Dental Students’ Perception, Awareness and Knowledge About HPV Infection, Vaccine, and Its Association with Oral Cancer: A Multinational Study

Figures & data

Figure 1 Original survey that was circulated.

Table 1 Demographic Characteristics of Participants

		Frequency	Percent
Gender	Female	648	73.1
	Male	238	26.9
Education	Third year	246	27.8
	Fourth year	239	27
	Fifth year	115	13
	Sixth year	79	8.9
	Internship	207	23.4
Country	Egypt	110	12.4
	India	260	29.3
	Pakistan	133	15
	Saudi Arabia	193	21.8
	Sudan	96	10.8
	Sudan	4	0.5
	UAE	90	10.2
Marital status	Divorced	20	2.3
	Married	112	12.6
	Single	754	85.1
Do you Smoke?	No	735	83
	Previous smoker	5	0.6
	Yes	146	16.5

Table 2 Association of Gender- with Attitude-Based Questionnaires

			Gender		χ^2 Value	P value
			Female	Male
What would be your reasons, if you are unwilling to get vaccinated	Not sexually active	N(%)	149(74.1)	52(25.9)	82.5	0.001*
	Too expensive	N(%)	75(84.3)	14(15.7)
	Doctor did not recommend	N(%)	140(69.)	63(31.)
	Worried about safety of vaccine	N(%)	132(86.8)	20(13.2)
	Do not know where to get vaccine	N(%)	138(60.3)	91(39.7)
	My spouse/family member against it	N(%)	5(5.6)	4(4.4)
	Do not know enough about vaccine	N(%)	238(73.)	88(27.)
	Embarrassed to receive STD vaccine	N(%)	31(46.3)	36(53.7)
	Currently/Previously infected with HPV	N(%)	15(78.9)	4(21.1)
	Vaccinated against HPV already	N(%)	60(78.9)	16(21.1)
Are you willing to discuss about HPV vaccine with the same and with the opposite gender patients?	(a) Yes	N(%)	488(71.2)	197(28.8)	5.53	0.019*
	(b) No	N(%)	160(79.6)	41(20.4)
Are you comfortable to discuss with your patients their personal health	(a) Slightly comfortable	N(%)	270(69.9)	116(30.1)	34.37	0.001*
	(b) Not comfortable	N %)	239(85.4)	41(14.6)
	(c) Most comfortable	N(%)	139(63.2)	81(36.8)
What makes you difficult to discuss with your parents regarding HPV connection with oral cancer?	Lack of privacy	N(%)	251(66.9)	124(33.1%)	47.4	0.001*
	Fear of offending patients	N(%)	288(68.1)	135(31.9)
	Language barrier	N %)	131(71.2)	53(28.8)
	Lack of time	N(%)	96(89.7)	11(10.3)
	I do not know enough	N(%)	275(71.1)	112(28.9)
	I do not think it is relevant	N(%)	53(85.5)	9(14.5)
Are you willing to participate in any professional training or continuous dental education program to achieve better knowledge and understanding about HPV & its association with oral cancer	(a) Yes	N(%)	493(74.2)	171 (25.8)	1.66	0.198
	(b) No	N(%)	155(69.8)	67(30.2)

Note: *Statistical significance set at 0.05; N: Number of samples; χ² value: Chi-Square value.

Table 3 Comparison of Knowledge Between Males and Females

			Gender		P value
			Female	Male
			N(%)	N(%)
Awareness of oral cancer and its association with HPV	What are the risk factors of oral cancer?	Poor knowledge	156(24.1)	44(18.)	0.078
		Good knowledge	492(75.9)	194(81.5)
	What is the common site of occurrence of oral cancer?	Poor knowledge	334(51.5)	100(42.0)	0.012*
		Good knowledge	314(48.5)	138(58.0)
	Which of the following describes the clinical appearance of the early lesion of oral cancer?	Poor knowledge	351 (54.2)	84(35.3)	0.001*
		Good knowledge	297(45.8)	154(64.7)
Knowledge about HPV	What diseases you know that HPV can cause?	Poor knowledge	441(68.1)	122(51.3)	0.001*
		Good knowledge	207(31.9)	116(48.7)
	What diseases you know that HPV can cause?	Poor knowledge	234(36.1)	52(21.8)	0.001*
		Good knowledge	414(63.9)	186(78.2)
	Most HPV infections resolve within a short time	Poor knowledge	473(73.0)	193(81.1)	0.013*
		Good knowledge	175(27.0)	45(18.9)
Knowledge and perception about HPV vaccine	Do you know there exists a vaccine against HPV?	Poor knowledge	338(52.2)	150(63.0)	0.004*
		Good knowledge	310(47.8)	88(37.0)
	Who are eligible to take HPV vaccine?	Poor knowledge	541(83.5)	216(90.8)	0.007*
		Good knowledge	107(16.5)	22(9.2)
	Do you think it is important to get vaccinated for HPV?	Poor knowledge	273(42.1)	138(58.0)	0.001*
		Good knowledge	375(57.9)	100(42.0)

Note: *Statistical significance set at 0.05; N: Number of samples; χ² value: Chi-Square value.

Table 4 Association of Education with Awareness-Based Questionnaires

		Education					χ^2 Value	P value
		3rd Year	4th Year	5th Year	6th Year	Internship
Are you confident to identify clinically, early lesions of oral cancer?	Not confident	31.6%	25.9%	15.%	10.6%	16.9%	123.2	0.001*
	Somewhat confident	26.7%	30.2%	14.4%	2.2%	26.5%
	Very confident	21.1%	16.5%	0.9%	32.1%	29.4%
Before taking this survey, have you heard about HPV before?	No	15.%	13.6%	20.7%	25.%	25.7%	77.1
	Yes	30.2%	29.5%	11.5%	5.9%	22.9%
From where you heard about HPV vaccine?	Gynecologist	18.5%	75.9%	1.9%	0.%	3.7%	135.6	0.001*
	Dentist	10.6%	25.4%	21.6%	2.7%	39.8%
	Online websites	34.5%	34.%	15.5%	1.%	15.%
	Books	31.1%	27.1%	17.6%	14.5%	9.7%
	Friends /family	31.%	12.%	38.%	2.%	17.%
Who are eligible to take HPV vaccine?	(a) Only females >30 yrs	0.%	36.1%	0.%	2.8%	61.1%	416.1	0.001*
	(b) Only males >30 yrs	0.%	50.%	50.%	0.%	0.%
	(c) Both genders >30 yrs	61.9%	25.4%	1.6%	3.2%	7.9%
	(d) Females ˂ 30yrs	27.1%	16.7%	27.1%	8.3%	20.8%
	(e) Males ˂ 30yrs	0.%	8.1%	0.%	86.5%	5.4%
	Everyone	0.%	0.%	0.%	0.%	100.%
	(f) Both genders ˂ 30 yrs	42.6%	24.8%	20.9%	0.%	11.6%
	(g) No idea	24.4%	29.1%	12.8%	7.%	26.7%
Are you vaccinated for HPV?	No	26.8%	29.6%	13.%	10.3%	20.2%	40.63	0.001*
	Yes	32.7%	14.%	12.7%	2.%	38.7%

Note: *Statistical significance set at 0.05; N: Number of samples; χ² value: Chi-Square value.

Table 5 Comparison of Knowledge Between Students from Different Undergraduate Years

			Education										P value
			3rd Year		4th Year		5th Year		6th Year		Internship
			N	%	N	%	N	%	N	%	N	%
Awareness of oral cancer and its association with HPV	What are the risk factors of oral cancer?	Poor knowledge	44	17.9	38	15.9	31	27.0	36	45.6	51	24.6	0.001*
		Good knowledge	202	82.1	201	84.1	84	73.0	43	54.4	156	75.4
	What is the common site of occurrence of oral cancer?	Poor knowledge	70	28.5	130	54.4	70	60.9	57	72.2	107	51.7	0.001*
		Good knowledge	176	71.5	109	45.6	45	39.1	22	27.8	100	48.3
	Which of the following describes the clinical appearance of the early lesion of oral cancer?	Poor knowledge	82	33.3	106	44.4	60	52.2	57	72.2	130	62.8	0.001*
		Good knowledge	164	66.7	133	55.6	55	47.8	22	27.8	77	37.2
Knowledge about HPV	What diseases you know that HPV can cause?	Poor knowledge	99	40.2	123	51.5	102	88.7	74	93.7	165	79.7	0.001*
		Good knowledge	147	59.8	116	48.5	13	11.3	5	6.3	42	20.3
	What diseases you know that HPV can cause?	Poor knowledge	66	26.8	70	29.3	31	27.0	10	12.7	109	52.7	0.001*
		Good knowledge	180	73.2	169	70.7	84	73.0	69	87.3	98	47.3
	Most HPV infections resolve within a short time	Poor knowledge	183	74.4	173	72.4	92	80.0	68	86.1	150	72.5	0.079
		Good knowledge	63	25.6	66	27.6	23	20.0	11	13.9	57	27.5
Knowledge and perception about HPV vaccine	Do you know there exists a vaccine against HPV?	Poor knowledge	129	52.4	108	45.2	64	55.7	63	79.7	124	59.9	0.001*
		Good knowledge	117	47.6	131	54.8	51	44.3	16	20.3	83	40.1
	Who are eligible to take HPV vaccine?	Poor knowledge	191	77.6	207	86.6	88	76.5	79	100.0	192	92.8	0.001*
		Good knowledge	55	22.4	32	13.4	27	23.5	0	0.0	15	7.2
	Do you think it is important to get vaccinated for HPV?	Poor knowledge	156	63.4	52	21.8	70	60.9	41	51.9	92	44.4	0.001*
		Good knowledge	90	36.6	187	78.2	45	39.1	38	48.1	115	55.6

Note: *Statistical significance set at 0.05; N: Number of samples; χ² value: Chi-Square value.

Table 6 Association of Country with Awareness-Based Questionnaires

Question		Country						χ^2 Value	P value
		Egypt	India	Pakistan	KSA	Sudan	UAE
Are you confident to identify clinically, early lesions of oral cancer?	Not confident	27.2%	21.2%	16.6%	20.3%	14.7%	0.%	295.1	0.001*
	Somewhat confident	1.1%	38.1%	15.1%	24.5%	11.6%	9.6%
	Very confident	16.5%	16.5%	10.1%	14.7%	0.%	42.2%
Before taking this survey, have you heard about HPV before?	No	12.9%	5.%	18.6%	20.%	11.4%	32.1%	114.4	0.001*
	Yes	12.3%	33.9%	14.3%	22.1%	11.3%	6.%
Do you know there exists vaccines against HPV?	(a) Yes	10.8%	41.2%	13.1%	21.1%	13.6%	0.3%	250.3	0.001*
	(b) No	10.5%	12.6%	14.1%	23.6%	16.2%	23.%
	(c) Maybe	0.6%	36.6%	24.2%	18.6%	0.%	19.9%
	(d) Do not know	33.8%	9.6%	11.%	25.%	11.%	9.6%
From where you heard about HPV vaccine?	Gyneclologist	1.9%	22.2%	25.9%	16.7%	33.3%	0.%	656.9	0.001*
	Dentist	8.7%	36.%	8.7%	29.9%	0.%	16.7%
	Online websites	1.5%	34.5%	19.4%	20.9%	23.8%	0.%
	Books	21.3%	27.1%	13.4%	9.5%	8.7%	20.%
	Friends/family	0.%	31.%	11.%	10.%	4.%	44.%
Who are eligible to take HPV vaccine?	(a) Only females >30 yrs	50.%	33.3%	0.%	16.7%	0.%	0.%	483	0.001*
	(b) Only males >30 yrs	0.%	0.%	50.%	50.%	0.%	0.%
	(c) Both genders >30 yrs	0.%	25.4%	34.9%	15.9%	23.8%	0.%
	(d) Females ˂ 30 yrs	0.%	45.8%	2.1%	52.1%	0.%	0.%
	(e) Males ˂30yrs	0.%	8.1%	0.%	5.4%	0.%	86.5%
	Everyone	100.%	0.%	0.%	0.%	0.%	0.%
	(f) Both genders ˂30 yrs	30.2%	45.7%	10.1%	14.%	0.%	0.%
	(g) No Idea	9.1%	26.%	16.8%	23.%	14.9%	10.2%
Are you vaccinated for HPV ?	No	7.2%	31.1%	16.2%	21.9%	11.4%	12.2%	122.1	0.001*
	Yes	38.%	20.7%	9.3%	21.3%	10.7%	0.%

Note: *Statistical significance set at 0.05; N: Number of samples; χ² value: Chi-Square value.

Table 7 Association of Country with Attitude-Based Questionnaires

		Country						χ2 Value	P value
		Egypt	India	Pakistan	KSA	Sudan	UAE
Do you think it is important to get vaccinated for HPV?	(a) Yes	18.9%	37.5%	6.5%	29.1%	8.0%	0.0%	344.6	0.001*
	(b) No	22.9%	3.6%	13.3%	21.7%	0.0%	38.6%
	(c) Maybe	0.3%	24.1%	27.7%	11.3%	18.9%	17.7%
Are you willing to discuss about HPV vaccine with the same and with the opposite gender patients?	(a) Yes	10.2%	34.7%	14.2%	17.4%	12.3%	11.2%	76.18	0.001*
	(b) No	19.9%	10.9%	17.9%	36.8%	8.0%	6.5%
Are you comfortable to discuss with your patients their personal health?	(a) Slightly comfortable	1.3%	39.4%	11.1%	19.2%	9.1%	19.9%	350.3	0.001*
	(b) Not comfortable	36.8%	14.3%	13.2%	25.4%	5.7%	4.6%
	(c) Most comfortable	0.9%	30.9%	24.1%	21.8%	22.3%	0.0%
What makes you difficult to discuss with your patients regarding HPV connection with oral cancer?	Lack of privacy	16.5%	16.3%	23.2%	15.2%	17.1%	11.7%	451.3	0.001*
	Fear of offending patients	10.2%	27.9%	16.1%	21.7%	16.5%	7.6%
	Language barrier	1.1%	30.4%	21.7%	21.2%	25.5%	0.0%
	Lack of time	36.4%	27.1%	15.0%	21.5%	0.0%	0.0%
	I do not know enough	21.7%	19.6%	15.0%	20.2%	8.5%	15.0%
	I do not think it is relevant	9.7%	48.4%	1.6%	40.3%	0.0%	0.0%
Are you willing to participate in any professional training or continuous dental education program to achieve better knowledge and understanding about HPV and its association with oral cancer?	(a) Yes	13.3%	34.8%	9.9%	22.6%	8.0%	11.4%	104.4	0.001*
	(b) No	9.9%	13.1%	30.2%	19.4%	21.2%	6.3%

Note: *Statistical significance set at 0.05; N: Number of samples; χ² value: Chi-Square value.

Table 8 Comparison of Knowledge Between Students from Different Countries

			Country						P value
			Egypt	India	Pakistan	Saudi Arabia	Sudan	UAE
			N(%)	N(%)	N(%)	N(%)	N(%)	N(%)
Awareness of oral cancer and its association with HPV	What are the risk factors of oral cancer	Poor knowledge	21(19.1)	34(13.1)	39(29.3)	41(21.2)	32(32.0%	33(36.7)	0.001*
		Good knowledge	89(80.9)	226(86.9)	94(70.7)	152(78.8)	68(68.0)	57(63.3)
	What is the common site of occurrence of oral cancer?	Poor knowledge	102(92.7)	80(30.8)	44(33.1)	84(43.5)	34(34.0)	90(100.0)	0.001*
		Good knowledge	8(7.3)	180(69.2)	89(66.9)	109(56.5)	66(66.0)	0(0.0)
	Which of the following describes the clinical appearance of the early lesion of oral cancer?	Poor knowledge	63(57.3)	87(33.5)	56(42.1)	103(53.4)	36(36.0)	90(100.0)	0.001*
		Good knowledge	47(42.7)	173(66.5)	77(57.9)	90(46.6)	64(64.0)	0(0.0)
Knowledge about HPV	What diseases you know that HPV can cause?	Poor knowledge	105(95.5)	121(46.5)	63(47.4)	149(77.2)	36(36.0)	89(98.9)	0.001*
		Good knowledge	5(4.5)	139(53.5)	70(52.6)	44(22.8)	64(64.0)	1(1.1)
	What diseases you know that HPV can cause?	Poor knowledge	65(59.1)	90(34.6)	41(30.8)	77(39.9)	0(0.0)	13(14.4)	0.001*
		Good knowledge	45(40.9)	170(65.4)	92(69.2)	116(60.1)	100(100.0)	77(85.6)
	Most HPV infections resolve within a short time	Poor knowledge	104(94.5)	196(75.4)	88(66.2)	139(72.0)	49(49.0)	90(100.0)	0.001*
		Good knowledge	6(5.5%	64(24.6)	45(33.8)	54(28.0)	51(51.0)	0(0.0)
Knowledge and perception about HPV vaccine	Do you know there exists a vaccine against HPV?	Poor knowledge	67(60.9)	96(36.9)	81(60.9)	109(56.5)	46(46.0)	89(98.9)	0.001*
		Good knowledge	43(39.1)	164(63.1)	52(39.1)	84(43.5)	54(54.0)	1(1.1)
	Who are eligible to take HPV vaccine?	Poor knowledge	71(64.5)	201(77.3)	120(90.2)	175(90.7)	100(100.0)	90(100.0%)	0.001*
		Good knowledge	39(35.5)	59(22.7)	13(9.8)	18(9.3)	0(0.0)	0(0.0)
	Do you think it is important to get vaccinated for HPV?	Poor knowledge	20(18.2)	82(31.5)	102(76.7)	55(28.5)	62(62.0)	90(100.0)	0.001*
		Good knowledge	90(81.8)	178(68.5)	31(23.3)	138(71.5)	38(38.0)	0(0.0)

Note: *Statistical significance set at 0.05; N: Number of samples; χ² value: Chi-Square value.

Figure 2 Reasons for unwillingness to get vaccinated.