Human papillomavirus (HPV) is a highly prevalent virus with more than 40 types transmitted sexually between adults. HPV infections could be asymptomatic infections; however, certain types could result in genital warts, while others could persist within the squamous cells and transform into malignancy in different organs, such as cervix, ovaries, vagina, anus, penis, and oropharynx (1, 2).

Globally, the estimated prevalence of HPV infection is 11.7% in a meta-analysis of over a million women with normal cervical cytology (3). In Saudi Arabia, HPV infection prevalence ranged between 4.7 and 30.4% during the period from 2013 to 2021 (4). Additionally, one study from Saudi Arabia found that 77% of women with cervical cancer were originally infected with HPV (5). Among women with cytological cervical abnormalities, the prevalence of HPV detection was 52.9% in a study that was conducted between 2021 and 2022 (6). According to a recent report from 2023, it is estimated that more than 10 million women in Saudi Arabia are at risk of HPV infection with a cervical cancer incidence rate of 2.44 per 100,000 woman (7). While the reported incidence rate of HPV infection in Saudi Arabia appears to be relatively low, prevention strategies are crucial for mitigating the transmission of the virus, and consequently reducing the burden of HPV-associated malignancies that are linked to increased morbidity, reduced quality of life with the use of chemotherapy, and perhaps increased mortality if undiagnosed timely (8, 9). Unfortunately, most Saudi females infected with HPV visit hospitals at an advanced stage. This could be attributed to several factors, including lack of awareness, knowledge, follow up screening recommendations, organized regional campaigns for HPV vaccine, and health promotion programs, which are currently heavily focused on other chronic diseases or common malignancies (such as breast cancer, diabetes, and obesity) (10). To improve the screening and early management, the Saudi Ministry of Health (MOH) published HPV screening practice guidelines in 2014 (11); however, there is no national screening program for HPV and cervical cancer yet (12, 13).

To combat the spread of HPV and consequently control the development of associated cancers, HPV vaccine was developed two decades ago. The first HPV vaccine was approved by the US Food and Drug Administration in 2006. However, the vaccines that are commonly used nowadays are those that cover the carcinogenic types (HPV16 and HPV18) (8). One vaccine covers only the two carcinogenic types (Cervarix^®), whereas the other vaccine covers both of these types in addition to seven other types that are associated with warts (Gardasil9^®). The vaccines are approved for both males and females from as early as 9 years. HPV vaccines could decrease the mortality rates among low-to-middle income women over the next decades according to World Health Organization (WHO) when administered to up to 90% of the targeted population of girls by the age of 15 (9). The first HPV vaccine was approved by the Saudi Food and Drug Authority in 2008 (14). Though, Cervarix^® has been available in Saudi Arabia since 2012, while Gardasil9^® has been available since 2024, both for females of the age range 9–45 years (15–17). Though, it was only recently widely administered in 2017 when the Saudi MOH included it in the national childhood immunization schedule for girls aged 11–12 years at no cost (18). Unfortunately, previous reports from Saudi Arabia found that most women, including students in health fields, were unaware of the HPV vaccine availability (10, 19–21).

We noticed that previous studies that evaluated the acceptability of HPV vaccine in Saudi Arabia uptake only included adult women (19–27). However, since the inclusion of the vaccine in the Saudi national immunization schedule in an effort to expand its administration among girls in Saudi Arabia, very few studies from Saudi Arabia have evaluated the acceptability of parents of children (both girls and boys) aged 9–14 years to administer the vaccine to their children. Though, most of these studies either did not include a sufficient sample size to achieve a high power or distributed the survey via online platforms risking multiple biases, such as selection bias and non-response bias. Therefore, this study aimed to evaluate HPV infection knowledge and HPV vaccine acceptability by parents in Saudi Arabia via in-person interview after calculating the required sample size to achieve high power. We also aimed to evaluate the impact of different sociodemographic factors and knowledge on the willingness to administer HPV vaccine to the parents’ children.

The present study sought to assess the knowledge and attitudes of parents regarding the HPV vaccine in Saudi Arabia. Major findings revealed significant gaps in awareness and hesitancy toward vaccine uptake, where only 8.5% of the surveyed population’s children received the HPV vaccine. Such a small percentage reflects a barrier to prevent HPV-related cancer. Though, such a finding should be interpreted carefully given the study’s limitations discussed later in this section.

Our results align with the results of multiple studies conducted in different regions of Saudi Arabia, which reported similar trends of limited knowledge, low vaccination rates, and substantial barriers to vaccine acceptance. A recent study by AlShamlan et al. (25) reported that 20% of female healthcare workers (HCWs) received at least one dose of the HPV vaccine, with an additional 45% expressing willingness to receive it. While these figures indicate some level of acceptance among HCWs, they also highlight a significant knowledge gap; the HCWs had similar misconceptions about the vaccine that mirror those observed among parents in our study. In both cases, awareness was correlated with educational attainment, suggesting that increasing educational outreach can be a pivotal strategy for improving vaccine uptake (25). Another study by Alosaimi et al. (27) also found that a longer medical experience, especially in immunizations, was associated with odds more than 5 times of having better knowledge and a more positive attitude toward the HPV vaccine. Furthermore, a study from the western region of Saudi Arabia demonstrated that only 34.6% of women were aware of HPV, and awareness was higher among younger participants (22). Our findings echoed this trend, with older parents showing lower vaccination acceptance rates and a tendency toward risk minimization. Both studies suggest that younger aged participants are more informed about HPV and its vaccine, highlighting the need for targeted educational initiatives aimed at older parents who may be less engaged in health-related topics. In another study, it was found that only 32.9% of parents knew about the HPV vaccine, with a staggering 75.2% believing they were not at risk (30). This perception of risk is a substantial barrier to vaccination, as reflected in our findings, where many parents expressed uncertainty or hesitancy. The alignment of these results underscores a pressing need to address misconceptions surrounding HPV and its associated health risks in order to foster a more informed and proactive attitude toward vaccination. Despite the positive attitude toward vaccination among many parents in our study, where 60% expressed willingness to vaccinate, the actual uptake was significantly low, akin to findings from other studies. For instance, in the study by AlShamlan et al. (25), while there was a willingness among HCWs, actual vaccination rates remained low, revealing a disconnect between intention and action. This highlights the necessity of developing intervention strategies that not only educate parents about HPV and the vaccine but also facilitate the vaccination process through school-based programs and community initiatives.

The findings on awareness and understanding of HPV among participants revealed a significant gap in public knowledge. A majority (63.9%) reported being unaware of HPV, consistent with another study conducted in Saudi Arabia, where more than half of the participants (51%) were also uninformed about the virus (23). Moreover, the main source of information about HPV reported by participants in our study was the internet and social media, which is similar to previous studies from Saudi Arabia, which found that 33–73.7% of participants used social media as their source of information (23, 26, 31). Additionally, our results indicated a lack of understanding regarding how HPV is transmitted. Over half of the participants were uncertain about its transmission routes, with only 32.5% identifying sexual contact as a means of transmission. The low percentage suggesting public toilets as a transmission route highlights misconceptions that should be clarified through targeted educational efforts. This lack of knowledge of HPV could be attributed to the source of information (internet and social media), which may not have been credible resources. Though, many participants perceived HPV as a potentially dangerous disease. Less than half of those unaware of HPV had sufficient information to assess its severity, yet nearly half believed it to be dangerous. Furthermore, less than half of the participants (49.5%) expressed being uninformed about diseases associated with HPV, with only 32.4% recognizing cervical cancer as a related disease. In contrast, a study conducted in Switzerland found that while most participants primarily associated HPV with cervical cancer, many were unaware that it can also lead to other cancers, such as anal and oropharyngeal cancers (32). This gap in knowledge underscores the necessity for comprehensive educational efforts to illuminate the connections between HPV and various health outcomes.

Vaccination against HPV has been shown to be the single most effective method to prevent acquiring the virus. Yet public acceptance of the HPV vaccination is yet to be achieved in Saudi Arabia. The majority of respondents acknowledged the effectiveness of vaccines, yet a few were uncertain. Our study showed that 48.2% of participants primarily use the internet and social media for information, consistent with another study from Riyadh in the central region (31). While these platforms provide valuable resources, they also risk spreading misinformation and reinforcing negative beliefs, emphasizing the importance of accurate communication in public health initiatives. Similarly, the impact of misinformation on social media is evident in our findings, where 7.5% of respondents believed vaccines could be harmful. This mirrors findings from the perception of the public regarding COVID-19 vaccines who mostly obtained their information from social media (33). These observations confirm that anti-vaccine content on social media plays an influential role in shaping negative beliefs regarding the risk of vaccination. To combat misconceptions, it is crucial to use reliable online sources like the Saudi Ministry of Health’s social media and website. Promoting digital literacy and critical evaluation of online content is essential for identifying credible information. On the other hand, a study from Spain revealed that 92.1% of parents were aware of the HPV vaccine, with 62.3% relying on pediatricians for information (28). This reliance on credible healthcare professionals over social media suggests that effective education can improve awareness and acceptance, ultimately boosting vaccination rates.

Among the participants in our study, only one-third (33.7%) have heard of the HPV vaccine, demonstrating low awareness. Previous studies from Saudi Arabia demonstrated an awareness level of the vaccine in the range of 10.9–45.8% (10, 22–24, 30, 34). The difference in awareness between these populations may reflect the variability in public health campaigns and the dissemination of HPV vaccine information. Nonetheless, more than half of the participants in our study said that women and girls should receive the vaccine (56 and 51.3%, respectively) vs. about one-third stating the same for men and boys (29 and 29.3%, respectively). This observation was reflected in the answers on the question pertaining to the conditions that could be prevented by HPV vaccine, where cervical cancer was the most selected answer, though at a small rate of 32.4%. Similarly, a study by Akkour et al. (10) revealed that only 18.1% of women in Saudi Arabia were aware of the role of HPV vaccine in preventing cervical cancer.

The findings of this study offer valuable insights into parental acceptability and knowledge about the HPV vaccine. A particularly noteworthy observation is that a significant proportion of parents (84.5%) reported not getting vaccinated against HPV. This low uptake is likely multifactorial. A primary contributing factor appears to be a substantial lack of awareness, as evidenced by over two-thirds of our study’s population reporting no prior knowledge of the HPV vaccine. Furthermore, the cultural stigma associated with HPV infection as a sexually transmitted disease within the conservative cultural context of Saudi Arabia may also significantly contribute to vaccine hesitancy and a lack of interest in uptake. Further research is warranted to elucidate the relative contributions of these factors and to develop targeted public health interventions. Moreover, numerous participants were unaware of the inclusion of the HPV vaccine in the Ministry of Health’s childhood vaccine schedule of girls. This may be attributed to the fact that the vaccine was incorporated into the Saudi immunization schedule only recently in 2019 (18). Moreover, our results indicate that the acceptability of the HPV vaccine among parents is a mere 56%, reflecting a concerning level of hesitance despite the reported perception of the vaccine’s benefit over its risk was expressed by less than half of the respondents (41.4%). These low values raise significant doubts about the willingness to support vaccination efforts for both girls and boys, suggesting substantial barriers for public health initiatives aimed at enhancing awareness and understanding of the vaccine’s benefits. Our findings correspond with other studies concerning HPV vaccine awareness and acceptance, which reveal a troubling trend. A recent study conducted in the Eastern Province of Saudi Arabia indicated that only 47.7% of participants expressed a willingness to receive the HPV vaccine (23), while a study from Jazan in the southern region reported a slightly better, yet still inadequate, acceptability rate of 53% (35). Furthermore, another study focusing on parents of daughters in Riyadh (central region) revealed a somewhat higher acceptance rate of 60% (31); however, this still indicates that a considerable portion of parents remains either opposed to or indifferent regarding vaccination. In contrast, studies from Turkey, Africa, Thailand, and Spain revealed a much higher parental acceptance rate of 70, 79.5, 85, and 86.1%, respectively (28, 36–38). However, in Japan, the acceptance rate was only 21.8% (39). Collectively, these values underscore the significant disparity and the urgent need for focused interventions in Saudi Arabia to enhance vaccine acceptance.

The role of healthcare providers in recommending the HPV vaccine is crucial, as our findings showed that 15.8% of the participants heard of HPV from different healthcare providers. Awareness offered by healthcare providers can significantly influence parental decisions regarding their children’s health. However, it is concerning that 50% of parents were uncertain about whether their child’s physician recommends the HPV vaccine. This gap in communication highlights the need for improved dialog between healthcare providers and parents, as clear recommendations from physicians could enhance awareness and acceptance of the HPV vaccine, leading to higher vaccination rates and better public health outcomes.

While some parents expressed hesitancy to vaccinate their children due to fears of side effects and lack of information, this underscores the need for educational resources to clarify the HPV vaccine’s safety and efficacy. In contrast, a study in the Eastern Province of Saudi Arabia found that 48% of parents felt protected, with 38% citing information gaps as their reason for hesitancy (23). Similarly, 38% of parents in Jazan (southern Saudi Arabia) were hesitant due to perceptions of the vaccine being new (35). These regional differences highlight the necessity for tailored educational interventions to effectively address specific concerns.

Regarding the factors associated with vaccine uptake acceptability, we noted that only parents of two or more children tended to be hesitant to accept the vaccine, whereas the perception of HPV infection risk to others was positively associated with vaccine acceptability. This indicate that spreading the awareness of HPV risks and its oncogenic nature may enhance the acceptability of the vaccine among the public. The reason behind the lack of vaccine acceptance among parents of more than two children is unknown, but it is probably due to the burden placed on the parents to vaccinate multiple children and keep up with the childhood vaccines schedule. Nevertheless, the availability of numerous immunization clinics in urban and rural regions of Saudi Arabia should allow an easy access to vaccinations. Of note, other factors including parent’s gender, parent’s age, child gender, level of education and employment, having heard of HPV, perception of HPV danger, and perception of vaccine’s effectiveness and harmfulness were not significantly associated with disposition toward HPV vaccination. This contrasts with a study conducted on nurses in the United State, where the belief in efficacy of the HPV vaccine strongly predicted acceptance of the vaccine (40). Additionally, a study by Fallatah et al. (26) found that a better knowledge of HPV infection and risk of cervical cancer was significantly associated with a positive attitude regarding HPV vaccine uptake. Notably, the gender disparity in our study, where fathers outnumbered the mothers, did not impact the attitude toward HPV vaccine. Such observation was also seen in previous studies from Saudi Arabia where no significant difference was observed in terms of both HPV knowledge and attitude toward HPV vaccine between males and females (26, 27).

While this study provides some useful insights into the knowledge of the public in Saudi Arabia regarding HPV and its vaccine, as well as the willingness to vaccinate children, some limitations should be acknowledged. Some eligible people were hesitant to participate and thus refused to take part in the study, which led to the extension of the data collection period to secure a sufficient number of participants to meet the required sample size. Furthermore, the utilization of purposive sampling method was another contributing factor to the extension of the data collection period to ensure surveying only the targeted population. It may also limit the generalizability of the results to future parents, as well as to other regions of Saudi Arabia as interviewing with participants was mainly done in one city; though, many participants reported coming from different cities of the country. Recall bias is another important limitation, where participants may have had difficulty remembering certain information regarding HPV knowledge and vaccine uptake history and recommendations by the child’s physician. Moreover, the expression of socially acceptable answers is typically expected in survey-based studies, which represent social desirability bias. These two forms of bias may have an impact on the reliability of the results, which should be interpreted carefully. Additionally, the response rate could not be calculated due to the lack of a defined sampling pool as sampling was done randomly though only with a targeted population. Lastly, we did not collect data on socioeconomic status of the participants to assess the impact of such a factor on HPV vaccine acceptability. We also did not analyze the impact of regional differences among the participants since a reasonable proportion of the study’s population were non-Saudis and because data collection took place in only one city.

Results from this study indicated an overall lack of knowledge of the public in Saudi Arabia regarding HPV infection and its associated cancer risks, which may have been associated with a reduced willingness to vaccinate their children. Healthcare providers are encouraged to educate their patients and the public about HPV and the importance of the vaccine in media outlets and in their areas of practice.