Overview of knowledge, attitudes and barriers associated with HPV vaccination in Beirut, Lebanon

Figures & data

Table 1. Participants characteristics.

Demographic information*		Frequency	Valid percent
Age	18–20	52	25.9
	21–23	70	34.8
	24–26	36	17.9
	27–29	15	7.5
	30–32	16	8
	33–36	12	6
Gender	Male	81	40.3
	Female	116	57.7
	Other	2	1
	Prefer not to say	2	1
Marital status	Single	178	88.6
	Married	19	9.5
	Divorced	2	1
	Widowed	2	1
Highest educational degree received	Middle School or Below	3	1.5
	High School Degree	43	21.4
	University Degree	106	52.7
	Graduate Degree	49	24.4
Do you work or study in a health-related field (public health, medicine, nursing, pharmacy, health sciences, etc.)? (Working status)	No	138	68.7
	Yes	63	31.3
Are you a Lebanese citizen?	Yes	201	100
Where do you live?	Outside Beirut	37	18.6
	Beirut	162	81.4
	Missing (n = 2)
Have you ever lived abroad?	No	120	59.7
	Yes	81	40.3
If yes, did you live in an Eastern or Western country?	Western Country	41	51.9
	Eastern Country	38	48.1
	Missing (n = 2) Not applicable (n = 120)

* 201 participants in total.

Table 2. Pre-assessment.

		Frequency	Valid percent
Are you sexually active?	No	111	55.2
	Yes	90	44.8
Do you or your partner utilise protection for sexually transmitted diseases (e.g. condoms)?	No	30	33.7
	Yes	59	66.3
	Missing (n = 1) Not applicable (n = 111)
Do you get regular testing for sexually transmitted diseases?	No	99	83.9
	Yes	19	16.1
	Missing (83)
Were you vaccinated for HPV	No	143	71.1
	Yes	37	18.4
	Planning to take it	21	10.4
If not, for what reason?	Medical	5	3.2
	Personal	50	32.2
	Religious	1	0.7
	Lack of availability / access	81	52.3
	Planning to take it	18	11.6
	Missing (n = 9) Not applicable (n = 37)
If yes, were you vaccinated before or after the age of 18?	Less than 18	26	72.2
	More than 18	10	27.8
	Missing (n = 1) Not applicable (n = 164)
If you were vaccinated for HPV, who gave you your HPV vaccine?	Pediatrician	17	47.2
	Primary Care Physician	11	30.6
	Gynecologist	8	22.2
	Missing (n = 1) Not applicable (n = 164)
How did you hear about the HPV vaccine?	Pediatrician	25	12.4
	Primary Care Physician	16	8
	Gynecologist	15	7.5
	TV Programme	12	6
	Internet	50	24.9
	Newspaper/magazine	0	0
	Family/Friends	33	16.4
	Leaflet at a clinic or hospital	5	2.5
	School	12	6
	Healthcare workers	21	10.4
	Other	29	14.4
If you did not take the vaccine and you are still eligible to take it, are you planning on taking it?	No	57	35.6
	Yes	103.0	64.4
	Missing (n = 4) Not applicable (n = 37)
Has anyone recommended you take the HPV vaccine?	No	125	63.7
	Yes	71	36.3
	Missing (n = 5)
If yes, which of the following sources recommended it?	Pediatrician	19	9.5
	Primary Care Physician	20	10
	Gynecologist	17	8.5
	Family	13	6.5
	Friends	26	12.9
Have you ever had a pap smear (if applicable)?	No	94	87.8
	Yes	13	12.2
	Missing (n = 13) Not applicable (n = 81)
Have you ever received any kind of sexual education?	No	51	25.6
	Yes	148	74.4
	Missing (n = 2)
If yes, where did you receive this sexual education from?	TV Programme	44	21.9
	Internet	97	48.3
	Newspaper/magazine	14	7
	Family/Friends	75	37.3
	Leaflet at clinic or Hospital	18	9
	School	63	31.3
	Healthcare Workers	35	17.4
	Other	13	6.5
Have you ever been diagnosed with any of the conditions listed below?	Cancer	5	2.5
	Hypertension	6	3
	Diabetes	2	1
	Hyperlipidemia	3	1.5
	Sexually Transmitted Diseases	1	0.5
	Cardiovascular Disease	5	2.5
	Autoimmune	8	4
If you were diagnosed with cancer, please specify the type of cancer:	Cervical Cancer	−	−
	Vaginal Cancer	2	1
	Vulvar cancer	−	−
	Another type	−	−
	Throat cancer	2	1
	Anal Cancer	−	−
	Penile Cancer	−	−
	Another type	1	0.5
Have you ever been diagnosed with HPV infection?	No	197	98
	Yes	4	2
Do you know of friends or family diagnosed with sexually transmitted diseases?	No	173	86.1
	Yes	28	13.9
Do you know of friends or family diagnosed with HPV infection?	No	188	93.5
	Yes	13	6.5
Do you know of anyone who took the HPV vaccine?	No	141	70.1
	Yes	60	29.9
How would you rate your knowledge about HPV?	No knowledge	55	27.5
	Poor	52	26
	Fair	37	18.5
	Good	29	14.5
	Very Good	12	6
	Excellent	15	7.5
	Missing (n = 1)
Did you receive a vaccine for COVID 19?	No	18	9
	Yes	179	89.1
	Planning to take it	4	2
If not, for what reason?	Medical	2	9.5
	Religious	1	4.8
	Personal	17.0	80.9
	Lack of availability/access	1	4.8
	Missing (n = 1) Not applicable (179)
Were you exposed to any COVID-19 vaccination awareness campaigns?	No	38	19.1
	Yes	161	80.9
	Missing (n = 2)

* We have 201 participants in total.

Table 3. Frequency distribution of correct answers on questions pertaining to knowledge about HPV among the 201 total participants.

Knowledge questions	Correct answers
	Frequency	Valid percent	Missing
Evaluate the following statement: The HPV vaccine is recommended to be taken between the ages of 9–26. (T)	83	41.5	1
Evaluate the following statement: HPV can cause oropharyngeal, genital and anal cancers. (T)	83	41.9	3
HPV is very rare (F)	94	46.8	−
HPV has always visible signs and symptoms (F)	70	34.8	−
HPV can cause cervical cancer (T)	82	40.8	−
HPV can be passed on by genital skin-to-skin contact. (T)	79	39.3	−
There are many types of HPV. (T)	82	40.8	−
HPV can cause HIV/AIDS. (F)	55	27.4	−
HPV can be passed on during sexual intercourse. (T)	131	65.5	1
HPV can cause genital warts. (T)	81	40.3	−
Men cannot get HPV. (F)	113	56.2	−
Using condoms reduces the risk of getting HPV. (T)	133	66.2	−
HPV can be cured with antibiotics. (F)	61	30.3	−
Having many sexual partners increases the risk of getting HPV. (T)	127	63.2	−
HPV usually doesn’t need any treatment. (T)	9	4.5	−
Most sexually active people will get HPV at some point in their lives. (T)	40	19.9	−
A person could have HPV for many years without knowing it. (T)	87	43.3	−
Having sex at an early age increases the risk of getting HPV. (T)	56	27.9	−
An HPV test can tell how long you have had an HPV infection. (F)	29	14.4	−
If a woman tests positive for HPV, she will definitely get cervical cancer. (F)	97	48.3	−
An HPV test can be done at the same time as a [Pap test/Smear test/Pap smear test]. (T)	55	27.4	−
HPV testing is used to indicate if the HPV vaccine is needed. (F)	27	13.4	−
When you have an HPV test, you get the results the same day. (F)	27	13.4	−
If an HPV test shows that a woman does not have HPV her risk of cervical cancer is low. (T)	46	22.9	−
HPV vaccines require three doses. (T)	35	35	−
The HPV vaccines offer protection against all sexually transmitted infections. (F)	80	39.8	−
The HPV vaccines are most effective if given to people who have never had sex. (T)	51	25.4	−
Someone who has had HPV cannot develop cervical cancer. (F)	85	42.3	−
The HPV vaccines offer protection against most cervical cancers. (T)	69	34.3	−
One of the HPV vaccines offers protection against genital warts. (T)	59	29.5	1
Girls who have had the HPV vaccine do not need a [Pap test/Smear test/Pap smear test] when they are older. (F)	75	37.3	−

Remaining frequency and percentage reflect either wrong answer or no knowledge.

‘True’ (T) is the correct answer to the corresponding question.

‘False’ (F) is the correct answer to the corresponding question.

Table 4. Frequency distribution of positive attitude on questions pertaining to attitude towards HPV vaccines among the 201 total participants.

Attitude questions	Positive attitude
	Frequency^¥	Valid Percent^¥	Missing
The HPV vaccine is safe to use. **	113	57.1	3
I am afraid to take the HPV vaccine. ++	105	53	3
Educating parents about vaccine is an important way to connect vaccination coverage to the population. **	150	76.5	5
The doctor has an important role in educating parents about the importance of HPV vaccination. **	163	81.9	2
It is safer to be vaccinated against HPV than contracting the disease. **	146	73.7	3
Vaccines contain substances that have been proven harmful to people's health. ++	79	39.9	3
There is not enough evidence that HPV immunisation prevents infection from HPV. ++	54	27.2	3

^¥ Remaining frequency and percentage reflect either neutral or negative attitude.

** Agreeing to these questions indicates a positive attitude.

++ Disagreeing to these questions indicates a positive attitude.

% reflects valid percent.

Table 5. Hesitancy levels towards HPV vaccines.

Hesitancy questions	High N (%)	Neutral N (%)	Low N (%)	Missing	Total
Confidence++
I am completely confident that vaccines are safe	38 (19.3)	32 (16.2)	127 (64.5)	4	197
Vaccinations are effective.	21 (10.5)	26 (13)	152 (76.4)	2	199
Regarding vaccines, I am confident that public authorities decide in the best interest of the community.	64 (32.3)	52 (26.2)	82 (41.4)	3	198
Complacency**
Vaccination is unnecessary because vaccine-preventable diseases are not common anymore.	9 (4.5)	25 (12.6)	165 (82.9)	2	199
My immune system is so strong, it also protects me against diseases.	31 (15.6)	33 (16.6)	134 (67.7)	3	198
Vaccine-preventable diseases are not so severe that I should get vaccinated.	19 (9.6)	34 (17.2)	144 (73)	4	197
Constraints**
Everyday stress prevents me from getting vaccinated.	22 (11.1)	31 (15.6)	145 (73.2)	3	198
For me, it is inconvenient to receive vaccinations.	29 (14.6)	31 (15.6)	138 (69.7)	3	198
Visiting the doctor’s makes me feel uncomfortable; this keeps me from getting vaccinated.	31 (15.6)	23 (11.6)	144 (72.7)	3	198
Calculation**
When I think about getting vaccinated, I weigh benefits and risks to make the best decision possible.	106 (53.3)	42 (21.1)	51 (25.6)	2	199
For each and every vaccination, I closely consider whether it is useful for me.	111 (55.7)	37 (18.6)	51 (25.6)	2	199
It is important for me to fully understand the topic of vaccination before I get vaccinated.	144 (73.1)	27 (13.7)	26 (13.2)	4	197
Collective responsibility
When everyone is vaccinated, I don’t have to get vaccinated as well.**	43 (21.7)	19 (9.6)	136 (68.7)	3	198
I get vaccinated because I can also protect people with a weaker immune system.++	26 (13.2)	17 (8.6)	154 (78.2)	4	197
Vaccination is a collective action to prevent the spread of diseases.++	19 (9.7)	19 (9.7)	158 (80.6)	5	196
Total	713 (24)	448 (15)	1807 (61)	47	2968

% reflects valid percent; ** Agreeing to these questions indicate higher hesitancy; ++ Disagreeing to these questions indicate higher hesitancy.

Table 6. Knowledge/attitude levels and Hesitancy towards HPV vaccination.

		Knowledge levels ±		Attitude levels ±
		Gamma	P-value	Gamma	P-value
	Hesitancy Levels	−0.7415	0.001327	−0.5826	<0.01
Hesitancy sections	Confidence	0.7940	<0.01	0.7774	0
	Complacency	−0.7763	<0.01	−0.6739	<0.01
	Constraints	−0.37	0.0795	−0.3676	0.0047
	Calculation	0.0331	0.84	0.0845	0.5124
	Collective responsibility	0.6639	0.00134	0.7042	<0.01

Knowledge levels were stratified into three categories: low, moderate and high knowledge.

Attitude levels were stratified into three categories: negative, neutral and positive attitude.

Hesitancy levels were stratified into three categories: low, neutral and high hesitancy.

± Test of ordinal trend based on gamma statistic.

Table 7. Knowledge, attitude and hesitancy.

	Unadjusted ¥			Adjusted* ¥
	OR	95% CI	P-value	OR	95% CI	P-value
Knowledge score
Hesitancy levels	0.89	0.839–0.956	0.001	0.914	0.839–0.996	0.042
Confidence	1.101	1.054–1.150	0.000	1.090	1.026–1.158	0.005
Complacency	0.888	0.835–0.945	0.000	0.935	0.866–1.009	0.087
Constraints	0.974	0.935–1.015	0.222	0.969	0.915–1.026	0.293
Calculation	1.002	0.969–1.037	0.867	1.023	0.975–1.074	0.345
Collective responsibility	1.082	1.027–1.139	0.003	1.082	1.006–1.163	0.033
Attitude score
Hesitancy levels	0.881	0.815–0.953	0.002	0.873	0.779–0.979	0.020
Confidence	1.307	1.196–1.429	0.000	1.237	1.116–1.370	0.000
Complacency	0.857	0.791–0.928	0.000	0.846	0.757–0.946	0.003
Constraints	0.936	0.878–0.997	0.042	0.923	0.848–1.005	0.067
Calculation	1.0362	0.983–1.092	0.185	1.068	0.993–1.150	0.074
Collective responsibility	1.259	1.140–1.391	0.000	1.225	1.089–1.378	0.001

*Adjusted for age, working status, vaccination for HPV, recommendation by anyone to take the HPV vaccine, knowing someone who took the HPV vaccine, vaccination for COVID-19 and if not for what reason.

Knowledge score was taken on a continuous scale as our main predictor.

Attitude score was taken on a continuous scale as our main predictor.

Hesitancy levels were stratified into three categories: low, neutral and high hesitancy (ordinal outcome).

¥ Cumulative logit model with proportional odds property was used.

Table 8. Attitude towards HPV vaccination before and after the survey.

		Attitude towards HPV vaccination after the survey			Total
		Negative	Neutral	Positive
Attitude towards HPV vaccination before this survey	Negative	4	3	6	13
	Neutral	1	26	94	121
	Positive	0	0	64	64
Total		5	29	164	198

P-value < 0.001 using extended McNemar’s test for 3 × 3 Table.

χ² = 101, degrees of freedom  = 3.