Human papillomaviruses (HPV) are double-stranded DNA non-enveloped viruses that are associated with carcinogenesis (Abdelaziz et al., 2025). HPV infects squamous epithelial cells in the skin and mucosa and usually causes benign warts. However, persistent infection with high-risk oncogenic HPV strains causes cervical, anal, vulvar, vaginal, penile and oropharyngeal cancers.

(Abdelaziz et al., 2025). HPV have almost 200 genotypes and are categorized as high- or low-risk per their capacity to cause cancer. HPV is commonly transmitted through sexual or skin-to-skin contact among other mediums (Albayat et al., 2024). While most HPV infections resolve spontaneously, others may persist causing skin lesions, genital warts, or cancer (de Sanjosé et al., 2018). With more than 300 million affected women worldwide, HPV infection is considered a global public health concern (Kombe Kombe et al., 2021). In fact, 12% of women with normal cervical cytology are carrier of HPV.

According to the World Health Organization (WHO) global statistics, HPV is responsible for an estimated 620,000 and 70,000 cancer cases in women and men, respectively (World Health Organization, 2024). Of these cancers, cervical cancer is associated with the most significant morbidity and mortality as it is the fourth cause of death across all female cancers (Sung et al., 2021). Fortunately, the risk of HPV infections can be mitigated by vaccines. As of writing this study, three vaccine types have been approved to prevent HPV genotypes implicated in cervical cancer (Wang et al., 2020). Current evidence points to the high safety and efficacy of these commercially available HPV vaccines despite the need for long-term studies (Porras et al., 2020; Alsanafi et al., 2023).

In the Middle East and North Africa (MENA) region, there are significant barriers to the uptake of the HPV vaccine. These include financial restraints, poor infrastructure, competition with other vaccines, and general lack of awareness (Abdelaziz et al., 2025). However, these barriers are context sensitive to the cultural and religious norms characterizing the MENA nations. Such factors could reduce the effectiveness of vaccination campaigns or increase resistant to its uptake among both the general public and medical students. Nonetheless, the literature shows that gaps in HPV knowledge exists also for healthcare professionals (Sallam et al., 2022).

While exact numbers on HPV infections and HPV-associated cancers in Jordan are currently unavailable, one study of 650 cases referred from gynecology clinics found HPV in 25.7% of native Jordanians’ samples (Annab et al., 2025). Estimates suggest that 115 women are diagnosed with cervical cancer, and 71 women die from the disease every year in Jordan (HPV Information Centre). Considering that 90% of cervical cancer cases are preventable through HPV vaccination (CDC, 2025), this emphasizes the vital role of vaccination as a preventive measure.

Currently, Jordan lacks a national screening program for cervical cancer nor includes HPV as part of its national immunization policy. Moreover, this is complicated by the lack of reliable data and updates on the prevalence of HPV across the kingdom (Mahafzah et al., 2008; Qaqish et al., 2023). Therefore, this paper aims to examine the understanding and awareness and the attitudes towards HPV infection among Jordanian medical students and the factors influencing vaccine uptake.

In this study, we demonstrated an alarming gap in HPV and vaccine knowledge among medical students. Only 72.3% were aware of the disease, while only 49.0% were aware of the vaccine. Significant knowledge gaps exist for epidemiology, treatment, transmission, and vaccination for HPV. Intention to self-vaccinate was lower than willingness to recommend the vaccine to family or patients. Factors associated with intention to vaccinate or recommending the vaccine were female gender, higher knowledge scores, and being in the clinical phase of undergraduate medical studies.

These findings, while alarming, are parallel to the existing body of literature. Poor HPV awareness, vaccine knowledge, and subpar intention to vaccinate were documented among university students in Saudi Arabia, Kuwait, Qatar, Iran, Morocco, Oman, Bahrain, and India (Ghojazadeh et al., 2012; Rashid et al., 2016; Alshammari and Khan, 2022; Bencherit et al., 2022; El Mansouri et al., 2022; Yacouti et al., 2022; Alsanafi et al., 2023; Alghalyini et al., 2024; Cheema et al., 2024). Interestingly, a similar trend was found across studies focusing on exclusively medical students (Mehta et al., 2013; Farsi et al., 2021; Haddad et al., 2022; Abdelaziz et al., 2025). A reliable explanation for this phenomenon originates in the sociocultural characteristics of the Middle East and North Africa (MENA) region. The MENA region is a conservative culture dominated by Islamic practices (Abi Jaoude et al., 2018). While the earlier could lead individuals to believe that safer sexual practices may lead to promiscuity and tarnish family prestige, the latter considers any extra-marital sexual activities to divinely prohibited; therefore, there exists a regional taboo on discussing any matters related to sexual activity (Hamdi, 2017).

On a more locally focused note, the Hashemite Kingdom of Jordan is known for an extremely limited cancer screening and prevention program, which only pertains to breast cancer (Al-Shamsi et al., 2022). Screening for cervical cancers through “pap smears”, prevention through vaccines, or even raising awareness through campaigns are yet to be complied into a policy despite somewhat shy efforts to promote prevention by private institutions and individuals. In fact, in a country where the minimum wage is about 410$, the HPV vaccine is estimated to cost 250$. Therefore, vaccination is only limited for those with high-end resources. This is particular importance as vaccine costs represent the most commonly reported factor for HPV vaccine resistance (Gamaoun, 2018). In response to cost barriers, Murewanhema et al., recommends enhanced vaccine cost coverage by insurance providers, the development of local infrastructure for the production of HPV vaccine, and embedding vaccine administration programs within schools, all of which serves of lower costs within resource limited countries (Murewanhema et al., 2024). While Jordan does not qualify for the Global Alliance for Vaccines and Immunizations (GAVI) monetary support, concerned policy makers could attempt negotiating cost-effective pricing of vaccines for the economically disadvantaged sectors of the population.

Across the literature, females demonstrated significantly higher knowledge of HPV and its associated vaccine compared to males (Rashid et al., 2016; Dai et al., 2022; Teeluck et al., 2022; Alghalyini et al., 2024; Chen et al., 2024). This is attributed to the stereotypical portrayal of HPV and cervical cancer. It could be also explained by the Health Belief Model, as the stereotypical portrayal could enhance the perceived susceptibility of disease among females compared to males (Al-Sabbagh et al., 2021; Oh et al., 2023). However, this is not entirely the case for some populations as Rashid et al., demonstrates that despite higher levels of awareness and knowledge of HPV, females were less likely to vaccinate compared to their male counterparts (Rashid et al., 2016). It is believed that such hesitancy stems from societal, religious, and prejudice ideas as well as poor socioeconomic status.

There is a consistent trend throughout the literature for a higher intention to vaccinate among those with biological/medical backgrounds, university degrees, or have received dedicated sexual education courses (Rashid et al., 2016; Dai et al., 2022; El Mansouri et al., 2022; Yacouti et al., 2022; Chen et al., 2024). The Theory of Planned Behavior (TPB) encapsulates such findings as it demonstrates that one’s attitudes and subjective norms affect behavior indirectly through behavioral intentions which are considered a direct precursor of behavior (Ajzen, 1991); this phenomenon is well documented for HPV vaccination intentions (Shah et al., 2021; Orji et al., 2025). Therefore, should all environmental factors be constant, better education will encourage individuals to pay more attention to potential diseases and have positive attitudes toward taking meaningful measures to either prevent the problem or cope with it. Unfortunately, while a plethora of studies indicate gaps within their sexual education programs at both the secondary and graduate levels, such courses are not provided within Jordanian institutions nor even attempted. This is owed to the complex interplay of Jordanian socio-religious culture that could stigmatize any efforts involving raising awareness on sex-related matters (Othman et al., 2022).

Moreover, a number of studies throughout the MENA region documented the role of conspiracy theories in augmenting vaccine hesitancy/resistance. Embracing vaccine conspiracies and vaccine resistance was documented for the COVID-19 vaccine, influenza vaccine, and the HPV vaccine (Knobel et al., 2022; Pertwee et al., 2022; Alsanafi et al., 2023; Alshehri and Sallam, 2023). This may have an unforeseen impact on participants’ intentions as nearly 44% of the current sample obtain their HPV-related knowledge through social circles, social media, or self-reading. The latter is particularly important as reliance on internet-based sources was linked with lower intentions to self-vaccinate against HPV (Alsanafi et al., 2023).

Jordan and so does many of the MENA countries require extensive efforts in promoting HPV knowledge and vaccine uptake. According to the Community Guide’s Data Abstraction (CGDA) framework, improving the status of HPV awareness and vaccine uptake must rely on through phases of evidence-based interventions: informational, behavioral, and environmental (Cheema et al., 2024). At the informational level, concerned authorities must dedicate resources to the development and dissemination of media campaigns to boost knowledge about HPV and its vaccine. A successful example includes the “Healthy China 2023” plan which is attributed as a significant factor in improving the public’s collective knowledge on HPV vaccination and cervical cancer screening (Wang et al., 2021; Chen et al., 2024). These campaigns should be mediated through healthcare workers, religious leaders, and social media platforms. The latter is especially relevant as it allows for an active role of susceptible individuals when interacting with information, ultimately contributing to informed health decision-making (Wang et al., 2021). Such plans should target not only susceptible individuals but also their immediate family as a plethora of studies demonstrated the role of parental encouragement and education in increase HPV vaccine uptake (Abdullahi et al., 2020; Rani et al., 2022).

At the behavioral level, the patient-healthcare provider relationship must be revamped to further increase vaccine uptake and general knowledge through providing cues to action (Al-Sabbagh et al., 2021; Al-Ani et al., 2024). Examples of these interventions include peer group advocacy, provider-led reminders to get vaccinated, and home visits. Reno et al., emphasizes that healthcare workers should also be trained and equipped with the necessary communication skills as to provide a clear message about the risks of HPV and building rapport with susceptible individuals (Reno et al., 2019). Improving the trust between patients and providers will likely reduce the impact of misinformation and contribute to the development of a more informed patient. Finally, environmental policies should be adopted at the national level. Governments are encouraged to include HPV vaccine as part of their national vaccination policy or subsidize their costs, making them more accessible. These policies, while cost intensive at an initial glance, may provide significant economic savings in the long-term by preventing HPV-related disease costs.

At the level of medical students, policy makers and university administrations should revise and re-develop their existing curriculums. Medical students, which are considered future practitioners, should be well equipped to prevent HPV across both themselves and their future patients. The content, approach, and style of medical educational materials could be improved as to provide these students with the necessary evidence and theoretical basis for circumventing the disease (Solis-Torres et al., 2024; Abdelaziz et al., 2025). Moreover, any changes made should take into consideration the stigma around sexually transmitted diseases which may influence attitudes of even medical students towards the promotion of the vaccine (Abdelaziz et al., 2025). Medical students should be encouraged and trained to approach these sensitive topics educating the public and addressing hesitancy.

In light of what’s above, our findings should be interpreted within the context of a number of limitations. These include the cross-sectional nature of study’s design, close-ended questionnaire, and due to logistics, inability of the questionnaire to account for all factors affecting HPV knowledge. Participants may also demonstrate social desirability bias or a neutral bias which might have distorted responses or compromised data accuracy. Additionally, due to the fact that this study is comprised of medical students only, its results cannot be generalized to other university students in non-medical fields or even other medical fields such as nursing or pharmacy. The use of convenience sampling and the over-representation of students from the Hashemite University may also limit the external validity of our findings to all medical students. Certain demographics of students may have been missed by the sampling strategy and since each Jordanian University represents a number of Jordanian prefectures, the over-representation of students from one university may produce results that may not be replicable in other Jordanian institutions. Finally, due to the different answer scales for some questions, the questionnaire was not subjected to an exploratory factor analysis to quantitatively measure its construct validity.

The study implies that the overall awareness and attitudes regarding HPV and its vaccine is alarmingly poor among medical students. Moreover, there exists a gender difference in the knowledge and attitudes favoring females. Our findings call for an urgent need for qualitative research to explore the barriers and facilitators to vaccination. This is necessary for designing multi-faceted, context sensitive, evidence-based interventions at the informational, behavioral, and environmental levels from all concerned authorities to improve knowledge of HPV among young adults and increase vaccine uptake.