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

ABSTRACT

Background:

Human Papillomavirus (HPV), a prevalent sexually transmitted infection carrying significant risks ranging from benign lesions to various types of malignancies, represents a matter of great public health concern. Notably, most Arab countries lack public awareness campaigns or national immunization programs. This study aims at assessing the overall knowledge on HPV and HPV vaccination among the Lebanese population, exploring the prevalent attitude on the matter, and identifying barriers and misconceptions that prevent individuals from receiving the HPV vaccine.

Methods:

A cross-sectional study was conducted in Beirut, on 201 participants aged between 18 and 36 years old. We performed ordinal analysis to assess the trend between Knowledge levels, attitude levels and hesitancy Levels.

Results:

Majority of participants (77%) demonstrated a low level of knowledge on HPV vaccination, 50% held a positive attitude, with only 18.4% being already vaccinated. Negative trend was identified between levels of knowledge, attitude and hesitancy (gamma = −0.7415, p-value < 0.01; gamma= −0.58, p-value < 0.01 respectively). Unavailability or limited access to the vaccine, and misconceptions about HPV immunization were shown to be impeding vaccination.

Conclusion:

Analysis of our results strongly suggests that improving knowledge and attitudes is likely to foster trust and reduce hesitancy, thereby promoting higher vaccine uptake.

KEYWORDS:

• Human papillomavirus (HPV)
• HPV vaccination
• HPV knowledge
• HPV attitude
• HPV hesitancy

Introduction

Human Papillomavirus (HPV) is a prevalent sexually transmitted infection, with approximately 80% of sexually active people being infected with at least one type of HPV at some point in their lives (HPV and Cancer - NCI, 2019). Most HPV infections have an asymptomatic course and tend to clear within 1–2 years, which increases the risk of infection spreading. Other HPV infections tend to become more chronic and long-lasting and carry significant risks ranging from benign lesions to various types of malignancies. Low-risk HPV types (e.g. HPV6 and HPV11) are causative agents of genital warts, while high-risk types (e.g. HPV16 and HPV18) are associated with the development of over 90% of cervical cancers, as well as several other cancers including vulvar, vaginal, penile, anal and oropharyngeal (How Many Cancers Are Linked with HPV Each Year?, 2022). At present, among the preventive measures against HPV-related cancers are HPV vaccinations such as 9-valent HPV vaccine (Gardasil 9, 9vHPV) recommended for all genders. As of 2020, HPV vaccination has been approved in the national immunisation schedules of over 131 countries (Human-Papillomavirus-Vaccine-Market-Update-October2020.Pdf, n.d.).

HPV vaccinations have been marketed in Lebanon since 2007, yet the absence of official national recommendations has resulted in a lack of structured guidance regarding its use. Gardasil 9’s is currently priced at 180$ in Lebanon, and is not subsidised by the government or covered by insurance companies. It is also not currently included in Lebanon’s national immunisation schedule (Bahr et al., 2019). Available data concerning HPV knowledge and vaccine uptake in Arab communities is of noteworthy scarcity, with limited research covering data on Lebanon. A study conducted in 2015 reported that HPV vaccine knowledge among Lebanese college female students was poor to moderate (Dany et al., 2015). Another study carried out in 2020 similarly revealed a significant lack of knowledge on HPV among Lebanese medical students, along with a markedly low vaccination rate (16.4%) (Haddad et al., 2022). Additionally, HPV vaccine recommendation by physicians in Lebanon has been found to be heavily relied on factors external to international guidelines (Abi Jaoude et al., 2018), which constitutes a matter of great concern. For example, it was shown that physicians are more likely to recommend the vaccine to patients presenting from non-conservative backgrounds, and less likely to recommend it to married patients. Physicians with higher knowledge scores also tend to recommend the vaccine more often. Furthermore, awareness about the HPV vaccine was found to be significantly low (34%) among mothers of girls at the age of primary HPV vaccination in Lebanon (Abou El-Ola et al., 2018).

Although these studies examined some aspects of the HPV vaccine, there is a notable absence of comprehensive data regarding awareness, perception and acceptability of HPV vaccination among the general Lebanese population, indicating a critical need for further research in this area. Accordingly, we aim here at providing a thorough assessment of the HPV vaccination and its correlates through a survey-based cross-sectional study developed on the basis of the Theory of Planned Behaviour Model (TPB), a well-established theoretical framework (Ajzen, 1991). Our data was comprised of a sample of Lebanese population selected from Beirut, the capital of Lebanon and one of the largest cities in the country. The main objective of this research work is to examine the overall knowledge of, and attitudes towards HPV and HPV vaccination, explore factors that influence vaccine uptake, and identify barriers and misconceptions that prevent individuals from receiving the vaccine. The main theoretical idea is that increased knowledge about HPV vaccine and its effectiveness in reducing some HPV-related diseases, helps in improving the attitude and shaping the behaviour towards more acceptance and less hesitancy towards its utilisation.

Thus, understanding the factors that can encourage and the barriers that impede the uptake of the HPV vaccine is crucial for designing effective public health policies and strategies to increase HPV vaccination rates in Lebanon and ultimately reduce the burden of HPV-related diseases.

Methods

Study design and participants

A cross-sectional study was conducted between March 2022 and January 2023. The inclusion criteria consisted of men and women between the ages of 18 and 36 years old. This age group encompasses individuals who are at age to potentially get vaccinated, ranging between 9 and 26 years as per the recommendation of the Centers for Disease Control and Prevention (CDC) (HPV Vaccine Information For Young Women, n.d.), or who could have already gotten vaccinated, given that the HPV vaccine was officially recommended for both males and females in the U.S. starting 2011.

Data collection

Data collection was conducted through an online self-administered questionnaire using LimeSurvey software. The link to the survey was disseminated through social media platforms via online advertising on Instagram and WhatsApp. The questionnaire was also distributed in hardcopy form to pedestrians on the streets of Beirut. The areas covered included the main regions in Beirut the capital of Lebanon. Participants could choose to answer the survey in both online and hardcopy versions. The survey took approximately 10 minutes to complete, A total of 201 surveys were completed, with a full completion rate.

Concepts and indicators

The questionnaire construction was based on the Theory of Planned Behaviour Model (TPB), a well-established theoretical framework (Ajzen, 1991). This model has been successfully used to predict and explain a wide range of health behaviours such as smoking cessation, medication adherence, health services utilisation, breastfeeding and physical activity, among others (Steinmetz et al., 2016). It primarily posits that intentions to perform a behaviour are influenced by attitude towards the behaviour, which is heavily affected by a variety of background factors which include age, gender, education, knowledge, culture, media and geography among other factors.

The questionnaire consisted of 88 close-ended questions divided into 7 sections that were developed based on the general conceptual framework of the TPB and on various previously validated sources as detailed below. Variables collected from all sections are aimed to assess important background factors that play a role in shaping intentions and hence behaviours related to HPV (i.e. vaccination).

Section 1: Demographics

This section looked into demographic information with variables such as age, gender, marital status, educational degree, healthcare-related field of work or study, geographic location, having ever lived abroad (West/East) (Table 1). Age was grouped into intervals of 3–4 years, in order to capture salient periods (late teens, early/mid/late-twenties, early/mid-thirties). Distinguishing between Western and Eastern countries was important in view of the marked difference in exposure to HPV vaccination in regards to awareness, knowledge and access.

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.

Section 2: Pre-assessment

The second section was a pre-assessment of variables such as sexual activity, safe sex practices and regular Sexual transmitted infection (STI) testing, HPV vaccination status, age upon vaccination or reason for not being vaccinated, HPV vaccine awareness, HPV vaccine recommendation, previous sexual education and its source, previous Pap Smear if applicable, previous or present medical conditions, history of HPV infection or other STI, friends/family with a history of HPV or other STI, and friends/family vaccinated for HPV. Assessment of Covid-19 vaccination status and exposure to Covid-19 vaccination awareness campaigns were also included in this section with an intent to determine whether a relation exists between getting immunised with Covid-19 vaccine, which was introduced in the market in an expeditious manner, and getting immunised with the HPV vaccine. For the questions on HPV and Covid-19 vaccination, an option of ‘Personal’ reason for not taking the vaccines was included to allow for reasons that could be particular to each and every participant which were not captured in the list. The pre-assessment section also asked the participants to self-rate their knowledge on HPV (Table 2).

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.

Section 3: Knowledge

The third section of the questionnaire included 29 True or False questions assessing HPV knowledge, adopted from a previously developed study (Waller et al., 2012). More details on the questions, and their correct answers, are presented in Table 3, and the computation of the knowledge score and levels is detailed in Appendix A and the Plan of Analysis section.

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.

Section 4: Attitude

The fourth section consisted of seven 5-point Likert Scale questions overviewing attitudes towards HPV vaccination, adopted from a validated questionnaire (Cvjetkovic et al., 2017) and presented in Table 4. Details on the computation of the attitude score and levels are included in Appendix A and the Plan of Analysis section.

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.

Section 5: Hesitancy

The fifth section included fifteen 7-point Likert Scale questions from the psychometrically validated 5C Vaccine Hesitancy Measure, which assesses psychological antecedents of vaccination (confidence, complacency, constraints, calculation and collective responsibility) (Betsch et al., 2020) reported in Table 5. Details on the computation of the hesitancy score and levels of hesitancy are discussed in Appendix A and the Plan of Analysis section.

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.

Section 6: Pamphlet

The sixth section presented the participant with an informative pamphlet including supported facts, myths and vaccine information on HPV (Appendix B). Information was directly retrieved from the CDC website (Std Facts - Human papillomavirus (HPV), 2022) (Basic information about HPV and cancer, 2023). The aim of having this section in the study was to improve the knowledge among the sample of participants on the diseases related to HPV infection and the benefits of the HPV vaccine in protecting against different types of cancer. This was followed by a pre–post analysis to assess the participants’ attitude towards this vaccine before and after going through the survey and the pamphlet. This pre–post analysis determines if a positive change in attitude can be captured when participants become more aware of this vaccination and the diseases it can help prevent.

Section 7: Attitude change

The seventh and last section consisted of two questions asking the participants to rate their attitude towards HPV vaccination before and after having taken the survey and read through the pamphlet. The response options included neutral, negative, or positive attitudes towards HPV vaccination. This section was intended to assess whether a modest increase in knowledge (stemming from reading section 6) would be correlated with a change in attitude towards HPV vaccination. Accordingly, these two sections (6 and 7) help in determining whether our theoretical idea which states that improved knowledge contributes to shaping the attitude and behaviour towards the HPV vaccine translated by more willingness and less hesitancy towards its utilisation.

Plan of analysis

The frequency and valid percentages were computed for the participant characteristic section (Table 1), the pre-assessment section (Table 2), the distribution of correct answers on questions related to knowledge about HPV vaccination (Table 3), the distribution of positive attitude on questions pertaining to attitude towards HPV vaccines (Table 4), and the hesitancy levels towards HPV vaccines (Table 5).

Knowledge: Each correct answer provided by the participants in the knowledge section of the questionnaire was assigned a value of ‘1’, while an incorrect answer received a value of ‘0’. The knowledge score for each participant was determined by adding up the scores earned on all the questions related to knowledge (31 questions). So a total maximum knowledge score that can be reached is 31. Higher levels of knowledge score indicated higher knowledge. Knowledge score was also stratified into ordinal categories which were ‘High’, ‘Moderate’ and ‘Low’ (Jaoude et al., 2019) as explained in Appendix A.

Attitude: The attitude section contained seven questions as indicated in Table 4. Questions 1, 3, 4 and 5 were reflective of a positive attitude when agreed on and questions 2, 6 and 7 reflected a negative attitude when answered affirmatively. We recoded the attitude questions in a way that reflects a better attitude towards HPV vaccination when the attitude score is higher. The total attitude score for each participant was obtained by adding up the scores earned on all the questions related to Attitude (7 questions) so the maximum score that can be reached is 35. The Attitude score was considered as a continuous scale, and as ordinal categories with three levels (Alzahrani et al., 2021) which were positive, neutral and negative. Details on the computation of attitude score, recoding of questions and classification of the attitude score into positive, neutral and negative categories are included in Appendix A.

Hesitancy: The hesitancy section contained 15 questions, equally stratified into 5 subsections which included ‘Confidence’, Complacency’, ‘Constraints’, ‘Calculation’ and ‘Collective Responsibility’ (Pingali, 2022). The hesitancy questions are presented in Table 5. The ‘Confidence’ section, and the last two questions in the ‘Collective Responsibility’, when agreeing on, indicated low hesitancy towards the HPV vaccine. Agreeing on the remaining subsections implied high hesitancy. For each respondent, a total hesitancy score was computed by adding all the scores for each of the 15 hesitancy questions, where the maximum total hesitancy score that can be obtained is ‘105’, and the minimum total hesitancy score can be ‘15’. A total score for each of the five subsections was also computed by adding the scores on all the three questions pertinent to each subsection. The maximum total score for each subsection that can be reached is ‘21’, whereas the minimum total score for each subsection is ‘3’. The overall hesitancy and the sub-sections were then categorised into low, neutral and high. All the details on the calculation of the overall hesitancy score, and the categorisation of the overall hesitancy into low, neutral and high, and the ones for the five subsections are presented in Appendix A.

With respect to the data analysis, we used the test of ordinal trend based on the gamma statistic and its p-value to evaluate the trend between knowledge levels (low, moderate and high), attitude levels (negative, neutral and positive) and the hesitancy Levels (low, neutral and high), as well as the five subsections within hesitancy, each classified as low, neutral and high (Table 6).

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.

We then conducted cumulative logit model with proportional odds property to analyse the ordinal response of hesitancy and the five subsections each stratified as low, neutral and high as outcomes of interest. The total knowledge score and attitude score were used as main predictors in this ordinal analysis for the hesitancy levels. To identify the covariates significantly associated with hesitancy, we did simple and multiple cumulative logit regressions (Table 7). The crude and adjusted odds ratios (ORs), 95% confidence intervals (CIs) and p-values were calculated. Covariates that demonstrated a p-value of ≤0.05 in the simple regression were the ones considered eligible for inclusion in the multiple logit models for hesitancy, the reason why our multivariable models were adjusted for some and not all of the studied variables in the survey.

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.

Finally, to assess any potential changes in attitude towards HPV vaccination before and after the survey, we performed extended McNemar’s test for 3 by 3 table (Table 8).

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.

Ethical considerations

This study was approved by the Institutional Review Board (IRB) of the American University of Beirut with IRB ID: SBS-2021-0435. Prior to beginning the survey, participants were presented with a consent page informing them about the aims and purposes of the research, the assurance of anonymity, the confidentiality of all amounted data and the right to withdraw from the study at any time without any adverse consequences.

Results

1. Characteristics of the study population

The characteristics of the participants included in the study are summarised in Table 1. The table provides an overview of the participant demographics and relevant information. Summary statistics are presented in terms of frequency and valid percentages.

Out of the total 201 participants, 79% were below the age of 26 and thus eligible to take the HPV vaccine. Nearly half of the participants were females (57.7%), while most of them (88.6%) were single, and 52.7% held a university degree. Additionally, a third (31.3%) of the participants did work in any health-related field and most of the participants (81.4%) resided in Beirut.

2. Pre-assessment

Approximately 44.8% of the participants in our study reported being sexually active. Among them, 66.3% reported using protection against sexually transmitted diseases (STDs). However, only a small percentage (16.1%) stated that they undergo regular testing for STDs (Table 2). Regarding HPV vaccination, most participants (71.1%) reported not being vaccinated. This was primarily due to two reasons: 52.3% of the participants cited a lack of availability and access to the vaccine, while 32.2% mentioned personal reasons for not getting vaccinated (Table 2; Appendix C: Figure 1a,b).

When it comes to information sources about HPV vaccination, the internet played a significant role, with 24.9% of participants obtaining information from online sources. A small percentage of participants learned about HPV vaccination from school (6%), paediatricians (12.4%), or gynaecologists (7.5%) (Table 2; Appendix C: Figure 2).

Interestingly, a substantial proportion of participants (74.4%) reported receiving some form of sexual education. Of those, almost half (48.3%) received information from the internet, one-third (31.3%) obtained sexual education from schools, while healthcare workers accounted for a smaller percentage (17.4%) (Table 2; Appendix C: Figure 3a,b).

Within our study sample, only four individuals (2%) were diagnosed with HPV infection. In terms of knowledge about HPV vaccination, only a few participants rated their understanding as excellent (7.5%) or very good (6%). The highest proportion of participants (27.5%) reported having no knowledge about HPV vaccination (Table 2).

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

Our results revealed that majority of participants (77%) had in general an overall low level of knowledge, 16% moderate level and 7% high level (Appendix C, Figure 4a). The lowest percentages of accurate responses were observed in questions concerning HPV treatment and testing. For example, only 30.3% correctly acknowledged that HPV cannot be cured with antibiotics. Additionally, a mere 4.5% answered correctly when asked if HPV typically requires treatment. Similarly, only 14.4% and 13.4% accurately responded to questions regarding the ability of an HPV test to determine the duration of infection and the indication for HPV vaccine administration, respectively.

Conversely, nearly half of the participants demonstrated accurate knowledge on various other aspects related to HPV vaccination (Table 3). For instance, 41.5% correctly answered questions regarding the eligible age for vaccination. Similarly, 41.9% correctly acknowledged HPV's capacity to cause oropharyngeal, genital and anal cancer, while 40.8% recognised its link to cervical cancer. Furthermore, 46.8% of participants accurately recognised that HPV is relatively common. Similarly, 42.3% correctly responded that individuals who have had HPV are still susceptible to cervical cancer. A significant proportion of participants (39.8%), correctly answered that HPV vaccines do not provide protection against all sexually transmitted infections. Furthermore, an equivalent percentage of 37.3% recognised the need for girls who have received the HPV vaccine to undergo a pap smear as they grow older. The highest percentages of correct responses were linked to the knowledge regarding HPV transmission through sexual intercourse (65.5%), the role of condom usage in reducing HPV risk (66.2%) and the increased risk of acquiring HPV through multiple sexual partners (63.2%).

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

With respect to the overall general attitude, our results showed that 42% of the participants had a positive attitude towards HPV, 50% were neutral and 8% had negative attitude towards it (Appendix C, Figure 4b). With respect to the frequency distribution of the positive attitude in each of the questions that formed the attitude scale, our analysis showed that there was some evident positive attitude in several areas. For instance, many respondents (76.5%) recognised the importance of parental education to increase vaccination coverage among the population. Additionally, a considerable number of participants (81.9%) emphasised the role of doctors in informing parents about the significance of the vaccine. Furthermore, a considerable proportion of individuals (73.7%) acknowledged that getting vaccinated is a safer alternative to contracting the disease (Table 4).

However, there were some aspects of the HPV vaccine that respondents had negative attitudes towards. For instance, when asked about their perception on the safety, efficacy of the HPV vaccination in preventing HPV infection, immunisation and composition of the vaccine itself, respondents were inclined to hold a negative attitude. This negative attitude primarily stems from the fear that HPV vaccines may contain substances that could be harmful to people's health and that immunisation do not prevent HPV infection (Table 4). In relation to this concern, only 40% of respondents expressed a positive attitude and disagreed to the question that concerned the belief that vaccines contain substances proven to be harmful to people's health. Similarly, only 27.2% held a positive attitude regarding the efficacy of HPV immunisation in preventing HPV infection.

5. Hesitancy levels towards HPV vaccines

The levels of hesitancy, and frequency distribution and percentage of hesitancy associated with each question that constituted the hesitancy scale were presented in Table 5 and Figure 4c (Appendix C). Overall, our results indicated that 24% of the respondents had a high level of hesitancy, 15% were neutral about the HPV vaccine and 61% displayed low levels of hesitancy towards it (Appendix C, Figure 4c).

Notably, individuals expressed a high level of confidence regarding HPV vaccination. Specifically, a significant majority (76.4%) showed low hesitancy by acknowledging the effectiveness of vaccinations. In contrast, the calculation section revealed a higher level of hesitancy whereby 73.1% of respondents expressed high hesitancy by stressing on the importance of fully understanding the topic of vaccination before getting vaccinated. Additionally, 55.7% expressed high hesitancy through displaying doubts and concerns regarding the calculation of vaccination benefits. However, a considerable proportion (80.6%) agreed that vaccination is a collective responsibility to prevent the spread of diseases, while 78.2% acknowledged that getting vaccinated offers protection to individuals with weaker immune systems, resulting in lower hesitancy. Furthermore, almost 70% of respondents demonstrated low hesitancy concerning constraints and complacency.

6. Knowledge levels/attitude levels and hesitancy

a. Knowledge levels and its ordinal trend with hesitancy levels, confidence, complacency, constraints, calculation and collective responsibility levels

Analysis of our data revealed a significant inverse trend between knowledge levels (low, moderate and high), and hesitancy levels (low, neutral and high) (Table 6). The calculated gamma value was −0.74, which is remarkably close to −1, indicating a strong negative trend. Specifically, as knowledge levels increased from low to high, hesitancy levels decreased significantly (p-value = 0.001). Furthermore, our findings indicated a significant inverse trend between knowledge and complacency, whereby, complacency decreased with the increase in the levels of knowledge (gamma = −0.7763, p-value < 0.01) (Table 6).

Conversely, a positive gamma value which suggests a positive linear trend was detected between knowledge and confidence levels towards the HPV vaccine (Table 6). This result indicated that as knowledge levels increased, confidence levels also increased with gamma = 0.7940, which is close to 1, reflecting a strong positive linear trend (p-value < 0.01). Similarly, as knowledge levels increased, we observed a notable increase in collective responsibility (gamma = 0.66, p-value < 0.01) indicating a significant positive trend between knowledge and collective responsibility (Table 6). Overall, our results provide compelling evidence for the relationships between knowledge levels, and hesitancy levels, complacency, confidence and collective responsibility.

b. Attitude levels and its ordinal trend with hesitancy levels, confidence, complacency, constraints, calculation and collective responsibility levels

Similar to knowledge, our results showed a significant inverse trend between attitude levels (negative, neutral and positive), and hesitancy levels (low, neutral and high). The calculated gamma value was −0.58, indicating that as attitude levels increased from negative to positive, hesitancy levels decreased significantly with a p-value < 0.01 (Table 6). Additionally, as attitude levels increased, complacency and constraints significantly decreased with respective gamma values of −0.67 (p-value < 0.01) and −0.36 (p-value = 0.0047) (Table 6).

Positive trend was detected between attitude and confidence levels indicating that as attitude levels increased, confidence levels also increased (gamma = 0.777, which is close to 1, indicating a strong positive trend, p-value <0.01). Similarly, a positive trend was also detected between attitude levels and collective responsibility, suggesting that the better the attitude the higher the collective responsibility (gamma = 0.704, p-value < 0.01).

7. Knowledge score/attitude score and hesitancy using cumulative logit model with proportional odds property

a. Knowledge score and hesitancy

Table 7 displays the trend between knowledge score and the different levels of hesitancy: low, neutral and high as outcome of interest using the cumulative logit model with proportional odds property. Additionally, Table 7 presents the trends between knowledge score and the various subsections of hesitancy, including confidence, complacency, constraints, calculation and collective responsibility measured as low, neutral and high. Both unadjusted and adjusted analyses are included in Table 7. Our adjusted analysis accounted 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’ (Table 7). The adjusted analysis revealed a significant trend between knowledge scores and the following factors: hesitancy levels, confidence levels and collective responsibility levels. In this regard, our results showed that when knowledge score increased by one point, the odds of having high hesitancy compared to low hesitancy decreased multiplicatively by 0.914, indicating an 8.6% decrease in hesitancy (OR = 0.914; 95%CI: 0.839–0.996; p-value = 0.042). On the other hand, as knowledge increased by one point, the odds of having high confidence compared to low confidence increased multiplicatively by 1.09, indicating a 9% increase in confidence (OR = 1.09; 95% CI: 1.026–1.158; p-value = 0.005). Moreover, we observed an 8.2% higher level of collective responsibility for each one-point increase in knowledge (OR = 1.082; 95%CI: 1.006–1.163; p-value = 0.033).

b. Attitude score and hesitancy

Table 7 presents the unadjusted and adjusted trends between attitude scores and various levels of hesitancy (low, neutral and high) as the outcome of interest. It also illustrates the ordinal association between attitude scores and various subsections of hesitancy (confidence, complacency, constraints, calculation and collective responsibility) each stratified as low, neutral and high and used as outcomes of interest. The cumulative logit model with proportional odds property was utilised and adjustments were conducted on the same covariates as in Table 7.

Our adjusted analysis revealed an inverse ordinal association between attitude score and hesitancy levels whereby a one-point increase in attitude is linked to a 12.7% decrease in hesitancy (OR = 0.873; 95%CI: 0.779–0.979; p-value = 0.020). Similarly, a one-point increase in attitude was associated with a 15.4% decrease in complacency (OR = 0.846; 95%CI: 0.757–0.946; p-value = 0.003). Conversely, as attitude increased by one point, confidence levels increased by 23.7% (OR = 1.237; 95%CI: 1.116–1.370; p-value = 0.000). Moreover, we observed a 22.5% higher level of collective responsibility for each one-unit increase in attitude (OR = 1.225; 95%CI: 1.089–1.378; p-value = 0.001). Hence, the adjusted analysis showed significant trends between attitude scores and the following outcomes: hesitancy levels, confidence levels, complacency levels and collective responsibility levels.

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

Results of the survey showed a notable change in attitude following its completion (p-value <0.01; extended McNemar Chi2 = 101.00). Initially, 13 participants exhibited a negative attitude towards HPV vaccination, which decreased to five participants after the survey. This represents a 61.5% decrease in negative attitude, and improvement in attitude resulting from the distribution of a simple pamphlet (Appendix B). Prior to the survey, 121 participants held a neutral attitude, while only 29 maintained a neutral attitude after the survey. Furthermore, 94 out of 198 participants who were initially neutral shifted to a positive attitude following the survey. Finally, 64 participants displayed a positive attitude before the survey, and this number increased to 164 after the survey (Table 8).

Discussion

Despite the early availability of HPV vaccines in Lebanon, the absence of official national recommendations and high vaccine costs, relative to the purchasing power among the Lebanese citizens, present significant barriers to vaccine accessibility and uptake. Moreover, limited awareness and knowledge about HPV among certain Lebanese populations, as evidenced by previous studies, further compound these challenges. The influence of the Theory of Planned Behaviour Model in this study provides a robust framework for understanding the complex interplay of factors influencing HPV vaccination behaviours. By assessing background factors, knowledge, attitude and hesitancy levels, the study delves into the multifaceted nature of vaccine decision-making processes.

Our study’s investigation stemmed from a sample of the Lebanese population collected from different regions of Beirut, capital of Lebanon. This is the first study in the country which thoroughly assesses all three variables of knowledge, attitude and hesitancy with such rigour. This study also provides broader insight given that the Beirut population encompasses a rich amalgamation of individuals with diverse backgrounds, embracing both the traditional viewpoints as well as the more progressive perspectives. This is well reflected by the fact that 40.3% of the studied population has lived abroad at some point in their lives (21% in an Eastern country and 19% in a Western one).

The present findings revealed a low vaccination rate of 18.4% among the study participants, all of whom were vaccine eligible. This rate is markedly lower than that of developed countries such as the United States (75.1%) (Pingali, 2022). A significant proportion (52%) of the participants who had not received the vaccine cited unavailability or limited access as the primary reason, which aligns with the ongoing socioeconomic challenges in the country and the high cost associated with vaccination. On the other hand, an alarming finding was the fact that only 36.3% of the population had received a recommendation for HPV immunisation. Notably, friends emerged as the most prevalent source of such recommendation. This raises solid concerns regarding the role of healthcare workers in endorsing HPV vaccination and aligns with previous research demonstrating that Lebanese physicians are not adhering to International guidelines when it comes to recommending the HPV vaccine (Abi Jaoude et al., 2018; Jaoude et al., 2019).

Moreover, our results indicated strikingly inadequate knowledge about HPV, spanning all aspects including infection, testing and vaccination. Notably, it was found that 73% of the population held the misconception that HPV can cause HIV/AIDS. Furthermore, 95.5% of individuals were unaware that HPV infection usually does not require any form of treatment. These findings reflect significant gaps in the general population’s understanding and goes in line with similar observations made in numerous Arab countries (Almehmadi et al., 2019; Knowledge and Awareness about Human Papillomavirus Infection and Its Vaccination among Women in Arab Communities Scientific Reports, n.d.; Ortashi et al., 2013).

Regarding the general attitude towards HPV vaccination, it was found that 50% of the population held a positive outlook. Interestingly, the primary factors responsible for diminishing this percentage were prevalent beliefs that vaccines contain substances that have been proven harmful to people’s health (60%) and that there is insufficient evidence supporting the effectiveness of HPV immunisation in preventing HPV infection (73%). Concerns about the safety profile of the vaccine were similarly found to be held by mothers of schoolgirls in Lebanon as reported by a previous study (Abou El-Ola et al., 2018). These factors strongly relate to the gaps in knowledge that were observed. The findings also suggest that reinforcing awareness and knowledge among the Lebanese population regarding the scientific evidence supporting the safety and efficacy of the HPV vaccine could build trust and improve attitudes.

Upon evaluation of psychological antecedents towards vaccine, the realm of calculation yielded the highest levels of hesitancy, implying that participants prioritise acquiring a comprehensive understanding of risks, benefits and efficacy before deciding to get vaccinated. This highlights once again the ongoing necessity for increased efforts towards improving awareness and knowledge. Supporting this point further, the results demonstrated a significant negative agreement between hesitancy levels as compared to both knowledge and attitude levels. This is additionally emphasised by the results of our adjusted analysis which showed that the higher the knowledge and the more positive the attitude, the lower the hesitance towards HPV vaccination. In essence, the findings suggest that increased knowledge and positive attitudes are associated with decreased levels of hesitancy and vice-versa. Our results parallel those reported by Santhanes et al. which affirm that lower knowledge level and less confidence in safety and efficacy of the vaccine negatively affected intention to vaccinate in South East Asian and Western Pacific regions (Santhanes et al., 2018).

Finally, comparing the attitudes of participants towards HPV vaccination before and after completing our survey and reading through the informational pamphlet revealed a remarkable improvement. A total of 164 individuals self-rated their attitude as positive by the end of the survey as compared to merely 64 people at the beginning of it. Consequently, it is well-reasonable to conclude that the implementation of large-scale awareness campaigns, incorporating evidence-based information on the vaccine’s efficacy and safety, would play a crucial role in enhancing knowledge, fostering positive attitudes, reducing hesitancy and ultimately improving vaccine uptake among the Lebanese population.

It is also important to note that knowledge is not the sole factor at play when shaping behaviour change, and a broader approach encompassing shifts in social norms and equitable access to healthcare would be of valuable significance. For instance, parallel efforts by the Lebanese Ministry of Public Health to render HPV immunisation more affordable would be instrumental in improving vaccine accessibility and uptake among Lebanese populations. Further qualitative research would also be highly welcomed in order to better understand the optimal ways in which health representations and practices can be enhanced in the specific context of Lebanon.

Ultimately, achieving meaningful behaviour change and improving HPV vaccination rate will require a multifaceted strategy that considers not only knowledge levels but also broader socio-cultural factors and healthcare system considerations. By adopting a holistic approach that addresses the complexities of vaccine uptake within the Lebanese context, stakeholders can work together to advance public health goals and promote better health outcomes for the population.

This study is subject to certain limitations, including the modest sample size (201 participants), as well as the restriction of survey distribution to the Beirut area, which might affect the representation of our sample to the general population of Lebanon and the generalizability of our results. In this respect, it would be sound to hypothesise that knowledge, attitude and vaccine coverage would likely decrease when moving away from the capital. However, despite these limitations, the obtained results proved to be significantly impactful and should hopefully inspire the drive for further research endeavours.

Conclusion

HPV vaccination coverage is significantly low in the Lebanese population. Several factors were identified as barriers against immunisation, including scarce availability, high cost, lack of recommendations from healthcare providers, limited knowledge, conflicting attitudes and high levels of hesitancy. Analysis of the results strongly suggests that improving knowledge and attitudes is likely to foster trust and reduce hesitancy, thereby promoting higher vaccine uptake.

IRB approval

This study was approved by the Institutional Review Board (IRB) of the American University of Beirut with IRB ID: SBS-2021-0435.

Consent

Prior to beginning the survey, participants were presented with a consent page informing them about the aims and purposes of the research, the assurance of anonymity, the confidentiality of all amounted data and the right to withdraw from the study at any time without any adverse consequences.

Authors’ contribution

LH conceptualised the research question. MJ and LH finalised the conceptualisation of the research question. LH and JH identified the scales. LH, JH, MY developed the survey. KK and HJ gave feedback on the survey. MJ supervised the finalisation of the development of the survey. LH, KK, NE, MY, JM, JH collected data. JH and LH developed the LimeSurvey. JH, LH, KK, NE, MY, HJ, JM entered data. MZ entered data and double checked all the data entry. MZ did all the data cleaning, data management, data analysis, construction of the tables of results and figures under the close supervision of MJ. MZ wrote the methodology, plan of data analysis, discussion of results in the manuscript. MJ revised these sections. LH wrote the methodology, introduction and discussion and MJ revised these sections. MZ put all the sections together in the manuscript. MJ revised the manuscript. MJ supervised the implementation of the whole project. All authors read and approved the manuscript.

Acknowledgements

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

The author(s) reported there is no funding associated with the work featured in this article.