1. Introduction
Human papillomavirus (HPV) is the most common cause of sexually transmitted infection globally [
1]. HPV is also a common cause of cervical cancer, which is reported to be the 4th most common female cancer worldwide [
2]. In developing countries, cervical cancer is the leading cause of morbidity and mortality among women [
3]. In Saudi Arabia, there is a dearth of data evaluating HPV prevalence and its associated complications. However, Alhamlan et al. conducted a hospital-based cohort between 2013 and 2015 among Saudi women and reported 17% positive cases for HPV among 400 tested samples. HPV genotypes 16 and 18 were mostly reported as they were found to be responsible for more than 90% of cases [
3,
4,
5]. Further, it was previously reported that cervical cancer is not rare. It is considered the 9th female cancer in prevalence, with about 358 cases of cervical cancer reported annually [
3,
4,
5,
6].
Despite the existence of a safe and effective vaccine against HPV, there has been an increase in HPV cases and its associated complications in the last few years [
1]. Implementing programs to raise awareness of the importance of the vaccine varies worldwide. Still, few studies in our region have been conducted to investigate the impact of public knowledge of HPV [
2,
7,
8,
9,
10,
11,
12,
13,
14]. A few regional and national studies from Saudi Arabia showed that the knowledge of HPV is low [
9,
10,
11,
12,
13,
14]. Further, studies from Arabic countries and the middle east and north Africa regions indicated poor knowledge of HPV and its consequences [
15,
16], findings that may reflect cultural and religious factors in the region.
The World Health Organization (WHO) estimates that the HPV vaccine will save more than 4 million women’s lives in low- and middle-income countries over the next decade [
17]. In this regard, the Saudi Food and Drug Administration (SFDA) has approved the prophylactic HPV vaccinations for females aged 11 to 26 [
18]. HPV vaccinations have been added to the routine immunization schedules for females in Saudi National Immunization Schedule, and HPV vaccines (bivalent and quadrivalent vaccines) have been available in Saudi Arabia since 2010 [
19,
20]. However, there is a lack of studies that assess vaccine effectiveness and safety.
Education plays a crucial role and enhances knowledge about HPV, and studies have revealed that students who belong to health-sciences faculties, including applied medical sciences and medicine, have better knowledge and perception of HPV vaccination, and those with higher education usually have better knowledge of HPV [
12].
Studies about HPV prevalence, knowledge, and HPV vaccine acceptance are absent in Jazan province, southwestern Saudi Arabia, which has almost 2 million inhabitants. Therefore, we aimed in this study to assess the level of knowledge of HPV and the acceptability of the HPV vaccine among adult people who reside in Jazan Province.
4. Discussion
HPV is a common sexually transmitted disease and a common cause of genital warts and cervical cancer [
1]. To overcome the burden of HPV, Saudi Arabia has approved the prophylactic HPV vaccine for females aged 11 to 26. Since 2010 the HPV vaccine has been included in females’ routine immunization schedules in the updated Saudi National Immunization Schedule, and the ministry of health is responsible for its delivery and enforcement [
18,
19]. However, studies are limited data on the healthcare coverage and the effectiveness of the vaccine or cervical cancer screening, and a few studies from central and western regions of Saudi Arabia reported a lack of knowledge regarding HPV and its associated complications [
2,
5,
6,
11,
12,
13]. Participants in the current study, which covered the southwestern region, had poor knowledge of HPV. We found that the percentage score was 20%, and that about 50% of the participants did not agree that HPV is a common sexually transmitted disease. Only 38% believed HPV is a causative agent for cervical cancer (
Table 2). As reported by others [
2,
8,
11], we found that older age and a higher level of education are positively associated with a level of knowledge about HPV (
Table 2). Despite this poor knowledge among the participants of this study, about half of the respondents in our study were interested in the HPV vaccine and were indifferent about the vaccine’s safety, efficacy, or cost (
Table 5 and
Table 6). These data are coherent with an earlier study conducted in Riyadh in 2016, where only 37% of the participants refused to receive the vaccine [
8]. Further, in a recent national study in Saudi Arabia (2021), about 55% were willing to take the HPV vaccine if offered, and 73% would advise others to take the HPV vaccine [
12]. Likewise, about 50% of male medical students in Jeddah were interested in receiving the HPV vaccine [
2]. To date, no official programs included HPV education in general or higher schools in Saudi Arabia. All gathered knowledge resulted from the personal efforts of healthcare workers, and this may explain the poor level of knowledge we found in the current study, and as reported by others [
2,
5,
6,
11,
12,
13]. These findings indicate the importance of implementing national educational programs about HPV and vaccine campaigns directed to the public. This action would increase public knowledge of HPV and consequently enhance public attitudes toward the HPV vaccine.
Despite being incorporated into females’ routine immunization schedules in the national immunization schedule in Saudi Arabia [
18,
19]. HPV vaccine for men remained optional, and a few articles discussed men’s perception and knowledge of the HPV vaccine. However, as previous studies suggested, gender does not seem an important factor in the level of knowledge and HPV vaccine acceptability. For example, Farsi et al. published a study in 2020 in which data were collected from 517 male medical students. Despite the studied population being medical students, about 75% of the male students had heard of HPV, and only 42% had heard of the HPV vaccine, with poor knowledge scores regarding HPV and its vaccine [
2]. On the other hand, Altimimi conducted a study in 2020 among female students at Hail university [
22]. Likewise, poor knowledge was reported among participants, and better knowledge could be related to a longer duration of education and being students in medical schools [
22]. In the current study conducted on a population of Jazan, and participants were mostly females (80%) and students (60%) (
Table 1), questions about HPV in males and females were directed to participants. Poor knowledge was also observed, in that only 36% knew that the HPV vaccine is available for males and females (
Table 2), an answer affected neither by the level of education nor gender of the participants (
Table 3). However, 53% believed that the HPV vaccine should be given to males (
Table 6). Thus, we believe that improving male and female students’ HPV knowledge is crucial, especially for those enrolled in medical faculties as future healthcare providers. Moreover, integrating information about HPV vaccines into the curricula of medical schools is mandatory to guarantee better knowledge among this population.
Religion and religious practices are important factors that could affect the knowledge level concerning HPV and acceptance of the HPV vaccine. In our study, about 30% of the participants were opposed to the HPV vaccine for religious reasons (
Table 6). It has been reported, by Bodson et al. in a study published in 2017 and conducted in Utah, that those religious young females were under-vaccinated and, more importantly, under-informed about HPV and its vaccine [
23]. However, the relationship between religious practice and vaccine attitudes seems more complex, as it was found by Redd et al. that religious tradition is positively associated with HPV vaccine knowledge and attitudes, and adherence to religious instructions could be a protective factor against HPV [
24,
25]. In Saudi Arabia, Akkour et al. conducted a national study and found that only 9% of the population admitted to having relationships outside current marriage, either as previous marriages or polygamy [
12]. Further, they reported that most females did not know that HPV is transmitted sexually (79%) or that it causes genital warts (82%) and cervical cancers (82%) [
12]. Thus, we believe that it is important to discuss HPV consequences and the advantages of the HPV vaccine openly with young females, especially in conservative and religious cultures where females do not feel comfortable discussing their sexual behavior [
9].
Despite being one of the few studies in Saudi Arabia that discussed knowledge of HPV and the acceptability of its vaccines, our study bears many limitations. The data have been collected by a self-administered online survey, a method with a known reporting bias. However, due to the conservative nature of our community and the relativity of this topic to sexual aspects, we preferred to limit the interaction with participants as most of them were females (83%). Therefore, data collection was actively distributed via an online self-reported questionnaire, and its distribution depended on the authors’ networks. As such, most of the participants were young, students, and female. It would be insightful to ask participants if they have been diagnosed with HPV and received the HPV vaccine or included questions about smoking as an important cervical cancer risk factor. However, we know that national awareness about HPV increased recently, i.e., a few months before conducting this study [
26], and the availability of HPV testing is still limited in our province. Thus, it would be helpful to include national data about the number of HPV infections and those who benefited from the vaccine in future research. Despite these limitations, these data will be useful for encouraging the implementation of community education programs for the general population.