knowledge. Each correct answer is calculated as "1," and the other wrong answers are considered "0." The “Kamel’s scoring system for students’ knowledge” was implemented (Table 5), and the calculated scores were interpreted as very low (0-2), low (3-4), moderate (5-6), high (7-8), and very high (9-10). The majority of participating students had a very low level of knowledge (130, 31.63%) with statistical significance (P-value <0.00001).

For assessment of students’ attitudes towards HPV vaccine utilization, we postulated 9 pre-structured questions (Table 6). The students have to answer these by either “Yes”, “No”, or “I am not sure”. Each “yes” answer is calculated as "1," and the other two answers are considered "0." Then, “Kamel’s scoring system for students’ attitude” was implemented (Table 7), and the calculated scores were interpreted as inadequate or poor (0-2), reasonable or fair (3-4), sufficient or good (5-6), remarkable or very good (7-8), and outstanding or excellent (≥ 9). The majority of participating students had an inadequate or poor attitude (136, 33.09%) with statistical significance (P-value <0.00001).

To know which of our study’s hypotheses is correct (H0 or H1), we used the scatter plot, where the x-axis represents the constant variables (awareness and knowledge scores) and the y-axis represents the dependable variable (attitude towards HPV vaccine). After calculation of the correlation coefficient (r) for both elements, we found that there is a strong positive linear correlation between students’ awareness score and their attitude towards the HPV vaccine (r = 0.9403) which means that with a higher score of students’ awareness, there is a confident active attitude concerning HPV vaccine utilization and recommendation to others (Figure 4). Similarly, there is a strong positive linear correlation between students’ knowledge score and their attitude to HPV vaccine (r = 0.9024), which means that with a higher level of students’ knowledge, there is an assured energetic attitude concerning HPV vaccine utilization and recommendation to others (Figure 5). Accordingly, we can agree with the real hypothesis (H1).

Figure 4 Correlation between students' awareness and attitude.

Figure 5 Correlation between students' knowledge and attitude.

Thus, among the individuals’ cognitive variables linked to HPV vaccination uptake are awareness and knowledge about the vaccine, a favourable attitude for more intake, and advice (confidence in the vaccine's safety and effectiveness).

Over the last 15 years, many studies have assessed awareness and knowledge about HPV vaccination in a variety of different Saudi populations (parents and guardians,^11–16 vulnerable female patients,^17–29 healthcare professionals,^30–33 and university students^{7, 34–47}) and in diverse settings, making a comparative study difficult. Except for physicians and undergraduate medical students (have good awareness and deprived vaccine utilization), all studies pointed to a substantial lack of awareness and knowledge with poor attitudes towards the HPV vaccine resulting in a low vaccination rate and increasing HPV infection cases.

In 2014, Al-Darwish A et al.,³⁴ investigated the awareness and knowledge of 188 university students (111 males and 77 females) at King Faisal University in Al-Ahsa City, Saudi Arabia. The awareness reported was 33% and the knowledge was 52.5% among the 5^th-year medical students. In the same academic year, Al-Shaikh et al.,³⁵ examined 1249 female students of health colleges at Princess Nora bint Abdul-Rahman University, Riyadh City, Saudi Arabia. Their awareness was 4.3%, with 95.7% having poor knowledge. The recorded utilisation rate of the HPV vaccine was only 13.5%. This variance in results between the upper two studies might be attributed to the high medical background information among the students of the last-year medical college.

In 2020, Al-Shrari AS,³⁶ studied 402 students of health colleges (35.82% males and 64.18% females) at Northern Border University, Saudi Arabia. The awareness level was 8%, and the knowledge was 18.66%. In the same academic year, Altamimi T,³⁷ investigated 966 female students from health colleges at the University of Hail, Saudi Arabia. The awareness was 31%, while the knowledge was 10.49%.

In 2021, Farsi NJ et al.,⁷ investigated 517 students from the 3^rd and 4^th year medical schools at 4 different medical colleges in Jeddah City, Saudi Arabia (King Abdul-Aziz University, King Saud bin Abdul-Aziz University for Health Sciences, Ibn Sina National College for Medical Studies, and the Batterjee Medical College). Although awareness was 42%, knowledge was poor, with a 48.9% positive attitude (interested in receiving the HPV vaccine). In the same academic year, Bokhary N et al.,³⁸ conducted a cross-sectional study at King Abdul-Aziz University, Jeddah City, Saudi Arabia. From the medical college, 462 students (49.13% males and 50.87% females) were included with 70.1% awareness, 38.7% poor knowledge, 37.2% fair knowledge, and 24% excellent knowledge.

In 2022, Ali MD et al.,³⁹ studied 125 students from the pharmacy college (12.8% males and 87.2% females) at Mohammad Al-Mana College for Medical Sciences (MACHS) in Dammam City, Saudi Arabia. The awareness was 35%, and the attitude was 32.8%. Azer SA et al.,⁴⁰ investigated 172 students (52.3% from medical schools and 22.1% from non-medical colleges) at King Saud University, Riyadh City, Saudi Arabia. The reported utilisation was 60.5% for medical students and 26.7% for non-medical students. In the same academic year, Al-Shammari F. and Khan KU,⁴¹ presented a study of 386 students (63% males and 37% females) at the University of Hail, Saudi Arabia. The knowledge was poor, with a low attitude.

In the year 2023, Easwaran V et al.,⁴² studied 140 female pharmacists at King Khalid University, Abha City, Saudi Arabia. Their awareness was 8.5%, with poor knowledge and a 6.4% attitude. Aldawood E. et al.,⁴³ have investigated 403 students from health colleges (57.1% males and 62.7% females). The score of knowledge was poor (8.8±3.6). Abdelaliem SMF et al.,⁴⁴ did a study at the College of Nursing, Princess Nourah bint Abdulrahman University, Riyadh City, Saudi Arabia. The awareness level was 26.5%, the knowledge score was 2.77±1.78, and the attitude was low (10.7%). Lastly, in the same academic year, Aldawood E et al.,⁴⁵ conducted a cross-sectional study at King Saud University, Riyadh City, Saudi Arabia. The knowledge was 66.7%, with a low attitude (5.2%).

In the current year, 2024, Al-Fhaid F et al.,⁴⁶ investigated 159 students from health colleges at Majmaah University, Saudi Arabia. The knowledge was 15.7%, while the attitude was 7.5%. While Aftab T et al.,⁴⁷ studied 200 students (52% males and 48% females) from the College of Medicine at Northern Border University, Arar City, Saudi Arabia. The awareness score was 28% and the knowledge score was 4.20 ± 0.79% with a low attitude. 

Comparably, in our study (with taking the potential differences in the scoring systems used), the calculated scores for students’ awareness were as following; not acceptable (124, 30.17%), fairly acceptable (101, 24.57%), moderately acceptable (95, 23.11%), acceptable (71, 17.27%), and highly acceptable (20, 4.87%). The calculated scores for students’ knowledge were as following; very low (130, 31.63%), low (110, 26.76%), moderate (90, 21.90%), high (50, 12.17%), and very high (31, 7.54%). Accordingly, the calculated scores for scores for students’ attitude were inadequate or poor (136, 33.09%), reasonable or fair (100, 24.33%), sufficient or good (80, 19.46%), remarkable or very good (70, 17.03%), and outstanding or excellent (25, 6.08%). All results were of statistical significance (P-value is <0.00001).

The status is not different in other countries of the Middle East, such as the United Arab Emirates (UAE),⁴⁸ Kuwait,⁴⁹ Qatar,⁵⁰ Jordan,^51,52 and Lebanon.^53,54 Similarly in Asia countries, such as Turkey,⁵⁵ Iran,⁵⁶ Pakistan,⁵⁷ Cyprus,⁵⁸ Malaysia,⁵⁹ Indonesia,⁶⁰ Thailand,⁶¹ Japan,⁶² Hong Kong,⁶³ Korea,⁶⁴ India,⁶⁵ and China.⁶⁶ Equally in Africa countries, such as Ethiopia,⁶⁷ Nigeria,⁶⁸ Uganda,⁶⁹ Kenya,⁷⁰ Somalia,⁷¹ and Senegal.⁷² Even in countries termed “developed countries”, such as the USA,⁷³ European countries (like the UK,⁷⁴ France,⁷⁵ Germany,⁷⁶ Italy,⁷⁷ Sweden,⁷⁸ Poland,⁷⁹ Spain,⁸⁰ and Greece⁸¹), as well as Australia.⁸¹ Despite lack of knowledge, the majority of medical students would accept a ‘catch-up’ HPV vaccination. Female participants were significantly more willing to accept HPV vaccinations than to males.

Limitations of previous studies

Up-to-date, there are few provincial studies that have evaluated medical students' awareness and knowledge about the HPV vaccination.^{1–9, 34–47} Furthermore, no research has examined the variables underlying the low acceptance rate of the HPV vaccine among medical students, especially in Jeddah City, Saudi Arabia. Thus, in order to prepare the upcoming medical doctors, to serve at different healthcare facilities, the gap between their knowledge and practice (vaccine utilization) should be secured.

Strength of the current study

The current study addresses one of the preventive measures that significantly reduces health problems related to HPV infection among both males and females. Students at medical colleges frequently have the ability to make a difference in their communities, although a sizable fraction of them might not be sexually active yet in conservative Saudi society. Therefore, it is essential to involve local universities in vaccination campaigns in order to guarantee that students are aware of the vaccine’s value and its availability.

We recommend using, firstly introduced, Kamel’s scoring systems for students’ awareness, students’ knowledge, and assessment of students’ attitude (5-likert scales) in future studies with high reliability and validity; accordingly, we can compare studies with uniformly used scales.

Future studies

Future research should focus on testing methods for effective awareness and knowledge - raising directed all target groups about the human papilloma virus infection, cervical premalignant lesions and invasive cancer, early screening methods, and the role of HPV vaccination.

The awareness and knowledge of the undergraduate medical students (males and females) who participated in the study regarding HPV vaccination were discouraging. Therefore, we emphasize the need to run well-designed healthcare education programs and campaigns (by the BMC institution with the participation of the Ministry of Health) to promote the awareness and knowledge of students early in their schools, even before starting college study. We recommend using the world immunization week (April 24-30) every year for education and vaccination events. In addition, encourage medical schools to include more information about HPV infection and vaccines in their study curricula. The use of various media platforms to educate students’ parents about risk factors for HPV infection, the benefits of early vaccination, and its accessibility is vital to achieving a successful prevention strategy. Our recommendation should be applicable to all countries, all over the world, that are sharing the same problem.

None.

None.

Authors declare that there is no conflict of interest.

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