|Year : 2020 | Volume
| Issue : 3 | Page : 189-195
Awareness of human papillomavirus and its vaccine among patients attending primary care clinics at King Saud University Medical City
Maha F Alrajeh1, Sulaiman Abdullah Alshammari2
1 Department of Family and Community Medicine, College of Medicine, King Saud University Medical City, Riyadh, Kingdom of Saudi Arabia
2 Chair of Health Education and Health Promotion, Department of Family and Community Medicine, College of Medicine, King Saud University Medical City, Riyadh, Kingdom of Saudi Arabia
|Date of Submission||06-Jan-2020|
|Date of Decision||29-Feb-2020|
|Date of Acceptance||16-Mar-2020|
|Date of Web Publication||26-Jun-2020|
Sulaiman Abdullah Alshammari
Department of Family and Community Medicine, College of Medicine, King Saud University Medical City, P.O. Box: 2925, Riyadh 11461
Kingdom of Saudi Arabia
Source of Support: None, Conflict of Interest: None
Objectives: We aimed to assess the awareness, attitudes, and practice regarding human papillomavirus (HPV) and its vaccine among women attending primary care clinics in Riyadh. Methods: This cross-sectional study included 326 women aged 18–60 years who attended primary care clinics between June 2014 and June 2015. The participants completed a validated, self-administered questionnaire. Data collected included sociodemographic information (e.g., age, marital status, education, and employment), knowledge of HPV and its vaccine, and attitudes regarding HPV vaccine acceptance. Results: Among the respondents, 59.4% were married, and 43.6% had received a university education. The study population had a marked lack of information regarding HPV infection and vaccination. Only 32.8% of the women knew that HPV is transmitted sexually, while 21% knew that it could cause cervical cancer. A quarter of the participants were aware of the protective vaccine against HPV. There were no statistically significant differences in participants' knowledge levels, according to age, marital status, educational level, and occupational status. The doctors, the media, and the friends were the primary sources of information to 5.6%, 7.7%, and 24.5% of the participants, respectively. Conclusion: Overall awareness of HPV and its vaccine and cervical cancer screening is low among Saudi women. There is a need for formulating preventive strategies and effective awareness programs for better HPV-related education, vaccine availability, and the importance of cervical cancer screening.
Keywords: Cervical cancer, human papillomavirus, Saudi Arabia, screening
|How to cite this article:|
Alrajeh MF, Alshammari SA. Awareness of human papillomavirus and its vaccine among patients attending primary care clinics at King Saud University Medical City. J Nat Sci Med 2020;3:189-95
|How to cite this URL:|
Alrajeh MF, Alshammari SA. Awareness of human papillomavirus and its vaccine among patients attending primary care clinics at King Saud University Medical City. J Nat Sci Med [serial online] 2020 [cited 2022 Aug 13];3:189-95. Available from: https://www.jnsmonline.org/text.asp?2020/3/3/189/288825
| Introduction|| |
Cervical cancer is the second most common cancer among women worldwide, particularly those living in developing countries who lack resources for screening. The current estimate shows that about half a million cervical cancer diagnosed each year, resulting in about a quarter of a million deaths. The organized screening programs markedly decreased the incidence of cervical cancer in developed countries. The high-risk human papillomavirus (HPV) types 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, and 59 account for about 5% of all cancers worldwide. The majority of HPV infections do not cause symptoms, such as itching, burning, or vaginal discharge usually associated with other genitourinary infections. Furthermore, up to 90% of the HPV infection is cleared spontaneously within about 2 years postinfection commonly in young adults. A small proportion who fail to clear the infection are at risk of progression to malignancy of the anogenital and oropharynx regions. Smoking, hormonal exposure, HIV, Chlamydia trachomatis, and oral hormonal contraception are additional exposures that increase the risk of progression to cancer., Cigarette smoking had also demonstrated dose–response relationships with the risk of cervical cancer.
The prevalence of HPV and its risks in developing countries, especially in the Middle East, has not been adequately studied. Furthermore, almost all the studies on the prevalence of HPV were hospital based.
In Saudi Arabia, although there is no national screening program, the discovered cervical cancer cases showed a different low incidence to worldwide figures, according to the Saudi Cancer Registry 1992. It ranked number 12 among all types of cancer in Saudi women. In a subsequent report 2009, the cervical cancer rate increased to 4.1 cases/100,000 women, which accounted for 7% of all newly diagnosed women with cancer in Saudi Arabia.
Furthermore, it stands as the eighth leading cause of cancer-related death among Saudi women. However, there is no screening program to ascertain the full coverage of all cancer cases. The previous researcher attributed the low incidence to that the closed society and standards of mores could reduce women's exposure to HPV infection.
A previous genotype investigation in Saudi Arabia found that the rate of HPV16 genotype accounts for 30%, followed by HPV18 and HPV45, among other genotypes. The HPV6 and HPV11 genotypes are known to be associated with genital warts. A cross-sectional study on patients attending dermatology clinics in Kuwait found that oncogenic HPV types are detected in around 35% of the patients with genital warts.
Consistent with global studies, which found inadequate awareness and accurate understanding of HPV and its risks, a previous study in the United Arab Emirates investigated 640 women and found that only 29% had ever heard of HPV, while only 15% recognized it as a sexually transmitted infection. An investigation done in a Saudi family medicine clinic affiliated with a tertiary care hospital found that the awareness of the population of HPV infection and its relationship with cervical cancer accounted for 34.5% and 27.4%, respectively.
A cross-sectional, self-administered study of school women teachers, relatives, and friends from the western region of Saudi Arabia reported that the majority of the participants (84.6%) were not aware of HPV, and 95% never heard of a Pap smear test.
Three hospitals' observational study in Saudi Arabia reported that the women who were aware of HPV represented only 32.2%; however, about 90% showed an interest in receiving the vaccine.
The WHO recommends that girls and boys aged 9–14 years should receive a two-dose schedule of HPV vaccines before sexual debut as well as catch-up vaccinations for girls and women aged 13–26 years. Such recommendation, if followed, is expected to reduce cervical cancer disease worldwide over the next decades.
Despite the HPV vaccines' excellent safety, efficacy, and effectiveness profiles and curability of cervical cancer, most of our women present with advanced stages that require extensive therapeutic approach, lowering rates of survival. There is a need for continuous monitoring of awareness and promotion of HPV vaccination and PAP smear screening. We aimed to investigate the awareness, attitudes, and practice of women attending primary care clinics in Riyadh, regarding HPV and its vaccination.
| Methods|| |
We conducted a cross-sectional study at the primary care clinics of King Saud University Medical City (KSUMC) in Riyadh, Saudi Arabia, between June 2014 and June 2015. These clinics see around 230,000 patient visits annually. In addition to the King Saud University employees and their dependents, the clinics see patients referred to the KSUMC from all over Saudi Arabia. The study was approved by the Institutional Review Board (IRB), at King Saud University, and written infromed consent was obtained from the participants.
The investigators estimated the sample size according to the following formula:
N = Z2 × p × (1 − p)/C2,
where N = sample size, Z = 1.96 at 95% level of significance, p = prevalence of low awareness (20%), and C = degree of precision (0.05). In our study, the calculated sample size was approximately 243, but our true sample size was 326.
We selected patients attending the primary care clinics at KSUMC aged 18 years and above at random. We excluded those with a history of cervical cancer from the study. The authors developed a predesigned, validated, self-administered questionnaire, following the published literature.,, The questionnaire was distributed to the participants while they attended KSUMC clinics and included the following sections:
- Demographic data such as age, level of education, working, and marital status
- A total of 14 questions aimed to assess participants' knowledge of HPV and its association with cervical cancer, awareness about the Pap smear as a screening test, as well as the HPV vaccine and its protective ability, knowledge about the appropriate age for a Pap smear test, knowledge about possible signs of cervical cancer, and possible risk factors of cervical cancer, such as smoking and history of Chlamydia infections. The possible answers to these questions were “yes,” “no,” and “I do not know.” Correct responses were assigned a score of 1, while incorrect responses or “I do not know” were assigned 0. We calculated the mean of the sum of the scores for these 14 knowledge questions to compare groups
- Three questions were about attitudes and practices regarding the HPV vaccine and Pap smear test. The possible answers were again “yes,” “no,” and “I do not know.” The authors considered “no” and “I do not know” as one negative category. The participants answered questions about vaccine availability (i.e., where to find it) and sources of information about HPV and HPV vaccination (such as family doctors, friends, television, or the internet).
Five academic experts (three family physicians, two gynecologists, and one community medicine professor) reviewed the questionnaire. Before the start of the primary investigation, the authors tested the questionnaire in a pilot study on 30 participants to check the clarity and applicability of this tool and to identify any potential problems. Furthermore, the pilot tested the cultural and scientific suitability of the instrument for the Saudi community. The estimated time needed to complete it was between 10 and 15 min. The authors modified the questionnaire according to the findings of the pilot investigation and excluded the participants who took part in the pilot study from the main study. Cronbach's alpha for the 14-item knowledge scale of the modified instrument was 0.83.
We compiled and checked the data for completeness and used IBM SPSS Statistics for Windows, Version 21.0 (IBM Corp., Armonk, NY, USA) for analysis. Sociodemographic variables, knowledge of cervical cancer, Pap smear awareness, and attitudes toward acceptance of the HPV vaccine were tabulated, and descriptive analyses were performed. The students' test was used to perform comparisons between groups. P <0.05 was considered statistically significant.
| Results|| |
A total of 326 women aged 18–60 years participated in the study. The sociodemographic characteristics of the study population are shown in [Table 1]. On the 14 questions assessing awareness of HPV and its vaccine, of the 326 participants, 41.1% had a total score of zero (no correct answers), 39% scored between 1 and 5, and 19.9% had a total score between 6 and 11. The mean score for the total of 14 knowledge questions was 2.5 ± 3.0.
[Table 2] compares the mean score for a total of 14 knowledge questions by the participants' demographic characteristics. The individuals aged 50 years and younger achieved higher mean knowledge score of 2.6 than the other age group (2.4). In terms of education level, those at the university level achieved higher mean knowledge score of 2.6, compared with 2.5 of their below-university-level counterparts. In terms of marital status, unmarried women had a higher knowledge score of 2.7, compared with 2.4 of married women. In terms of occupation, the working women achieved higher knowledge scores, compared with 2.4 of not working women. However, all these demographic differences were not statistically significant.
|Table 2: The mean score of knowledge of human papillomavirus and its vaccine by sociodemographic characteristics (n=326)|
Click here to view
Regarding knowledge of HPV and its relation to cervical cancer, 32.5% knew that HPV infection is sexually transmitted, while 14.1% were aware that HPV produces genital warts. Only 20.6% knew that HPV could cause cervical cancer, and 28.8% are aware of the ability of the Pap smear test to detect it early. Regarding awareness of the HPV vaccine, 21.5% were aware that there is a vaccine against HPV, while 24.2% knew that vaccination against HPV could protect against cervical cancer. Moreover, 13.5% knew that the vaccine could be administered to girls starting at the age of 9 [Table 3].
|Table 3: Knowledge level regarding human papillomavirus, cervical cancer, and human papillomavirus vaccination (n=326)|
Click here to view
In terms of attitudes/practices related to the HPV vaccine, 29.1% of women had a positive attitude toward vaccinating their daughters, but only 14.4% had undergone Pap smears, and 3.4% had received the HPV vaccine. The positive attitude/practices regarding the HPV vaccine and Pap smear screening were associated with higher mean scores of knowledge. These differences were statistically significant [Table 4].
|Table 4: Participants' attitudes/practices regarding Pap smears and human papillomavirus vaccine by their mean knowledge score (n=326)|
Click here to view
Regarding the HPV vaccine availability, 13.8% believed that the vaccine is available at the KSUMC, while 3.4% believed that it is available at the Ministry of Health medical centers. Finally, the participants reported that their primary sources of HPV-related information were their friends (24.5%) and doctors (5.6%) [Table 5].
| Discussion|| |
The concept of preventing cervical cancer through HPV vaccine is relatively new in our area. The CDC's Advisory Committee on Immunization Practices 2006 recommended vaccinating females between the age of 11 and 12 years routinely, and later in 2011, they included males. Currently, the WHO recommends that both males and females should have two doses of HPV vaccines at the age of 9–14 years and then booster dose for females at the age of 13–26 years., The Saudi Food and Drug Authority approved the HPV vaccine in 2010 for women at the age of 11–26 years.
As such, awareness of this pathogen and its available vaccine is critical for implementing preventative measures. Few studies investigated the attitudes of Saudi women toward HPV and HPV vaccination, and our research is one among them. Our study revealed a widespread lack of knowledge among our target population concerning HPV infection and vaccination, with only 21% of the participants being aware of the HPV vaccine. This finding showed general similarity to the previous studies from different regions of Saudi Arabia, which showed undesirable results.,,, However, globally, young individuals reported low knowledge regarding HPV infection, vaccine, and cervical cancer.
Our findings of inadequate awareness and knowledge of cervical cancer screening are consistent with the previous study in Riyadh. As expected, higher educational achievement was associated with a better understanding of HPV infection, which is similar to other researchers' findings. However, we did not find a significant association between age and the participants' knowledge, as reported by others. Unfortunately, these findings of low awareness are almost the same for a long time.
Our findings of inadequate awareness and practice of the public concerning HPV and cervical cancer were consistent with the studies from other Arab countries, including the Gulf countries,, Turkey, Europe, and the USA. However, the situation in the developed countries was a little bit better than that in developing countries. The awareness in the West has increased since the introduction of HPV vaccination. However, about a quarter of women still have never heard of HPV.,,, Despite the inadequate overall knowledge, the awareness of screening among USA people is higher than the UK and Australian people.
Our participants' level of awareness was much lower than those from developed countries. The present study revealed that only 21.5% of participants were aware of the HPV vaccine, and nearly, the same proportion of the participants knew that this vaccine protects against cervical cancer.
Despite the positive attitude of 30% of the women in the present study toward HPV vaccination, only a small minority (3.4%) had received the vaccine themselves. These findings were less than reported by other investigators.,
In addition, the Pap smear was not popular among our study participants, as only 14.4% underwent this test. In contrast, women in the United States and Europe demonstrated much better regular testing.
Hence, providing more education on cervical cancer protection for both health professionals and the public cannot be overemphasized. It is time to include such health prevention topics in the school curriculum of both boys and girls. Furthermore, parents should be involved in such education campaigns, making use of the people acceptability and willingness to protect themselves.,,,
Health educational programs should target people regardless of their gender, level of education, and socioeconomic status. A previous study found that even though the participants had high education and socioeconomic status, they reported a lack of knowledge and awareness of cervical cancer and HPV vaccination.,
Furthermore, potential candidates may perceive themselves as having a low susceptibility to HPV infection or misinterpret the HPV as in other studies.
As suggested by other researchers, we should develop strategies to address vaccine hesitancy by focusing on maintaining trust in health professional recommendations, in addition to providing information about the safety and effectiveness of the vaccine.,
The lack of clear strategies toward the HPV vaccine contributed to the low awareness rate and explained the hesitancy of physicians to recommend the vaccine, although they perceived the HPV vaccine as necessary and essential., Primary care physicians and his team could play a vital role in boosting HPV vaccination, notably if they received the health authorities' clear recommendations and strategies toward the anti-HPV vaccine. Further, if the health professionals accompanied these recommendations with attention to planning culturally appropriate behavioral and informational interventions, This strategy would enhance knowledge about HPV infections and improve vaccine uptake efficiency.
However, the cost is not a barrier for Saudi women to access these preventive services as reported in some countries as health services provided free in Saudi Arabia.
The media were the source of information in <10% of our participants. As the media plays a significant role in increasing public awareness, improving their attitude and behavior, and implementing the multimedia approach utilizing pictorials, audio-visual communication on cervical cancer could yield beneficial results.,,
One more critical point is that about a quarter of the participants attributed their knowledge to friends. This point should lead health professionals to make sure that the information given is correct and supported by scientific evidence.
Limitation of the study
Our study was limited to the primary care clinics of KSUMC in Riyadh. We cannot ascertain the generalizability of our findings, as all of the participants come from a single center. Hence, it is advisable to recruit more centers and from all regions of Saudi Arabia. Despite these limitations, we believe that this study can improve awareness, attitude, and practice toward HPV and its vaccine in Saudi Arabia. The Pap smears, and the HPV vaccine status, were self-reported by the respondents, not subjected to independent verification, and potentially influenced by recall bias.
| Conclusion|| |
There is a widespread lack of knowledge regarding HPV and its association with cervical cancer and low uptake of cervical screening among Saudi women. Using these data can help in formulating preventive strategies and effective awareness programs.
It is crucial to increase awareness regarding HPV and its role as a significant risk factor for cervical cancer and to motivate them to get vaccinated. Besides, the vaccines can reduce the healthcare burden and associated sequelae; it could save many lives. Health decision-makers should implement a national preventive strategy to increase the uptake of the HPV vaccine and cervical screening tests following the current Saudi health sector reforming to emphasize prevention as part of Saudi vision 2030.
Various channels and appropriate multimedia can improve understanding and awareness of the vaccine, employing behavioral as well as informational interventions.
The Research and Ethical Committee approved the present study. Research project No.E-15-1531. Written informed consent was obtained from all participants in the study. The research and its purpose were explained to the participants, who were also informed that the extracted information would be used only for research purposes and kept confidential. Participation in the study was voluntary.
We are thankful to the Vice Deanship of Scientific Research Chairs at King Saud University for their support. Special thanks also to the patients who participated in the study.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Berman TA, Schiller JT. Human papillomavirus in cervical cancer and oropharyngeal cancer: One cause, two diseases. Cancer 2017;123:2219-29.
Pan J, Kavanagh K, Cuschieri K, Pollock KG, Gilbert DC, Millan D, et al
. Increased risk of HPV-associated genital cancers in men and women as a consequence of pre-invasive disease. Int J Cancer 2019;145:427-34.
de Sanjosé S, Brotons M, Pavón MA. The natural history of human papillomavirus infection. Best Pract Res Clin Obstet Gynaecol 2018;47:2-13.
Arbyn M, Weiderpass E, Bruni L, de Sanjosé S, Saraiya M, Ferlay J, et al
. Estimates of incidence and mortality of cervical cancer in 2018: A worldwide analysis. Lancet Glob Health 2020;8:e191-e203.
Mzarico E, Gómez-Roig MD, Guirado L, Lorente N, Gonzalez-Bosquet E. Relationship between smoking, HPV infection, and risk of cervical cancer. Eur J Gynaecol Oncol 2015;36:677-80.
Sait KH. Attitudes, knowledge, and practices in relation to cervical cancer and its screening among women in Saudi Arabia. Saudi Med J 2009;30:1208-12.
Alsbeih G. HPV infection in cervical and other cancers in Saudi Arabia: Implication for prevention and vaccination. Front Oncol 2014;4:65.
Turki R, Sait K, Anfinan N, Sohrab SS, Abuzenadah AM. Prevalence of human papillomavirus in women from Saudi Arabia. Asian Pac J Cancer Prev 2013;14:3177-81.
Al-Awadhi R, Al-Mutairi N, Albatineh AN, Chehadeh W. Association of HPV genotypes with external anogenital warts: A cross sectional study. BMC Infect Dis 2019;19:375.
Näsman A, Du J, Dalianis T. A global epidemic increase of an HPV induced tonsil and tongue-base cancer–potential benefit from a pan- gender use of HPV vaccine. J Intern Med 2020;287:134-52.
Ortashi O, Raheel H, Shalal M, Osman N. Awareness and knowledge about human papillomavirus infection and vaccination among women in UAE. Asian Pac J Cancer Prev 2013;14:6077-80.
Hussain AN, Alkhenizan A, McWalter P, Qazi N, Alshmassi A, Farooqi S, et al
. Attitudes and perceptions towards HPV vaccination among young women in Saudi Arabia. J Family Community Med 2016;23:145-50.
Gari A, Asiri A, Mohammed A, Al-Malki F, Melibari M, AlSheikh M, et al
. The awareness of the HPV's association with cervical cancer and the HPV vaccine among Saudi females. Life Sci J 2012;9:2538-46.
Alhamlan FS, Al-Qahtani AA, Al-Ahdal MN. Current studies on human papillomavirus in Saudi Arabia. J Infect Dev Ctries 2015;9:571-6.
World Health Organization. Human papillomavirus vaccines: WHO position paper, May 2017 – Recommendations. Vaccine 2017;35:5753-5.
Manji M. Cervical cancer screening program in Saudi Arabia: Action is overdue. Ann Saudi Med 2000;20:355-7.
Yakout SM, Moawed S, Gemeay EM. Cervical cancer and screening test (PAP test): Knowledge and beliefs of Egyptian women. A J Nurs 2016;5:175-84.
Salem MR, Amin TT, Alhulaybi AA, Althafar AS, Abdelhai RA. Perceived risk of cervical cancer and barriers to screening among secondary school female teachers in Al Hassa, Saudi Arabia. Asian Pac J Cancer Prev 2017;18:969-79.
Guvenc G, Akyuz A, Açikel CH. Health belief model scale for cervical cancer and Pap smear test: Psychometric testing. J Adv Nurs 2011;67:428-37.
Meites E, Kempe A, Markowitz L. Use of a 2-dose schedule for human papillomavirus vaccination—Updated recommendations of the advisory committee on immunization practices. Am J Transpl 2017;17:834-7.
Organization Health Organization. Cervical Cancer, Human Papillomavirus (HPV) and HPV Vaccines: Key Points for Policy-Makers and Health Professionals. Geneva: World Health Organization; 2008.
Al-Darwish AA, Al-Naim AF, Al-Mulhim KS, Al-Otaibi NK, Morsi MS, Aleem AM. Knowledge about cervical cancer early warning signs and symptoms, risk factors and vaccination among students at a medical school in Al-Ahsa, Kingdom of Saudi Arabia. Asian Pac J Cancer Prev 2014;15:2529-32.
Al-Shaikh GK, Almussaed EM, Fayed AA, Khan FH, Syed SB, Al-Tamimi TN, et al
. Knowledge of Saudi female university students regarding cervical cancer and acceptance of the human papilloma virus vaccine. Saudi Med J 2014;35:1223-30.
Johargy AK, Jamal A, Garout MA. Knowledge, attitudes and practices towards human papilloma virus among females in Saudi Arabia. Int J Trop Dis Health 2016:1-11.
Jradi H, Bawazir A. Knowledge, attitudes, and practices among Saudi women regarding cervical cancer, human papillomavirus (HPV) and corresponding vaccine. Vaccine 2019;37:530-7.
Gönenç İM, Abbas MN, Çalbayram N, Yılmaz S. A review of knowledge and attitudes of young people on cervical cancer and HPV vaccination. J Public Health 2020;28:97-103.
Al Khudairi H, Abu-Zaid A, Alomar O, Salem H. public awareness and knowledge of Pap smear as a screening test for cervical cancer among Saudi population in Riyadh city. Cureus 2017;9:e984.
Selmouni F, Zidouh A, Nejjari C, Bekkali R. Acceptability of the human papilloma virus vaccine among Moroccan parents: A population-based crosssectional study. East Mediterr Health J 2015;21:555-63.
AL-Hammadi FA, Al-Tahri F, Al-Ali A, Nair SC, Abdulrahman M. Limited understanding of Pap smear testing among women, a barrier to cervical cancer screening in the United Arab Emirates. Asian Pac J Cancer Prev 2017;18:3379-87.
Jassim G, Obeid A, Al Nasheet HA. Knowledge, attitudes, and practices regarding cervical cancer and screening among women visiting primary health care centres in Bahrain. BMC Public Health 2018;18:128.
Koç Z. University students' knowledge and attitudes regarding cervical cancer, human papillomavirus, and human papillomavirus vaccines in Turkey. J Am Coll Health 2015;63:13-22.
Gamaoun R. Knowledge, awareness and acceptability of anti-HPV vaccine in the Arab states of the Middle East and North Africa Region: A systematic review. East Mediterr Health J 2018;24:538-48.
Thomsen LT, Nygård M, Stensen S, Terning Hansen B, Arnheim Dahlström L, Liaw KL, et al
. Awareness of human papillomavirus after introduction of HPV vaccination: A large population-based survey of Scandinavian women. Eur J Cancer Prev 2017;26:170-8.
Oz M, Cetinkaya N, Apaydin A, Korkmaz E, Bas S, Ozgu E, et al
. Awareness and knowledge levels of Turkish College students about human papilloma virus infection and vaccine acceptance. J Cancer Educ 2018;33:260-8.
Dodd RH, McCaffery KJ, Marlow LA, Ostini R, Zimet GD, Waller J. Knowledge of human papillomavirus (HPV) testing in the USA, the UK and Australia: An international survey. Sex Transm Infect 2014;90:201-7.
Islam JY, Khatun F, Alam A, Sultana F, Bhuiyan A, Alam N, et al
. Knowledge of cervical cancer and HPV vaccine in Bangladeshi women: A population based, cross-sectional study. BMC Womens Health 2018;18:15.
Başer E, Onat T, Aydoǧan Kırmızı D, Demir Çaltekin M, Kara M, Yalvaç ES. Awareness of women about cervical smear, human papilloma virus and human papilloma virus vaccine. Turk J Obstet Gynecol 2019;16:193-8.
Aldohaian AI, Alshammari SA, Arafah DM. Using the health belief model to assess beliefs and behaviors regarding cervical cancer screening among Saudi women: A cross-sectional observational study. BMC Womens Health 2019;19:6.
Bhuiyan A, Sultana F, Islam JY, Chowdhury MAK, Nahar Q. Knowledge and acceptance of human papillomavirus vaccine for cervical cancer prevention among urban professional women in Bangladesh: A mixed method study. Biores Open Access 2018;7:63-72.
Saffiullah SA, Qureshi MS, Hameedullah BW, Arfeen N. Awareness and acceptance of human papilloma virus vaccination among medical students of Peshawar Medical College. KJMS 2016;9:399.
Wong LP, Raja Muhammad Yusoff RN, Edib Z, Sam IC, Zimet GD. Nationwide survey of knowledge and health beliefs regarding human papillomavirus among HPV-vaccinated female students in Malaysia. PLoS One 2016;11:e0163156.
Karafillakis E, Simas C, Jarrett C, Verger P, Peretti-Watel P, Dib F, et al
. HPV vaccination in a context of public mistrust and uncertainty: A systematic literature review of determinants of HPV vaccine hesitancy in Europe. Hum Vaccin Immunother 2019;15:1615-27.
Pratt R, Njau SW, Ndagire C, Chaisson N, Toor S, Ahmed N, et al
. “We are Muslims and these diseases don't happen to us”: A qualitative study of the views of young Somali men and women concerning HPV immunization. Vaccine 2019;37:2043-50.
Almughais ES, Alfarhan A, Salam M. Awareness of primary health care physicians about human papilloma virus infection and its vaccination: A cross-sectional survey from multiple clinics in Saudi Arabia. Infect Drug Resist 2018;11:2257-67.
Rodriguez AM, Do TQN, Goodman M, Schmeler KM, Kaul S, Kuo YF. Human papillomavirus vaccine interventions in the U.S.: A systematic review and meta-analysis. Am J Prev Med 2019;56:591-602.
Sait KH. Knowledge, attitudes, and practices regarding cervical cancer screening among physicians in the Western Region of Saudi Arabia. Saudi Med J 2011;32:1155-60.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]