Low rate of human papillomavirus vaccination among schoolgirls in Lebanon: barriers to vaccination with a focus on mothers' knowledge about available vaccines

Assessment of knowledge and perceptions of human papillomavirus vaccine and its determinants among women who have eligible daughters in Debre Berhan City, Ethiopia: a cross-sectional study

Introduction

Globally, cervical cancer(CC) is the second most commonly diagnosed cancer and the fourth leading cause of cancer-related deaths in women. Human papillomavirus (HPV) infection is the leading cause of CC. Persistent infection with HPV accounts for 90% of all CC cases. The human papillomavirus vaccine has the great potential to prevent HPV-related infections for millions of women and men. The current study aimed to assess knowledge and perceptions towards the HPV vaccine and its determinants among women who have eligible daughters in Debre Berhan City, Ethiopia.

Methods

A cross-sectional study was conducted from April 2, 2023, to May 15, 2023. A multistage sampling procedure was used to recruit 607 women participants. Descriptive statistics were used to summarize socio-demographic data. Univariable and multivariable binary logistic regression analyses were performed to measure the associations between the dependent and independent variables. A p-value of <0.05 was considered statistically significant.

Results

More than three-fourths of the participants, 479 individuals (80%) were currently married, and 243(40.1%) had a diploma or higher education level. Of 456(75.12) participants reported, they had information about cervical cancer. For 449(73.9%) of the participants, television was the main evidence. The majority of 352(59.99%) participants knew the HPV vaccine could be offered to a female child aged 9-14 years old. Only 215(35.4%) participants think the HPV vaccine was safe and effective. Women who had a degree and above educational level were about 9 times more likely to have good knowledge about the HPV vaccine than study participants who did not read and write (AOR=9.21; 95% CI=2.82-12.16; p=0.004). Women who did not have information about the HPV vaccine before this study were about 80% less likely to have a positive perception of the HPV vaccine than participants who had earlier information about the HPV vaccine (AOR=0.8; 95%CI=0.63-0.49; P=003).

Conclusion

Women had poor knowledge and perceptions about the HPV vaccine. Maternal marital status, age, and having information about the HPV vaccine were the only predictors of women's knowledge of the HPV vaccine.

Willingness to take human papillomavirus vaccine and its associated factors among school adolescent girls: A case of school-based dose one human papillomavirus vaccine campaign in Dire Dawa, Ethiopia

Objective

This study aimed to evaluate the willingness of human papillomavirus vaccine and its associated factors in Dire Dawa in 2022. Ethiopia is undergoing human papillomavirus vaccine implementation in the country with the support of the Global Alliance for Vaccines and Immunization. However, there is a scarcity of data on problems encountered and the receiver's acceptance of the vaccine.

Methods

An institution-based cross-sectional study was conducted among 634 female adolescents from 1 April to 1 May 2022. A simple random sampling technique was used to select study participants. Pretested structured self-administered questionnaires were used to collect data. Data were entered into EPI-data 3.1 and exported to Statistical Package for the Social Sciences version 23.00 software for analysis. Descriptive analysis was conducted to summarize data with text, tables, and figures. A binary logistic regression model was fitted to identify factors associated with the willingness of the human papillomavirus vaccine. Adjusted odds ratios with 95% confidence intervals and p-values less than 0.05 were used to determine the association between independent and dependent variables. Hosmer and Lemeshow test was used to determine model fitness.

Results

The magnitude of human papillomavirus vaccine willingness among adolescent girls was 56% with 95% CI (52.1%-59.9%). Discussion on sexual and reproductive health issues (AOR = 7.67, 95% CI: 3.82, 15.42), adolescent girls who were received permission from their family to take human papillomavirus vaccine (AOR = 4.49, 95% CI: 2.40, 8.43), adolescent girls who had good knowledge on human papillomavirus vaccine (AOR = 5.78, 95% CI: 3.18, 10.15), and adolescent girls who had favorable attitude toward human papillomavirus vaccine (AOR = 3.06, 95% CI: 1.73, 5.43) were positively associated with willingness to take human papillomavirus vaccine.

Conclusion

Knowledge about cervical cancer and the human papillomavirus vaccine as well as willingness to take the human papillomavirus vaccine was low. Factors such as maternal education, adolescents' discussion on sexual and reproductive health issues, parent approval of human papillomavirus vaccine, and knowledge and attitude toward human papillomavirus vaccine were significantly associated with willingness to take the human papillomavirus vaccine. Therefore, public health education regarding cervical cancer and human papillomavirus vaccination is still needed and has to be targeted at not only respondents but also their families.

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

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.

Determinants of human papillomavirus vaccine hesitancy among Lebanese parents

INTRODUCTION

Human papillomavirus (HPV) is the most common sexually transmitted infection. HPV is responsible for cancer of cervix uteri. Despite its safety and immunogenicity, HPV vaccine hesitancy is one of the most challenging topics that pediatricians face.

METHODS

We aimed to describe the impact of knowledge, attitude, and practice towards vaccines in general, on practice related to HPV vaccination in Lebanon. A questionnaire addressed to parents of students (3-18 years of age) was distributed in 2 public and 2 private schools randomly selected from the greater Beirut area during the school year 2017-2018. Questionnaires covered knowledge, attitude, and practices of vaccination in general and HPV vaccine in particular.

RESULTS

Out of 400 distributed questionnaires, 306 (76.5%) were returned. Of the 185 parents aware of HPV vaccine, 60% hadn't given or were not planning to give the HPV vaccine to their children. Of parents not in favor of HPV vaccine, 7.5 thought that vaccines aren't necessary versus none among those in favor of HPV vaccine(p = 0.02). Thirteen percent of those not in favor of HPV vaccine thought that vaccines are not safe versus 2.7% in the group in favor (p = 0.02). An effect of gender on vaccine acceptance was noted: mothers vs fathers and daughters vs sons. Lack of recommendation by pediatricians and the thought that too little is known about the vaccine were the most selected reasons for parents not wanting to vaccinate their children against HPV, whereas cost and religious and cultural beliefs seemed to have no impact.

CONCLUSION

Most parents in our study did not vaccinate or weren't willing to vaccinate their children against HPV even when they were in favor of vaccines in general. Physician recommendation was shown to be one of the most important predictors of vaccination. Effort should be put into educating parents about the importance of the vaccine and its well-established safety and efficacy regardless of gender. Lebanese physicians should also be educated and empowered to recommend HPV vaccine more strongly and consistently.

Factors associated with uptake of human papillomavirus vaccination among adolescent girls in Mettu town, southwest Ethiopia: a school-based cross-sectional study

OBJECTIVE

This study was designed to assess the level of uptake of human papillomavirus (HPV) vaccination and its associated factors among school-age adolescent girls.

DESIGN

School-based cross-sectional study.

SETTING

High schools in Mettu town, southwest Ethiopia, from 5 February to 10 March 2022.

PARTICIPANTS

Data were collected using a pretested and structured questionnaire through face-to-face interviews with 667 adolescent girls selected via multistage random sampling. Data were entered into EpiData V.3.1 and exported to SPSS V.26 for analysis. Simple binary logistic regression was done, and variables with a p value less than 0.25 were entered into a multivariable logistic regression model; variables with a p value <0.05 were considered significant.

RESULTS

About half (48.6%) of adolescent girls aged 14-18 years had received the HPV vaccine. Being in the 16-18 years age group (adjusted OR 2.7, 95% CI 1.50 to 4.80), having good knowledge (2.14, 95% CI 1.29 to 3.52), having a positive attitude (5.86, 95% CI 3.51 to 9.76), and getting encouragement from healthcare workers (3.04, 95% CI 1.36 to 6.79), teachers (2.14, 95% CI 1.05 to 4.34) and parents (2.39, 95% CI 1.02 to 5.64) were significantly associated with vaccine uptake.

CONCLUSION

The uptake of HPV vaccination was low. Having good knowledge and positive attitude as well as encouragement from parents, healthcare workers and teachers were identified as factors associated with HPV vaccine uptake. Improving knowledge about HPV and involving teachers and parents in the immunisation campaign might help promote HPV vaccine uptake.

Human papillomavirus vaccine knowledge and conspiracy beliefs among secondary school students in Lebanon

BACKGROUND

Human Papillomavirus (HPV) is widely prevalent across the globe. In Lebanon, the society is transitioning from traditional conservatism to a more open attitude. Although previous studies have examined the knowledge of adults in Lebanon with regard to HPV and its vaccine, there is a lack of research on secondary school students. Moreover, HPV is considered a worldwide public health matter that needs to be addressed. Therefore, the objective of our study is to assess factors associated with knowledge and conspiracy beliefs towards HPV vaccine among a sample of Lebanese adolescents.

METHODS

Between December 2022 and February 2023, we conducted a cross-sectional study on Lebanese adolescents aged 15 to 18 years old. Parental approval was needed in order to participate. We used a questionnaire to collect data, which included the HPV-knowledge questionnaire (HPV-KQ) and the Vaccine Conspiracy Belief Scale (VCBS).

RESULTS

Of the 406 participants who filled the survey, 64.8% were female, with a mean age of 16.62 ± 1.01. Results showed that 31.0% of students had high knowledge about HPV, while 27.6% had high conspiracy beliefs, and 48% of participants relied on the internet to access information on HPV. Students who had previously heard of HPV, received sexual education at school or outside, and had received at least one dose of the HPV vaccine demonstrated significantly higher knowledge of HPV. Additionally, students with high knowledge had a lower mean House Crowding Index, and those whose fathers had a university education had lower conspiracy beliefs. Females had a higher vaccination rate than males, while no significant difference was found between those who had engaged in sexual activity and those who had not. The multivariate analysis indicated that previous awareness of HPV and receiving sexual education outside school were significantly associated with higher knowledge.

CONCLUSION

Our study brings to light the urgent need for action to increase HPV awareness and vaccination among Lebanese secondary school students. The prevalence of vaccine misconceptions and conspiracy beliefs and the limited knowledge of HPV underscore the importance of more comprehensive sexual education in schools and the dissemination of accurate information about HPV and its vaccine. Furthermore, given the low vaccination rate among males, efforts should be made to promote HPV vaccination among this population. Addressing these issues can improve public health and help prevent the spread of HPV and its related diseases.

HPV Vaccination Prevalence among Lebanese Female University Students: A Cross-Sectional Study

Background

Cervical cancer is the fourth most common cancer in women, worldwide. Most often, cervical cancer is caused by a human papillomavirus (HPV) infection. A lack of studies concerning HPV knowledge and vaccination among the Lebanese population is noticed. We aim to assess the prevalence of HPV vaccine administration among female university students in Lebanon alongside determining the predictors influencing vaccine uptake. Lastly, knowledge scores concerning HPV and HPV vaccination are also computed.

Methods

This is a cross-sectional analytical study. It is an anonymous, online-based, close-ended questions survey conducted between the 24th of February 2021 and the 30th of March 2021. Our questionnaire was addressed to females aged between 17 and 30 years and enrolled in a Lebanese university. The collected data were analyzed using Statistical Package for Social Sciences (SPSS) v.26. We used bivariate analysis to compare the rate of vaccination with different variables. We used the chi-square test for categorical variables and Student's t-test for continuous variables. Logistic linear regression was conducted between the state of vaccination and other statistically significant variables from the bivariate analysis.

Results

We have received a total of 454 questionnaires. Among the respondents, only 18.9% had received a minimum of one dose of the HPV vaccine. The mean age of up taking the first dose of the vaccine was 17.5 years. In addition, 48% of the respondents were not willing to take the HPV vaccine during the upcoming year. Barriers to not taking the HPV vaccine were mainly the low levels of knowledge concerning HPV and its vaccine. In the multivariate analysis, three predictors were found to affect the rate of HPV vaccination: university type, paternal educational level, and HPV vaccine knowledge score. In detail, a student enrolled in a public university had 77% likelihood of not being vaccinated. Furthermore, female students with a paternal educational level higher than a university degree had 88% probability of being vaccinated. Finally, every increase in the HPV vaccination knowledge of one point increased the likelihood of being vaccinated by 37%.

Conclusion

A low vaccination rate among female university students in Lebanon was noticed in our study. In addition, a lack of HPV and HPV vaccine knowledge was found in our population. An awareness campaign alongside public vaccination programs is recommended in order to accomplish higher rates of HPV immunization.

Willingness to get HPV vaccination among female university students in Kuwait and its relation to vaccine conspiracy beliefs

A substantial burden of high-risk human papillomavirus (HPV) infections and HPV-related cancers can be mitigated by vaccination. The current study aimed to investigate the willingness of female students at the University of Kuwait to get HPV vaccination and its possible association with general vaccine conspiracy beliefs (VCBs). This cross-sectional survey study was conducted during September-November 2022 using a validated VCB scale as the survey instrument. The final sample comprised 611 respondents with a median age of 22 y and a majority of Arab ethnicity (n = 600, 98.2%). Only 360 respondents (56.9%) heard of HPV before participation and these students showed an above-average level of HPV knowledge (mean knowledge score of 12.7 ± 2.6 out of 16 as the maximum score), of whom only 33 self-reported HPV vaccine uptake (9.2%). The willingness to accept free-of-charge HPV vaccination was seen among 69.8% of the participants, with 20.1% who were hesitant and 10.1% who were resistant. The acceptance of HPV vaccination if payment is required was 23.1%. Reasons for HPV vaccine hesitancy/resistance included complacency to the HPV disease risks, lack of confidence in HPV vaccination, and inconvenience. The embrace of VCBs was associated with significantly higher odds of HPV vaccine hesitancy/resistance. The current study showed the detrimental impact of endorsing vaccine conspiracy beliefs manifested in lower intention to get HPV vaccination among female university students in Kuwait. This should be considered in vaccine promotion efforts aiming to reduce the burden of HPV cancers.

Knowledge, attitudes and acceptance toward Human papillomavirus (HPV) vaccination: Perspectives of Muslim women and men

OBJECTIVES

Human papillomavirus (HPV) infection is the leading risk factor for the development of anogenital cancers. Most Arab countries lack both HPV education and national HPV vaccination programs. The objective of this study was to assess knowledge, attitudes, and acceptance toward HPV vaccination in men and women from Oman, a country in the Middle Eastern North Africa region.

METHODS

This cross-sectional quantitative study used convenience sampling to recruit male and female participants, aged 18 years and above from all 11 governorates of Oman to complete a validated self-administered questionnaire online in the Arabic language. The questionnaire comprised five sections, with a total of 32 questions. The questionnaire, including Arabic and English versions, was content validated and piloted.

RESULTS

A total of 1403 participants, including 952 parents and 369 healthcare providers, completed the survey. The results showed a lack of knowledge regarding HPV infection and vaccines, including among healthcare providers. Less than a quarter of the participants had heard of HPV infection, with digital sources of information being the most common. Factors such as being a woman or a healthcare provider or completing higher levels of education were independently and significantly positively association with HPV awareness (p < 0.001). The majority of the participants lacked vaccine safety knowledge, had concerns about the vaccine's side effects, and sought reassurance of its protection against HPV infection (62%, 71.5%, and 84.6%, respectively). Nevertheless, nearly two-thirds of the participants agreed to take the HPV vaccine, with support for both boys and girls being vaccinated. There was almost universal agreement among the participants regarding the need for parental and adolescent HPV educational programs.

CONCLUSION

Omani women and men showed a high level of acceptance and favorable attitude toward HPV vaccination. The study findings support future efforts to implement school and public-level HPV education and a national HPV vaccination program in Oman.

Barriers to the HPV vaccination program in the Eastern Mediterranean region: a narrative review

Objective

The human papillomavirus (HPV) vaccine is regarded as one of the most effective ways of preventing cervical cancer. Despite the massive burden of this disease, only two countries in the Eastern Mediterranean Region (EMR) have implemented a national HPV vaccination program. The aim of the present study was to assess the main barriers to the integration of HPV vaccination in the national vaccination programs of EMR countries.

Material and Methods

We performed a narrative review with no inclusion and exclusion criteria. The electronic databases we searched included Medline, Scopus, Embase, and Web of Science (last update; December 2021). The search was not subject to any limitation in terms of time or method. Studies that dealt with the obstacles or the needs of vaccination programs in EMR countries were included in the investigation.

Results

After a full-text screening, the report comprised of 31 studies from 15 EMR countries. All of the studies were descriptive. The most common barriers to HPV vaccination are the following: a) lack of knowledge and awareness, b) economic barriers in terms of the cost-effectiveness of the HPV vaccination program, c) social insecurity in conflict zones, d) cultural norms and religion.

Conclusion

EMR countries should focus on modifiable barriers to the vaccination program. Steps to improve HPV vaccination coverage in these countries should include enhancing social awareness and mobilization, ensuring the support of the Global Alliance for Vaccines and Immunization in eligible countries, using national resources in an optimal way, and addressing HPV vaccination in undergraduate medicine and paramedic curriculums.

Genetic diversity of human papillomavirus (HPV) as specified by the detection method, gender, and year of sampling: a retrospective cross-sectional study

PURPOSE

This study assesses HPV prevalence and genotype distribution in Lebanon, and identifies differentials in HPV infection, infection with multiple genotypes, and with high-risk genotypes, by sex, age, and year of data collection.

METHODS

Study participants comprised 1042 female and 160 male participants between 2006 and 2018. HPV genotyping was done by PCR and hybridization (2006-2013) or real-time PCR (2013 onwards). Diversity of HPV genotypes across gender, age groups, and years of data collection was tested by applying Shannon Diversity Index.

RESULTS

The overall HPV prevalence was 44.8% among study participants, and threefold higher in women than men. Single HPV infection was seen in two-third of HPV-positive participants. Women were less likely to be infected with multiple HPV strains, but more likely to be infected with high-risk or mixed-risk HPV genotypes. HPV-16 (11.0%, 9.8%) and HPV-53 (8.5%, 4.9%) were the most prevalent high-risk HPV genotypes in women and men, respectively, while HPV-18 prevalence was 4.9% in men and 3.1% in women, while HPV-59 prevalence was 6.6% in men and 2.1% in women. Samples collected post-2011 from women showed twice higher odds of HPV infection than those collected earlier and were threefold more likely to be infected with multiple HPV strains, and twice more likely to be infected with high-risk genotypes compared to those tested earlier. Women scored higher on Shannon index indicating high diversity in HPV types and frequency, with trend of increased diversity over time. While the odds of HPV infection remained associated with sex and temporal trend in multivariable analysis, odds of having high-risk genotypes was mainly associated with infection with multiple HPV strains.

CONCLUSION

Our study showed high diversity in HPV genotypes and an increasing trend of infection with multiple and high-risk genotypes in recent years. Findings underscore the need for effective screening/surveillance and HPV vaccination programs.

Malaysian Women's Viewpoint on HPV Screening and Vaccination: A Study on Barriers

Cervical cancer is the second most common cancer in low-income countries and the third most common cancer in Malaysia among women aged 15 to 44. This is a huge concern because of the high mortality rate compared to other countries. Cervical cancer is caused by a common sexually transmitted human papillomavirus (HPV). Of cervical cancer cases, 80% are attributed to serotypes 16 and 18; therefore, early detection of premalignant lesions and infections from these viruses is important. Diagnosis can be carried out by polymerase chain reaction (PCR)-based HPV DNA analysis and Pap smear, which act as a viable preventive strategy. (1) Background: This study determined the adoption of the human papillomavirus (HPV) vaccine and the willingness to get vaccinated in Malaysian women. (2) Methods: An online survey was conducted with women from across Malaysia to gather their views on the barriers that prevent them from accessing HPV services. Sentiment analysis was performed to detect and classify the comments into three groups (positive, neutral, and negative). (3) Results: A total of 449 opinions were received, and the findings revealed that 41.3% were not afraid to be diagnosed early, and were prepared to accept positive or negative screening results. In addition, 18.6% of those surveyed indicated that they feared a Pap smear and were very concerned that they would not get good results. Of the respondents, 36% believed in vaccination and preferred to know more about it; 43.24% claimed that their family members were very supportive towards screening and vaccination; and 21.3% felt embarrassed and were afraid to undergo the screening procedure, as they had no prior experience and were unsure of how the procedure was conducted. In addition, 40.5% indicated that they had no concerns about HPV testing and related procedures, as this information is widely available. Only a few respondents (8.1%) talked about the time constraints and busy work schedules that prevented them from going to medical appointments. The survey also revealed that women are prevented from participating in cervical cancer screening and vaccination programs due to a lack of knowledge, shyness, personal rumors, privacy issues, financial issues, a lack of access to medical services, and ignorance and beliefs about rumors spreading online. (4) Conclusion: Results indicate that awareness of HPV and related prevention measures among women is vague and that negative perceptions continue to exist. It is strongly advised to develop a well-designed and knowledge-based application on the efficacy of screening and vaccination among Malaysian women.

Outcomes of Human Papilloma Virus Vaccination in a Private Women Health Clinic in Lebanon

Objectives

The study aims to report on the feasibility and associated adverse events of HPV-Vaccination (HPVV) in a private clinic setting in Lebanon and, when available, the results of subsequent cervical cancer screening.

Methods

Opportunistic HPV vaccination is offered at the Women's Health Center of the AUBMC. We retrospectively reviewed the patients' demographic data, the incidence of adverse events, and their cytological screening.

Results

A cohort of healthy women (n = 1013) aged 26.2 years (12-54 years) were opportunistically vaccinated with one of two HPV vaccines; 845 (83.4%) received the quadrivalent vaccine (Q4V), and 151 (14.1%) received the bivalent vaccine (B2V). The majority (75.8%) received three doses while 16% received two doses. Out of these women, 26.3% (267) became sexually active postvaccination (NS2), whereas 17% (174) were sexually active prior to vaccination (SA) and the rest 57% (572) reported no sexual activity (NS1). Among the SA group, 26% (46/147) presented with abnormal cytology at time of vaccination. As for the NS2 women, 5% (14/267) had subsequently abnormal screening within 37 (12-103) months following vaccination.

Conclusions

In this observational study, we report the successful introduction of HPVV with negligible adverse events. The incidence of abnormal cervical cytology was low among our patients.

Awareness of human papillomavirus and acceptability of the vaccine among women in Palestine: is it time for policy adjustment?

Background

Progress has been made in the reduction of morbidity and mortality of cervical cancer by the implementation of human papillomavirus (HPV) vaccination programs. This study aimed to assess the awareness of Palestinian women about HPV as well as their knowledge and acceptability of the HPV vaccine and to examine the factors associated with good awareness.

Methods

This was a national cross-sectional study. Adult women were recruited from hospitals, primary healthcare centers, and public spaces in 11 Palestinian governorates using convenience sampling. A structured questionnaire was used for data collection. For each correctly answered question, one point was given. The total score was calculated and categorized into poor (0–10) and good awareness (11–21).

Results

The questionnaire was completed by 7223 women out of 8086 who were approached (response rate = 89.3%). A total of 7058 questionnaires were included in the final analysis; 4403 from the West Bank and Jerusalem (WBJ) and 2655 from the Gaza Strip. Women recruited from the Gaza Strip were younger, getting lower monthly incomes, and with fewer chronic diseases than women recruited from the WBJ.

Only 33 women (0.5%) displayed good awareness of HPV and its vaccine with 0.7% of women from WBJ and only 0.2% of women from the Gaza Strip. Completing post-secondary education, being employed or a student, and having a higher monthly income were associated with an increase in the likelihood of having good awareness.

Among women who had heard of HPV (n = 571, 8.1%), only 46 women (8.1%) reported familiarity with its vaccine. Women from the WBJ were more likely than women from the Gaza Strip to have heard about the HPV vaccine (0.9% vs. 0.2%). Most women agreed to receive the HPV vaccine themselves or for their daughters if it was given without cost or with a co-payment. No differences were found in the likelihood of agreeing to receive the HPV vaccine among women in the WBJ versus the Gaza Strip.

Conclusion

The overall awareness of HPV and its vaccine was extremely low. Inclusion of the HPV vaccine in the national immunization program could change this, especially as the HPV vaccine appeared to be acceptable.

Human papillomavirus vaccination uptake and its associated factors among adolescent school girls in Ambo town, Oromia region, Ethiopia, 2020

Background

The Human Papillomavirus (HPV) vaccine has offered a great promise to reduce the cervical cancer burden; its utilization (uptake) however has been lagging. However, the levels and factors associated with the uptake of the vaccine have not been well investigated, especially in the local context.

Objective

To assess the uptake of human papillomavirus vaccination and its associated factors among adolescent school girls in ambo town, Oromia, Ethiopia, 2020.

Methods

An institution-based cross-sectional quantitative study design supplemented with the qualitative inquiry was employed to assess Human Papillomavirus vaccination uptake and its associated factors among 422 adolescent school girls in Ambo town, central Ethiopia from December 1–30, 2020. The collected data were coded, entered, and cleaned by using Epi info 7.2.3 and exported to SPSS version 25 for analysis. Descriptive statistics were used to compute summary statistics and proportions. Both bivariate and multivariable logistic regression was employed to identify factors associated with HPV vaccine uptake. Adjusted odds ratio and 95% confidence interval were used for the strength and directions of association. A P-value of < 0.05 was used to declare statistical significance. Qualitative findings have been analyzed with manual thematic analysis.

Result

The proportion of HPV vaccination uptake among school girls in this study was 44.4%. Hearing about HPV vaccine [AOR = 2.50, 95%CI: (1.045–5.959)], availability of awareness creation [AOR = 2.53, 95%CI: (1.507–4.258)], and favorable attitude [AOR = 2.049, 95%CI: (1.153–3.64)] were the key identified factors associated with vaccination uptake. In addition, poor perception, fear of side effects, and misunderstanding were among the major factors identified by qualitative findings.

Conclusion

There was low uptake of HPV vaccination among the school Adolescents in the study area. Availability of awareness creation programs, favorable attitude towards HPV vaccine, and hearing about HPV vaccine was significantly associated with the uptake of the HPV vaccination. Therefore, awareness creation and behavior change education are mandatory to scale up the vaccination.

Knowledge and Attitude Towards Human Papillomavirus Vaccine and Associated Factors Among Mothers Who Have Eligible Daughters in Debre Markos Town, Northwest Ethiopia

Purpose

This study aimed to assess knowledge and attitude towards the human papillomavirus vaccine and associated factors among mothers who have eligible daughters.

Methods

A community-based cross-sectional study with a total sample of 601 study participants was conducted in Debre Markos town from February to March 2021. The study participants were selected using a multistage sampling technique from mothers who have eligible daughters. The data was collected using an interview administration questionnaire. The data were entered into EPI data version 3.1 then, exported to SPSS version 25 for analysis. Variables with a p-value of < 0.25 in bivariate were a candidate for multivariate and those variables with a p-value of <0.05 in multivariate binary logistic regression were considered as a statistically significant factor for knowledge and attitude of the HPV vaccine.

Results

A total of 601 study participants with a response rate of 100% were included in the study. Among participants in this study, 47.6% have good knowledge and 77.4% have a positive attitude towards the HPV vaccine. Knowledge of mothers about HPV vaccine was affected by having degree and above (adjusted odds ratio (AOR) =7.687; 95% CI=1.837–32.168; p=0.005), did not hear about HPV vaccine (AOR=0.172; 95% CI=0.098–0.302; P=0.000), and positive attitude towards HPV vaccine (AOR=2.959; 95% CI=1.580–5.539; P=0.001). Attitude of mothers towards HPV vaccine was affected by did not hear about HPV vaccine (AOR=0.285; 95% CI=0.163–0.499; P=000), and good knowledge about HPV vaccine (AOR=2.705; 95% CI=1.454–5.035; 0.002).

Conclusion

Knowledge of mothers who have eligible daughters about HPV vaccine was low. Maternal educational level, hearing about the HPV vaccine, and attitude towards HPV vaccine were significantly associated predictors with knowledge towards HPV vaccine. However, the attitude was high and factors associated with attitudes towards the HPV vaccine were knowledge about the HPV vaccine and hearing about the HPV vaccine. An integrated work should be considered by Debre Markos town health office with other non-governmental organizations working on health and health-related issues to improve knowledge about the importance of HPV vaccine for mothers who have eligible daughters.

Knowledge, Attitude, and Practice of Cervical Cancer Screening, and HPV Vaccination: A Cross-Sectional Study Among Obstetricians and Gynecologists in Egypt

BACKGROUND

Although cervical cancer is potentially preventable, lack of knowledge and poor attitude among healthcare professionals toward cervical cancer screening and Human Papilloma Virus (HPV) vaccination can result in underutilization of these preventive strategies. Then, the objective of this study was to assess the knowledge, attitude, and practice of cervical cancer and its prevention through Pap test screening and HPV vaccination among obstetricians and gynecologists (Ob-Gyns).

METHODS

A cross-sectional study was conducted on 250 Egyptian attendees of a national Ob-Gyns professional conference. Data collection was performed using a pre-designed self-administered questionnaire, which tested participants' knowledge, attitude, and practices related to cervical cancer, Pap test screening, and HPV vaccination.

RESULTS

The study included 41.2% Ob-Gyns specialists and 37.6% of consultants from secondary and tertiary care hospitals or centers. About 45% of participants had poor-to-fair knowledge, 57% had negative-to-fair positive attitudes toward cervical cancer screening and HPV vaccination, and 44% had ever-performed Pap test, while 45% of participants had ever-prescribed the HPV vaccine to their patients. Physicians' knowledge and attitude were significantly associated with their age, professional level, work experience, and place of work. Although performing cervical cancer screening was significantly more common among older, more experienced, and highly professional participants, HPV vaccine prescription was associated with young, less experienced participants at lower educational and professional levels.

CONCLUSION

Ob-Gyns had poor-to-fair knowledge, Attitude, and practices related to cervical cancer, Pap test screening, and HPV vaccination.

Cervix Uteri Cancer in Lebanon: Incidence, Temporal Trends, and Comparison to Countries From Different Regions in the World

Background

Invasive cervix uteri cancer is the fourth most common malignancy in women globally. This study investigates the incidence and trends of cervix uteri cancer in Lebanon, a country in the Middle East, and compares these rates to regional and global ones.

Methods

Data on cervix uteri were obtained from the Lebanese national cancer registry for the currently available years 2005 to 2016. The calculated age-standardized incidence and age-specific rates were expressed as per 100,000 population.

Results

From 2005 to 2016, cervix uteri cancer was the tenth most common cancer among women. Its age-standardized incidence rate fluctuated narrowly between 3.5 and 5.7 per 100,000, with the lowest rate in 2013 and the highest rate in 2012. The age-specific incidence rate had 2 peaks, the highest peak at age group 70–74 years and the second at age group 50–59 years. The annual percent change (+.05%) showed a non-statistically significant trend of increase. The age-standardized incidence rate of cervix uteri cancer in Lebanon was comparable to that of the Western Asia region that has the lowest incidence rate worldwide. The rate was intermediate as compared to other countries in the Middle East and North Africa Region and relatively similar to the ones in Australia, North America, and some Western European countries.

Conclusion

The incidence rates of invasive cervix uteri are low in Lebanon. This could be attributed to the low prevalence of human papilloma virus infection and other sexually transmitted infections among Lebanese women, and the opportunistic screening practices. It is important to adopt a comprehensive approach to decrease the potential burden of cervix uteri, especially with the rising patterns of risky sexual behaviors. This includes improving awareness, enhancing access to preventive services, developing clinical guidelines, and training health care providers on these guidelines.

Awareness about the human papillomavirus (HPV) and HPV vaccine among medical students in Lebanon

As a developing country, Lebanon lacks adequate awareness about Human papillomavirus (HPV) among its population, whether working in the medical field or not. Lebanon is traditionally considered conservative with a low incidence of sexually transmitted infections in general, but recently the incidence of HPV infections has significantly increased. The present cross-sectional study aims to evaluate the level of awareness on HPV and the attitude toward HPV vaccine among Lebanese medical students in a self-administered questionnaire-based survey. A total of 1009 answers were collected and analyzed from a population of about 3000 Lebanese medical students. Our study revealed a significant lack of knowledge and awareness on HPV among medical students in Lebanon, with a strikingly low vaccination rate (16.4%) due to many barriers. Education initiatives in medical schools remain crucial to raise awareness on HPV and promote HPV vaccination, especially among medical students, who represent the country's future healthcare providers and policymakers.

Knowledge and Beliefs of Cancer Risk Factors and Early Cancer Symptoms in Lebanon: A Cross-sectional Survey Among Adults in the Community

Background

Lebanon has an increasing cancer burden. Sufficient knowledge of cancer risk factors and early cancer symptoms can help lower cancer burden by facilitating primary prevention and early diagnosis. This study (i) assessed Lebanese adults’ knowledge and beliefs of cancer risk factors and early cancer symptoms, (ii) analyzed whether knowledge was correlated with personal behavior, and (iii) assessed the presence of barriers that keep knowledge from turning into healthcare seeking behavior.

Methods

We performed a cross-sectional survey in the Lebanese adult population, consisting of a questionnaire administered during face-to-face interviews on a community-based non-probability sample (n = 726) that was frequency matched to national government estimates on age, level of education and gender.

Results

Recognition was high for carcinogens and protective factors (75%), but low for neutral factors (22%) which were often seen as carcinogenic. A quarter of participants (27.8%) could not name any early warning signs. For some risk factors, high knowledge scores were correlated with low-risk behavior, but this was not the case for cigarette smoking. The most frequent barriers for not seeking timely care were financial (57.0%) fear of finding illness (53.7%), and having other things to worry about (42.4%).

Conclusion

This study revealed important knowledge gaps which are likely to hamper primary prevention and early diagnosis. However, we also showed that high knowledge of risk was not always correlated with low-risk behavior. This, together with the barriers we found that kept people from seeking timely health care, emphasizes that efforts to lower cancer burden should not only focus on increasing knowledge.

Knowledge of HPV, its vaccines, and attitudes toward HPV vaccines among obstetrician-gynecologists, pediatricians and immunization services providers in Western China

Background

In mainland China, HPV vaccines have been available to the public. However, only a few related studies among health care providers, as the key information providers, were reported although public concerns on HPV vaccines still exist. In this study, we aim to assess the knowledge of HPV, its vaccines, and attitudes toward HPV vaccines among the three most important groups of health care providers in Western China.

Method

This was a cross-sectional questionnaire-based study. Health care providers including obstetrician-gynecologists (OB-GYNs), pediatricians, and immunization service providers in Western China were investigated regarding their knowledge of HPV and its vaccines and their attitudes toward HPV vaccines.

Results

Of 1079 health care providers completing the survey, 1015 (94.1%) knew HPV infection is the primary cause of cervical cancer. However, lower knowledge levels of other HPV-related diseases were also found (43.2%). About three-quarters (74.1%) of practitioners interviewed would be willing to recommend HPV vaccination, which was found to be lower among the OB-GYNs (69.6%) and the pediatricians (73.2%). “Lack of relevant knowledge,” “concerns on safety and efficacy” and price were the three most important concerns surrounding HPV vaccination.

Conclusion

The interviewed practitioners did not have adequate knowledge of HPV and its vaccines in depth. Education interventions are highly recommended to the health care providers, especially for OB-GYNs and pediatricians, to increase the coverage of HPV vaccination among the population. For the currently high price of vaccines, a future co-sharing mechanism between the government, the providers, and the individuals might be a solution.

Prevalence of STIs, sexual practices and substance use among 2083 sexually active unmarried women in Lebanon

Access to sexual and reproductive health in conservative communities and in the MENA region are particularly limited and, as such, increase women's vulnerability to unwanted pregnancies, unsafe abortions, and sexually transmitted infections (STIs). The aim was to assess the prevalence of STIs, sexual practices, recreational drug-use and their possible associations among cisgender unmarried women residing in Lebanon. Data on demographics, sexual practices and substance-use were collected from 2083 unmarried cisgender women who voluntarily attended a sexual health clinic in Lebanon between 2015 and 2019. They tested for HIV, Hepatitis B, Hepatitis C and Syphilis through rapid testing. Other infections (genital warts, Neisseria gonorrhea/Chlamydia trachomatis) were screened for. Regression models were computed between variables. There were two cases of HIV, one of Hepatitis B and syphilis, and no cases of Hepatitis C. Genital warts were present in 15% and symptoms indicative of Neisseria gonorrhea/Chlamydia trachomatis in 14%. Inconsistent condom-use (81%) was significantly associated with number of partners (adj. OR: 0.4). Inconsistent condom-use discussion with partners (33%) was significantly associated with unemployment (adj OR: 1.7), recreational drug-use (adj. OR: 1.4), and number of partners (adj. ORs 3.7-4.4). Unwanted pregnancies (11%) were significantly associated with age (adj. ORs 0.1-0.37), recreational drug-use (adj. OR: 2), using intrauterine device (adj. OR:2.9) and natural birth control methods (adj. OR: 2.4). Recreational drug-use (33%) was significantly associated with age (adj ORs 1.9-2.2), and smoking status (adj. OR: 0.6). The results indicate an urgent need for: (1) Accessible, non-stigmatizing, and inclusive sexual health services dedicated to women's sexual health; (2) Comprehensive and non-stigmatizing sexual health education for all, but especially women, in order to promote safer sexual practices and effective decision making with regards to contraception and condom-use.

A nationwide post-marketing survey of knowledge, attitude and practice toward human papillomavirus vaccine in general population: Implications for vaccine roll-out in mainland China

BACKGROUND

Human papillomavirus (HPV) vaccine has been increasingly discussed in mainland China since its first approval in 2016. To date, nearly all studies assessing HPV vaccine perceptions and attitudes were implemented during pre-licensure period. Therefore, the nationwide post-marketing survey was conducted to update knowledge, attitudes and practice on HPV vaccine among general population in mainland China.

METHODS

Participants aged 18-45 years living in mainland China were recruited in April 2019 by multi-stage non-randomized sampling. Sociodemographic factors, HPV and HPV vaccine related awareness, knowledge, attitudes, vaccine uptake and potential obstacles were assessed in questionnaires. Bivariate analysis and multivariate regression were used to identify disparity among subgroups with different sociodemographic characteristics.

RESULTS

4,000 women (32.1 ± 7.81y) and 1,000 men (31.8 ± 7.96y) were included in final analysis. Less than one third of participants had heard of HPV (female: 31%; male: 22%) and HPV vaccine (female: 34%; male: 23%). Knowledge score was also unfavorable on HPV (female: 3 out of 13; male: 1.8 out of 13) and HPV vaccine (female: 3 out of 6; male: 2 out of 5). Only 3% females had been vaccinated three years after HPV licensure in China, although willingness to get vaccinated among those unvaccinated were high (mean willingness score ± SD: female: 3.3 ± 0.97; male: 3.0 ± 0.98). Industry of employment and household income were the major factors related to awareness and knowledge of vaccine, whereas HPV and HPV vaccine awareness were key influential factors for willingness. The main obstacles of vaccination were safety concerns, lack of knowledge, and high price of HPV vaccines.

CONCLUSIONS

Findings highlight a lack of vaccine awareness, knowledge, and poor uptake in mainland China and underscore the necessity of health education campaigns. The identified priority groups, contents to be delivered and practical obstacles could furthermore provide insight into health education to reduce disparities and accelerate HPV vaccine roll-out in China.

HPV-related oropharyngeal cancer prevalence in a middle eastern population using E6/E7 PCR

Background

Given the paucity of data and widely variable rates that have been reported, the main objective of this study was to examine the prevalence of HPV-positivity in oropharyngeal squamous cell carcinoma (OPSCC) in Middle Eastern patients presenting to one of the region's largest tertiary care centers using polymerase chain reaction (PCR) amplification of the HPV E6/E7 oncogenes, a highly sensitive and specific method of detection.

Methods

Medical charts and archived pathological specimens were obtained for patients diagnosed with biopsy proven oropharyngeal cancer who presented to the American University of Beirut Medical Center between 1972 and 2017. DNA was extracted from paraffin-embedded specimens and tested for 30 high-risk and low-risk papilloma viruses using the PCR-based EUROarray HPV kit (EuroImmun).

Results

A total of 57 patients with oropharyngeal cancer were initially identified; only 34 met inclusion/exclusion criteria and were included in the present study. Most patients were males (73.5%) from Lebanon (79.4%). The most common primary tumor site was in the base of tongue (50%), followed by the tonsil (41.2%). The majority of patients (85.3%) tested positive for HPV DNA.

Conclusion

The prevalence of HPV-positivity amongst Middle Eastern OPSCC patients, specifically those from Lebanon, may be far greater than previously thought. The Lebanese population and other neighboring Middle Eastern countries may require a more vigilant approach towards HPV detection and awareness. On an international level, further research is required to better elucidate non-classical mechanisms of HPV exposure and transmission.

Barriers, Attitudes and Clinical Approach of Lebanese Physicians Towards HPV Vaccination; A Cross- Sectional Study

OBJECTIVES

HPV infection is associated with the development of cervical and oropharyngeal cancer. HPV vaccination prevents cervical cancer, but is still not part of Lebanon's routine vaccination schedule. As such, understanding physicians' practice towards HPV vaccination is essential.

MATERIAL AND METHODS

We conducted a cross-sectional study in Greater Beirut, Lebanon to assess the barriers, attitudes and clinical approach of Lebanese physicians towards HPV vaccination. We also aimed to analyze the factors associated with physicians' barriers to HPV vaccination.

RESULTS

In total, 228 physicians completed the survey. Our results show that physicians and parents consider the cost of HPV vaccination to be a main barrier (58.9% and 80.7% respectively). Also, parents tend to have concerns about vaccine safety (78.1%), efficacy (68.6%), and lack education concerning HPV infection (81.8%). Furthermore, female physicians tend to have fewer barriers when compared to male physicians (aOR = 0.39; p-value = 0.007). Additionally, physicians who completed residency programs in the USA also showed fewer barriers when compared to physicians who completed Lebanese residency programs (aOR = 0.24; p-value = 0.040). Finally, physicians with higher knowledge score have fewer barriers when compared to those with lower knowledge scores (aOR = 0.42; p-value = 0.018).

CONCLUSIONS

Physician gender, residency program and level of knowledge play a role in HPV vaccine barriers and recommendation in Lebanon. Future improvements in cost and awareness about HPV might improve vaccination rates. Creating uniform practices towards HPV vaccine is warranted to improve patient care.

Immunization Campaigns and Strategies against Human Papillomavirus in Italy: The Results of a Survey to Regional and Local Health Units Representatives

Objective. The study aimed to assess the impact of HPV immunization campaigns organizational aspects, the characteristics of immunization program (vaccination targets and type of offer), and communicative strategies adopted by four Italian administrative regions on vaccination coverage observed. Methods. From November 2017 to March 2018, regional and Local Health Units (LHUs) representatives were invited to complete an online survey including 54 questions evaluating vaccination invite systems, access systems to vaccination centres, reminder and recall systems, and adverse events surveillance. An overall descriptive analysis was conducted. Since observed vaccine coverage (VC) obtained in females (2002-2004 birth cohorts) was lower than objectives fixed by the Italian Ministry of Health, variables were assessed using the national VC mean obtained in the 2003 girls birth cohort as outcome. Results. Twenty-six LHUs belonging to 4 Northern and Southern Italian regions participated in the study. Organizational aspects significantly related to VC lower than the national mean were access to vaccine centres without appointment and parents' reservation as appointment planning system. Recall systems for both the first and the second dose, including the appointment in the invitation letter, the availability of regional immunization registry, and education of healthcare workers on universal HPV immunization strategies, instead, were related to higher VC. As regards preadolescent immunization strategies, both VC obtained in girls and boys were far from the Ministerial goals. Only 20% of LHUs introduced multicohort female strategies while all LHUs adopted copayment targeting both men and women. Immunizations strategies targeting subjects at risk were implemented only in half of participating LHUs. Conclusions. VC observed in participating LHUs are largely lower than the national objectives in all anti-HPV vaccine targets. Both organizational and educational strategies have to be implemented to improve the VC goals.

Vaccine coverage for Lebanese citizens and Syrian refugees in Lebanon

Article History

Following the refugee crisis in Lebanon, the on-going inflow of Syrian refugees presented new challenges to optimal immunization coverage for all the children living in the country. Healthcare facilities have been overburdened during this period and the country witnessed outbreaks of many infectious diseases. Thus, the evaluation of vaccine compliance for mandatory and non-mandatory vaccines as well as the factors affecting the vaccination rate among Lebanese residents and Syrian refugees is fundamental.

Background

Since 2012, Lebanon has hosted around 1.2 million Syrian refugees, a high number in a country whose population does not exceed 4.4 million. Healthcare facilities have been overburdened during this period, which has led to the spread of many infectious diseases, including outbreaks of measles, mumps and hepatitis. At the appearance of such outbreaks, it becomes essential to evaluate vaccine compliance and the factors influencing the vaccination rate among Lebanese residents and Syrian refugees in infants and children up to 15 y of age.

Methods

A total of 571 infants and children were recruited in Beirut and Mount Lebanon, two governorates that together host half of the Lebanese population.

Results

A very high rate of vaccine compliance was seen for mandatory vaccines, whereas an intermediate to very low rate of compliance was found for non-mandatory vaccines. Both bivariate and multiple regression analyses indicated that age group and regular consultation of a pediatrician were independently associated with immunization coverage. Bivariate analysis indicated that parental age, occupational and educational status of parents, family size and vaccine price were also independently associated with immunization coverage. Incomplete vaccination coverage was associated with socioeconomic factors.

Conclusions

From these results, it becomes apparent that it may be necessary to reassess vaccination priorities considering the current socioeconomic situation.

HPV VACCINE ADHERENCE AMONG ADOLESCENTS: INTEGRATIVE REVIEW

ABSTRACT Objective: to identify what factors are connected to adolescent adherence to the vaccination against Human Papillomavirus. Method: integrative developed using the following data base: Medical Literature Analysis and Retrieval System Online and Web of Science, Cumulative Index to Nursing and Allied Health Literature, Literatura Latino-Americana e do Caribe em Ciências da Saúde (Latin-American and Caribbean Literature in Health Sciences), and Base de dados de Enfermagem (Nursing Database); using the descriptors and keywords: Papillomaviridae, immunization, vaccines. The final sample had 31 original articles. Result: Vaccine adherence predictors were identified as: knowledge about virus infection risk, vaccination and its benefits; cervical cancer and genital warts prevention; sexual activity; being over 14 years old; mothers’ intention to adhere to vaccination; mother-child communication about sexually transmitted infections, contraception and condoms; vaccination offered in school; recommendation by teachers and health professionals; vaccine safety and effectiveness. Conclusion: Evidence points towards the necessity to redesign the presentation strategy of the vaccine, because despite the cultural differences among the countries where the studies were carried out, it is noticeable that society shelters adolescents aged from 10 to 14 years old, considering it early for sexual initiation and presenting difficulties to broach sexuality-related topics with children.

Factors associated with Human Papilloma Virus (HPV) vaccine recommendation by physicians in Lebanon, a cross-sectional study

Persistent Human Papilloma Virus (HPV) infection is associated with the development of cervical cancer, a leading cause of female death worldwide. In Lebanon, cervical cancer is the 6th most common cancer amongst girls and women aged 14-44 years. Cervical cancer is preventable through HPV vaccination; however, Lebanon does not include HPV vaccination in its national routine vaccination schedule. Hence, physician recommendation is key for patient vaccine uptake. We conducted a cross-sectional study in Beirut, Lebanon to assess factors affecting physician recommendation regarding HPV vaccination. Physicians practicing in Obstetrics and Gynecology (OBGYN), Pediatrics, Family Medicine and Infectious Diseases were included in the study. In total, 228 physicians completed the survey (28.79% response rate). The survey consisted of a set of demographic and HPV knowledge questions along with clinical vignettes. The vignettes presented theoretical patients who differed in gender, age, sexual activity, social background and whether the patient presented with his mother or not. The results show that physicians tend to recommend the vaccine more commonly for vignettes presenting female patients, with an Adjusted Odds Ratio (AOR) of 6.8. Also, physicians were more likely to recommend the vaccine for vignettes with patients coming from a non-conservative background (AOR = 2.1), vignettes where patients claim to be sexually active (AOR = 2.7) and vignettes where patients presented with their mother (AOR = 1.4). Physicians tend to recommend the vaccine less in vignettes with married patients (AOR = 0.5). Physicians with higher knowledge scores recommended the vaccine more often (AOR = 3.4). Overall, OBGYN physicians recommended the vaccine less than pediatricians (AOR = 0.5). These results show that Lebanese physicians' recommendations rely on factors external to international guidelines. The results also highlight the importance of knowledge in adequate patient consultation. Thus, improved physician awareness towards international guidelines and physician education regarding HPV vaccination is essential in order to improve patient care in Lebanon.