Awareness and knowledge of human papillomavirus vaccine among young adults in Saudi Arabia: A systematic review

Background

Human papillomavirus (HPV) infects numerous body tissues, but the skin, lungs, vulva, pharynx, throat, tonsils, back of the tongue, cervix, anus, vagina, and penis are the most commonly affected.^[1] HPV is a major cause of head-and-neck cancer, particularly oral and oropharyngeal squamous cell carcinoma, and is one of the most frequent sexually transmitted infections.^[2] It also accounts for the incidence of cervical cancer, which is the fourth fatal malignancy among women globally.^[3] In Saudi Arabia, cervical cancer ranks 11^th overall and 9^th among women aged 15–44.^[4] The recent statistics indicate that 358 new cases and 179 deaths of cervical cancer occur annually in Saudi Arabia.^[5] HPV includes low-risk (LR-HPVs) and high-risk (HR-HPVs) genotypes, with the former producing cutaneous and anogenital warts and the latter causing penile, cervical, vulvar, vaginal, anogenital, and oropharyngeal cancers. HR-HPV strains 16 and 18 account for 70% of all cervical cancer cases worldwide.^[5,6] HPV vaccinations can help prevent health issues associated with HPV and reduce the occurrence of cervical and other anogenital cancers. The World Health Organization (WHO) has prequalified bivalent, quadrivalent, and nonavalent vaccines targeting various HPV strains.^[7] In 2009, the WHO recommended listing the HPV vaccine in the National Immunization Schedules.^[7] The HPV vaccine is typically given to females aged 11–26 years old in three doses within 6 months. It proved its effectiveness in preventing cervical cancer and other HPV prone clinical problems.^[4] The vaccine was reported to decrease HPV infections and cervical lesions in females and genital warts in both males and females.^[8] For effective protection from cervical cancer, regular cervical screening is also recommended to identify and treat any emerging lesions.^[9] In 2010, the vaccine was available in Saudi Arabia and freely accessible to females who were directed to take the vaccine through medical prescriptions; they could also pay for the vaccine and obtain it from central healthcare institutions.^[4] However, several researches indicated that knowledge and awareness of HPV and its vaccine uptake among Saudi citizens remained limited. For instance, a study revealed that only 17% of college students could identify the HR genotypes associated with cervical cancer.^[10] A study reported that HPV vaccine uptake remained below 10% (7.6%) although many Saudi women were aware of the HPV hazards.^[11] Moreover, only 5.2% of health college students had actually received the vaccine, despite 49.9% of them having heard about it.^[12] These results underscore a critical gap between the availability of the vaccine and its uptake in the Saudi population.

Justification

Despite the presence of multiple studies reporting poor levels of awareness regarding HPV and its vaccine among Saudi Arabian citizens,^[10,13,14] there is no systematic review of the published studies in this field focusing on the young Saudi adults. Previous studies are limited to specific regions or only address a narrow population, such as the students of health-related colleges, limiting their generalizability. Moreover, sociocultural stigma associated with discussions of sexual health in Saudi society may exacerbate gaps in HPV awareness and acceptance of vaccination,^[10] indicating the essential need for a better understanding of how these factors influence vaccine uptake. Therefore, a systematic review is necessary to collect and reinforce the available evidence, detect gaps, and provide insights for targeted interventions.

Objective

The objective of this systematic review is to evaluate the level of awareness and understanding about HPV and its vaccination, identify sociodemographic and cultural factors that influence knowledge and attitudes, and highlight potential barriers and facilitators to vaccination. This systematic review aims to inform public health policies, support evidence-based policymaking, and guide education and communication efforts to reduce the burden of HPV-related illnesses in Saudi Arabia.

Research questions

This systematic review aims to answer the following research questions:

1. What is the level of awareness of HPV infection and its vaccine among young adults in Saudi Arabia?

2. What are the prospective factors that hinder and facilitate vaccination uptake?

Eligibility criteria

The eligibility criteria were established using the Population, Intervention, Comparator, and Outcome (PICO) framework to assist the selection of studies.^[16]

• Population (P): Young adults aged 18–30 years (both males and females) residing in Saudi Arabia.

• Intervention (I): The field of interest was the awareness, knowledge, attitudes, or barriers related to the HPV and/ or HPV vaccine.

• Comparator (C): No specific comparator was required for inclusion.

• Outcomes (O): The principal outcomes were the levels of awareness and knowledge, and the identified barriers to HPV vaccination.

Inclusion criteria

• Study design: Quantitative and cross-sectional studies that were based on survey data collection.

• Publication language: Studies published in English only.

• Publication time: Studies were published within the past 5 years (from January 2020 up to June 2025).

Exclusion criteria

• Publication type: Review articles, qualitative studies, case reports, commentaries, editorials, theses, dissertations, and any other forms of grey literature. This decision was made to ensure that all studies had undergone a rigorous and formal peer-review process.

• Population: Studies focused on populations outside the age range of 18–30 years or used undefined demographic data.

• Full text unavailability: Studies could not be accessed as full text.

Search strategy

A systematic literature search was conducted in several electronic databases, including PubMed, Scopus, Web of Science, Science Direct, and Google Scholar. The search was restricted to studies published between January 2020 and September 2025 and was limited to articles in the English language.

The search strategy was developed by combining relevant keywords (e.g., “HPV,” “vaccine,” “awareness”) and Medical Subject Headings (MeSH terms), where applicable. The following primary search string was constructed and then adapted for the syntax of each database.

(HPV OR “Human Papillomavirus”) AND (vaccine OR vaccination) AND (knowledge OR awareness OR perception OR attitude OR barriers) AND (“young adults” OR students) AND “Saudi Arabia”

Studies selection

All obtained records were imported into Zotero reference management software, and duplicates were removed with final confirmation by manual process. Subsequently, the two authors screened the selected paper independently. Study selection based on two stages; the first is screening of title and abstract, while the second is examination of full text according to inclusion criteria. Any disagreements between the authors’ extracted data were resolved through discussion and consensus.

Data extraction

The process of data extraction was conducted separately by the two authors using a pre-designed data extraction sheet developed in Microsoft Excel. The extracted information was collected using a standardized form that focused on study characteristics (author’s name, setting, study duration, and publication year), population features (age of participants and sample size), and key outcomes (level of awareness and identified issues against vaccination).

Quality assessment

Quality assessment was determined using the Joanna Briggs Institute (JBI) Critical Appraisal Checklist for Analytical Cross-Sectional Studies.^[17] The risk of bias in the included studies was assessed using the checklist, from which each study was assigned a quality score. Studies were then categorized as follows: high risk of bias (low quality) if they scored less than 50%; moderate risk of bias (moderate quality) if they scored between 50% and 69%; and low risk of bias (high quality) if they scored 70% or higher. The assessment was developed by two authors independently, and the discussion resolved any confusion.

Data synthesis

The considerable heterogeneity in study methodologies and outcomes made a meta-analysis not feasible. A narrative synthesis was performed to summarize the outcomes. The results were categorized into thematic groups, involving levels of awareness and knowledge of HPV and barriers to vaccination, to evaluate major similarities throughout the studies.

Study selection

The literature search initially identified 151 records. After the removal of duplicates, 123 records were screened based on their titles and abstracts, leading to the exclusion of 103 records. The full texts of the remaining 20 articles were assessed for eligibility. Of these, 10 articles were excluded. The primary reasons for exclusion at this stage were that the study’s data were not reported for the required age group (n= 7) or that the outcome of interest (awareness and knowledge) was not measured (n= 3). Ultimately, 10 studies were included in the final qualitative synthesis. The complete study selection process is detailed in the PRISMA 2020 flow diagram [Figure 1].

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Figure 1:

Preferred Reporting Items for Systematic Reviews and Meta-Analyses flow chart showing the selection process of included studies in the systematic review.

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Characteristics of included studies

A total of 10 cross-sectional studies published between 2022 and 2025 were included in this review. The characteristics of each study, including sample size, population type, and setting, are summarized in Table 1. Studies were included in this review, representing a cumulative sample size of 3540 participants. The sample sizes of the individual studies ranged from 114^[18] to 580.^[19] The study populations varied, including both university students (e.g., Alsalhani et al^[20]) and the public (e.g., Samannodi et al^[14]). Data collection was primarily conducted through online surveys. The methodological quality of the included studies was generally high. Based on the JBI critical appraisal checklist, nine studies were assessed as having a low risk of bias, while one study (Alghalyini et al^[10]) was assessed as having a moderate risk of bias.

Synthesis of findings

The findings from the ten studies were synthesized and grouped into two main themes: (1) Awareness and knowledge levels, and (2) barriers to vaccination. Awareness and knowledge levels reported in the studies were categorized as: high (>70%), moderate (50–69%), or low (<50%).

Awareness and knowledge of HPV and HPV vaccine

Across the included studies, the overall level of awareness regarding HPV and its vaccine among young adults in Saudi Arabia was found to be low to moderate, with reported rates ranging from 43% to 59.6%. Several key knowledge gaps were consistently identified, including poor knowledge of HR HPV genotypes, modes of transmission, and the appropriate age for vaccination. A common pattern observed was that female participants generally demonstrated higher levels of awareness and knowledge compared to male participants.

Barriers to HPV vaccination

The studies identified several significant barriers preventing HPV vaccine uptake, which are summarized in Table 2. Barriers to vaccination included lack of education and awareness, fear, and the need for parental approval. Other factors were vaccine hesitancy, misinformation about safety, and cultural or religious sensitivities.

Summary of main findings

This systematic review investigated young adults’ awareness of HPV and its vaccine in Saudi Arabia. There was a general pattern of limited awareness and low vaccination uptake throughout the analyzed studies, even among healthcare students. In addition, specific knowledge regarding HR HPV genotypes (e.g., HPV-16 and HPV-18), modes of transmission, and preventive measures was reported as being insufficient.^[10,12] Two studies conducted in the United Arab Emirates (UAE) and Qatar revealed similar results, where low awareness about HPV, its vaccine, and cervical cancer among university students was reported.^[25,26] This reflects a regional trend where awareness of HPV exists but often remains superficial and does not result in proper knowledge or actual vaccination uptake. This pattern of inadequate awareness also agrees with a study in Saudi Arabia, such as a study in Taif, which recorded “unsatisfactory levels of knowledge” regarding HPV among women, with 58.5% demonstrating poor knowledge.^[27]

Students in health-related disciplines unexpectedly showed significant knowledge gaps. Similarly, in Lebanon, a study reported poor knowledge regarding the HPV vaccine and low rates of vaccination among medical students.^[28] These findings indicate the essential need to update the current medical courses to include educational materials about HPV and its protective measures.

The investigated studies reported that poor knowledge about the HPV vaccine and vaccine hesitancy hinder effective protection against HPV infections and consequent disorders.^[12,18,24] A study conducted in the Gulf Cooperation Council (GCC) countries indicated high vaccine hesitancy and low rates of vaccination, where Saudi Arabia scored 4.6%.^[29] It was reported that >40% of the respondents showed their hesitation toward getting the HPV vaccine, despite its availability.^[29] The GCC study revealed that the main barriers to HPV vaccination were a lack of awareness and poor medical counseling.^[29] The GCC study also noted that individuals having health insurance were more than twice as willing to take the vaccine.^[28] This highlights the importance of ensuring vaccine accessibility and its impact on acceptance of immunization. Such regional conclusions conform with the findings of the studies conducted in Saudi Arabia, where lack of awareness represents the primary barrier to HPV vaccination.

In this systematic review, some studies suggested that females showed more awareness than males regarding the causative relationship between HPV and cervical cancer and its preventive measures.^[20] This gender gap may be attributed to sociocultural factors that prohibit the discussion of sexual health, resulting in the spread of misconceptions and inadequate education. Sociocultural factors can also include protective practices, for example, a study in India noted a significantly lower HPV prevalence among the Muslim community, suggesting that personal hygiene practices and male circumcision, rooted in cultural and religious norms, may play a protective role against HPV transmission.^[30] Accordingly, males may consider HPV infection as a feminine medical issue and misperceive their susceptibility to such infection.^[20] Aldosari et al (2024) emphasized this gender knowledge gap at two prominent universities in Riyadh, Saudi Arabia.^[31] The study highlighted that the conservative nature of Saudi society explains the sensitivity of discussing STDs, and many students depend mainly on the internet for information, leaving them vulnerable to misinformation and risky behaviors. It endorses the inclusion of suitable knowledge on HPV and STDs in university courses.

In Saudi Arabia, young adults face a number of challenges in receiving the HPV vaccine. The absence of precise and comprehensive information on the vaccine was a common issue in several studies; many participants were unaware of who was eligible, where to find it, and how much it costs. Persistent misconceptions are shown in the belief held by a few respondents that the vaccine is exclusively indicated for married women or those who are currently sexually active. Numerous participants stated that they had never received a recommendation from their physician or nurse, indicating that the function of healthcare professionals was also inefficient. Despite national recommendations, many participants expressed uncertainty about their ability to obtain the vaccine or where to obtain it. Accordingly, these challenges represent a lack of public awareness and communication rather than actual structural limitations. In addition, because the HPV vaccine is frequently linked to sexual conduct, individuals are discouraged from getting vaccinated due to cultural stigma and apprehension of judgment. In conclusion, the barriers hindering HPV vaccination include limited knowledge dissemination, ambiguous eligibility criteria, lack of medical counseling, and sociocultural restrictions. These results highlight the critical need for focused educational initiatives. According to the synthesized evidence, a future-forward approach to overcome these barriers must be comprehensive. Current initiatives depend on general awareness is inadequate. We suggest a conscious shift from passive awareness to constructive counseling. This requires, first, amending medical and nursing curricula to include practical communication training on sensitive health topics, ensuring future healthcare professionals can effectively encourage vaccination. Second, primary healthcare providers must be licensed to initiate the discussion about the HPV vaccine with all eligible individuals, rather than expecting to be asked. To address the cultural stigma and misunderstanding recognized these conversations, enhanced by national campaigns, must strategically re-frame the vaccine: highlighting its role as a significant cancer-prevention tool for both genders, instead of its relationship with sexual activity.

Limitations of the study

This systematic review may encounter some limitations. Only English-language studies were included, while relevant non-English research might have been excluded. The research keywords may be insufficient, which may impact the results. The scope of this review was young adults which may limit its generalizability. Furthermore, the heterogenicity of the populations of the included studies (ranging from medical students to the general public) may limit the ability to generalize the findings to the entire Saudi young adult population. In addition, the data collection methods were also heterogeneous varying from online surveys, which may provide selection bias, to in-person interactions. This methodological variance may affect the direct comparability of the results. The protocol of this systematic review was not registered in a public database prior to its commencement, but the methodology was rigorously developed and followed throughout the review process to minimize potential bias. This systematic review was limited to published peer-reviewed articles, which may have introduced a degree of publication bias, however, this approach was chosen to maintain high and consistent quality of evidence.

Recommendations for future research

Future research should apply more consistent methodological aspects, such as stratifying the target population (e.g., medical vs. public) to enhance the applicability of the findings. It should also consider standardized data collection measures to allow efficient comparisons between the results of the studies.