Knowledge about cervical cancer and

awareness about human papillomavirus

vaccination among medical students in
Jordan
Mervat M. Alsous1 , Ahlam Ali2 , Sayer Al-Azzam3 , Reema Karasneh4 and
Haneen Amawi1
1
Department of Clinical Pharmacy and Pharmacy Practice, Faculty of Pharmacy, Yarmouk University, Irbid,
Irbid Governorate, Jordan
2
Medical Biology Centre, School of Medicine, Dentistry and Biomedical Sciences, Queen’s University Belfast,
Belfast, United Kingdom
3
Department of Clinical Pharmacy, Faculty of Pharmacy, Jordan University of Science and Technology, Irbid,
Irbid Governorate, Jordan
4
Department of Basic Medical Sciences, Faculty of Medicine, Yarmouk University, Irbid, Irbid Governorate,
Jordan

ABSTRACT
Objectives. To assess the knowledge about cervical cancer and HPV infection and the
awareness towards and perceived barriers of HPV vaccination amid medical students
in Jordan.
Methods. The present study is a cross-sectional survey that was conducted for a period
of three months in the College of Medicine at six different universities in Jordan.
Third-year to sixth-year students from these medical colleges in Jordan were invited to
participate in the study.
Results. There were 504 students that took part in the study with 42.3% being males
and 57.7% females. The mean knowledge score of students in our survey was 21.4 ± 4.4
out of 34, which was categorized as a moderate level of knowledge regarding cervical
cancer and HPV. Only 40.5% knew about the availability of the HPV vaccine in Jordan,
Submitted 12 March 2021 and 65.9% accepted the idea that it is necessary to introduce the HPV vaccine for school
Accepted 24 May 2021 girls in Jordan.
Published 17 June 2021 Conclusions. This study highlights that there is inadequate knowledge about cervical
Corresponding author cancer and its screening among medical students in Jordan. Despite the limited
Mervat M. Alsous, awareness about the HPV vaccine among the study’s participants, there is a favorable
mervat.alsous@yu.edu.jo
opinion towards the introduction of the vaccine for school girls in Jordan. The data
Academic editor provide a benchmark on the level of knowledge about cervical cancer and awareness
Katherine Mitsouras
about HPV, which can be used to formulate an effective awareness program.
Additional Information and
Declarations can be found on
page 13
Subjects Gynecology and Obstetrics, Oncology, Public Health, Women’s Health, Science and
DOI 10.7717/peerj.11611 Medical Education
Keywords Cervical cancer, Jordan, Knowledge, Medical students, Human Papillomavirus,
Copyright Vaccine
2021 Alsous et al.

Distributed under
Creative Commons CC-BY 4.0

OPEN ACCESS

How to cite this article Alsous MM, Ali A, Al-Azzam S, Karasneh R, Amawi H. 2021. Knowledge about cervical cancer and awareness
about human papillomavirus vaccination among medical students in Jordan. PeerJ 9:e11611 http://doi.org/10.7717/peerj.11611
 INTRODUCTION
Cervical cancer (CC) is the fourth most common cancer in females with 270,000 women
dying from the disease annually; 90% of whom live in developing countries. In North
Africa and the Middle East, CC affects 19,500 women per year, leading to 9,930 deaths
annually. By 2035, these numbers are expected to double in this region unless effective
public health interventions are introduced (World Health Organization, 2020).
CC, caused by human papillomavirus (HPV), is the major cause of years of life lost
to cancer in the developing world. Since it affects women in their most productive years,
CC has a disturbing effect on the well-being of families (World Health Organization,
2019). In Jordan, current estimates indicate that 104 women are diagnosed with cervical
cancer every year and 61 die from the disease. Data on the HPV burden in the general
population of Jordan is not yet available (ICO/IARC Information Centre on HPV and
Cancer, 2018). However, in Western Asia, where Jordan is located, 72.4% of invasive
cervical cancers are attributed to certain types of HPV (World Health Organization, 2020).
Therefore, conducting comprehensive evaluations of HPV prevalence and examining
the knowledge, attitudes, and practices toward HPV vaccination will provide a clear
description of the situation in the region. Introducing a successful HPV vaccination
program will directly reduce morbidity and mortality from HPV types, improve women‘s
health, increase healthcare cost savings, and extend positive externalities on women’s
immediate communities.
Amongst all known risk factors, persistent infection from high-risk HPV plays a
considerable role in the pathogenesis of CC. The available screening tests for cervical
cancer include conventional and liquid-based cytologic tests (i.e., Pap tests) while the most
common test to detect HPV is to use a polymerase chain reaction (PCR) assay (Gargano et
al., 2017). Almost all cases of CC are attributed to HPV, with subtypes 16 and 18 accounting
for more than half of the CC cases worldwide (Schiffman & Castle, 2003; Trottier & Franco,
2005; Franco & Harper, 2005; Munoz et al., 2003; Lee & Chan, 2012). According to the
International Agency for Research on Cancer (IARC), ten additional HPV types (31, 33,
35, 39, 45, 51, 52, 56, 58, and 59) are associated with cervical cancer as they have adequate
evidence of carcinogenicity in humans. On the other hand, other HPV types, including
types 6 and 11, can cause genital warts, benign or low-grade cervical cell changes, and
recurrent respiratory papillomatosis (Gargano et al., 2017).
Successful achievements in basic and clinical research have expanded the possibilities of
CC prevention by introducing HPV testing as part of the screening technology and, most
importantly, by the production of efficacious prophylactic HPV vaccines (Franco & Harper,
2005). It is established that well-organized cervical screening programs or widespread good
quality cytology can reduce CC incidence and mortality. Diagnostic screening programs
for HPV lesions are generally available in the developed countries. However, all Middle
East countries including Jordan do not have a national CC screening program due to the
lack of public health policy, professional and general education, clinical settings, financial
resources, and media awareness. It is noteworthy that most female cancer awareness
campaigns in the Middle East are mainly focused on breast cancer (Jumaan et al., 2013).

Alsous et al. (2021), PeerJ, DOI 10.7717/peerj.11611 2/17

 The first vaccine against HPV for the primary prevention of CC was licensed in 2006
by the Food and Drug Administration (FDA) of the United States of America (USA).
Currently, two prophylactic vaccines against HPV are registered: quadrivalent Gardasil
(Merck, USA) and bivalent Cervarix (GlaxoSmithKline, Belgium). Both vaccines have
good profiles for efficacy in preventing HPV infection and are well tolerated. Published
studies have recognized a high efficacy of over 92% against precancerous lesions among
women (World Health Organization, 2009). However, the uptake of these vaccines has been
slow in the extended Middle East and North Africa regions due to several factors such as
financial limits, weak infrastructure for adolescent vaccine delivery, lack of reliable data on
the burden of HPV disease, and competition with high priority vaccines. Other barriers
include religious and cultural sensitivities as the vaccines are given to prevent a sexually
transmitted disease in young girls.
Several studies, mostly from developed countries, have demonstrated that the knowledge
about HPV infection and the acceptability of HPV vaccines amongst health care
professionals and the general public vary from low to high (Chawla, Chawla & Chaudhary,
2016; Warner et al., 2017; Pereira et al., 2019; Sherman et al., 2020). Recommendation of
HPV immunization by physicians has been recognized as one the most significant factors
in the individual’s willingness to receive the vaccine. Updated knowledge about the HPV
vaccine and the elimination of any barriers to prescriptions among physicians are the main
determinant factors (Riedesel et al., 2005; Pandey et al., 2012).
Physicians can play an imperative role in circulating knowledge about CC and the
available preventive vaccines. Therefore, the awareness of physicians and medical students
will greatly impact the success of CC prevention. The awareness programs should focus on
family physicians and gynecologists depending on the known immunizer in each country.
Targeted community education that responds to concerns about the HPV vaccine has
proven to be effective (Leung et al., 2019). It is therefore important to enhance promotion,
communication, and social mobilization strategies to increase awareness among decision
makers and demand among the population. The strategy should include several companion
organizations in the communities such as non-governmental organizations, women’s
groups, religious leaders, and professional organizations.
The objectives of this study were to evaluate the knowledge about CC and HPV infection
and awareness towards and perceived barriers of HPV vaccination among medical students
in Jordan who have the essential role as health care providers to raise community awareness
and to modify population behavior. This is the first time in Jordan that the assessment of
their knowledge about CC and HPV is being done.

METHODS
Study design and purpose
The present study is a cross sectional survey that was designed to investigate the knowledge
about CC and awareness about the HPV vaccine among medical students in Jordan.

Alsous et al. (2021), PeerJ, DOI 10.7717/peerj.11611 3/17

 Study participants and ethical considerations
The protocol of the study was approved by the Scientific Research Committee at Yarmouk
University. The study was conducted after obtaining ethical approval from the Institutional
Review Board (IRB) of Jordan University of Science and Technology (JUST) and King
Abdulla University Hospital (KAUH), Irbid, Jordan (13/128/2019).
The questionnaire was distributed utilizing an electronic format, through Google Forms.
The link to the survey was shared with medical students in six universities in Jordan. The
questionnaire was prefaced by a page explaining the nature and objectives of the study and
the voluntary nature of participation with a consent statement if they would like to take
part in the study. Participants who completed the questionnaire gave electronic informed
consent by declaring their acceptance to fill out the questionnaire. The questionnaire was
terminated automatically if participants declined to take part. This procedure was approved
by the IRB committee.
The participants were assured that the outcomes of the research would not be used
for routine appraisal of the participants. The individuals were requested to complete the
questionnaire without textbooks or consulting materials.
The study was conducted for a period of three months in the College of Medicine at
six different universities in Jordan. Third-year to sixth-year medical students from these
medical colleges in Jordan were invited to participate in the study.

Study instruments
The study questionnaire was developed by authors after an extensive review of literature.
A pre-validated questionnaire, consisting of items modified from questionnaires in
other studies (Pandey et al., 2012; Aljuwaihel et al., 2013) was used. The questionnaire
was reviewed by the authors and then subjected to pilot testing by 30 participants to ensure
the clarity of the questions, which resulted in several minor amendments.
The final version of the questionnaire consisted of three parts. The first one was about
the demographic information of participants which included age, gender, year of study,
and average monthly income. The second part assessed the knowledge of participants about
CC and HPV. Finally, the third part assessed the participants’ awareness and acceptance of
HPV vaccination.
The knowledge of the students about CC was evaluated using 14 multiple choice
questions with 34 statements related to disease etiology, risk factors, clinical features, and
screening recommendations according to the World Health Organization (WHO). Each
answer was scored as incorrect or correct. The respondent was given a zero point for each
wrong answer and one point for each correct answer.
The total knowledge score was calculated for each participant out of 34. Participants
were categorized to have poor, moderate, and good knowledge if their score was 0–17,
18–25, and 26–34, respectively.
Regarding respondents’ awareness about HPV vaccination, this part consisted of seven
questions. Each question was scored out of two points. A poor awareness level was allocated
to the medical students with a maximum 39% of awareness mean score (0–5 points), an

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 average awareness to those with at a 40–69% of awareness mean (6-9 points), and a good
awareness level to people with over 70% of awareness mean (10-14 points).
The last three questions in the questionnaire assessed the acceptance of HPV vaccination
among medical students in Jordan, the perceived barriers of HPV vaccination, and their
source of information about it.

Statistical analysis
Data was analyzed using SPSS software version 24. Descriptive data was expressed as
frequencies and percentages. Chi square was used to analyze significant differences between
categorical variables. Student’s t-tests were used to compare the means between two groups.
Analysis of Variance (ANOVA) was used to compare the means between three or more
groups. Analysis of Variance (ANOVA) was used to compare the means between three
or more groups. The questionnaire’s internal consistency and reliability was assessed by
measuring Cronbach’s alpha coefficient (α), values ≥ 0.70 were considered adequate.
All p-values were two sided and any p-value of less than 0.05 was considered statistically
significant.

Sample size calculation

Around 9,218 students are currently enrolled to study medicine at Jordanian
universities (Goussous, 2016). The sample size was calculated utilizing the online Raosoft
software sample size calculator. The minimum required sample size assuming a 95%
confidence level, 50% recruitment rate, 5% margin of error, and a maximal sample size of
6,000 students would be 362 participants.

RESULTS
Demographic characteristics
The number of total responses was 508, with 4 students disagreeing to take part in the study
and 504 of the students completing the questionnaire. Recruited students were from all
six medical colleges in Jordan including Yarmouk University (33.3%), Jordan University
of Science and Technology (25.0%), University of Jordan (16.1%), Hashemite University
(13.5%), Mutah University (6.3%), and Albalqa University (5.8%). About 42.3% were
males and the mean age was 22.3 ± 1.6 years. Table 1 shows participants’ demographic
characteristics. The questionnaire was deemed reliable based on the result of Cronbach
alpha coefficient (0.759) and its 95% CI (0.728−0.788).

Knowledge assessment about CC

Knowledge was assessed using 14 questions with a total of 34 points related to disease
diagnosis, risk factors, symptoms, and relation to HPV. In regards to knowledge about
CC, the mean knowledge score for students was 21.4 ± 4.4. Table 2 shows the proportion
of students who correctly answered questions related to CC and HPV. Most participants
knew that CC is caused by an infection (n = 413, 81.9%) and that HPV is responsible for a
wide array of diseases including CC (n = 455, 90.3%).
Concerning its epidemiology, 60.7% of students answered correctly that CC is a leading
cause of gynecological cancer.

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 Table 1 Participant demographic data (n = 504).

Age (Year), Mean ± SD 22.3 ± 1.6

Age range 20–29
Gender, N (%)
Male 213 (42.3)
Female 291 (57.7)
University, N (%)
All Public Universities in Jordan 504 (100)
Level of Education, N (%)
3rd year 131 (26.0)
4th year 63 (12.5)
5th year 113 (22.4)
6th year 197 (39.1)
Know someone with cervical cancer, N (%)
Yes 22 (4.4)
No 482 (95.6)
Nationality, N (%)
Jordanian 454 (90.1)
Not Jordanian 50 (9.9)
Place of living, N (%)
Urban 395 (78.4)
Rural 109 (21.6)
Family Income JD, N (%)
<500 33 (6.5)
501–1000 128 (25.4)
1001–1499 111 (22.0)
1500–2000 94 (18.7)
>2000 138 (27.4)
Notes.
N, number; SD, standard deviation.

Student knowledge about the clinical features of CC and percentages of correct answers
were 35.5% for no symptoms and 80.6% for bleeding of the vagina. The percentages of
students who were aware that fever, itching, and swelling of the cervix were not among
the clinical features of the disease were 87.5%, 70.0%, and 54.85% respectively. The mean
percentage knowledge score of this part was 59.7% ± 16.5%.
Concerning knowledge about CC screening and vaccine, 26.4% of participants knew
correctly that women aged 45–60 years should screen according to WHO once every 5
years. On the other hand, 76.6% were aware that there is a vaccine that protects from CC.
The mean percentage knowledge score of this part was 55.2% ± 25.9%.
Most students (90.3%) knew that HPV is responsible for a wide array of diseases
including CC. Most of them (88.9%) were aware that HPV is transmitted sexually. About
two thirds of students were aware that HPV subtypes 6 and 11 are commonly associated
with genital warts (65.1%) and HPV subtypes 16 and 18 are commonly associated with CC
(70.4%). The mean percentage knowledge score of this domain was 67.9% ± 21.5%.

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 Table 2 Participant’s knowledge about cervical cancer (n = 504).

Question Correct answer Wrong answer

N (%) N (%)
Epidemiology of cervical cancer
1. Is Cervical cancer the leading cause among gynecological 306 (60.7) 198 (39.3)
cancer?1
2. The cause of cervical cancer 413 (81.9) 91 (18.1)
Mean % score = 71.3% ± 30.8%
3. Risk factors of cervical cancer
- Multiple sexual partner 422 (83.7) 82 (16.3)
-Infection with HPV 482 (95.6) 22 (4.4)
-Early age of first coitus 245 (48.6) 259 (51.4)
-Smoking 301 (59.7) 203 (40.3)
-Family History of disease 324 (64.3) 180 (35.7)
-Poor Hygiene 201 (39.9) 303 (60.1)
-Old age (False) 366 (72.6) 138 (27.4)
-Contraception 178 (35.3) 326 (64.7)
-Nulliparity (False) 426 (84.5) 78 (15.5)
Mean % score = 64.9% ± 21.0%
4. Clinical features of cervical cancer
-No symptom 179 (35.5) 325 (64.5)
-Lower pelvic pain 200 (39.7) 304 (60.3)
-Bleeding per vagina 406 (80.6) 98 (19.4)
-Fever (False)* 441 (87.5) 63 (12.5)
-Discharge per vagina 318 (63.1) 186 (36.9)
Itching (False)* 353 (70.0) 151 (30.0)
-Weight loss 264 (52.4) 240 (47.6)
-Swelling of cervix (False)* 276 (54.8) 228 (45.2)
-Anemia 202 (40.1) 302 (59.9)
-Post coital bleeding 370 (73.4) 134 (26.6)
Mean % score = 59.7% ± 16.5%
Cervical cancer screening
5. Time of screening for women aged 25–44 years 180 (35.7) 324 (64.3)
6. Time of screening for women aged 45–60 years 133 (26.4) 371 (73.6)
7. Is there a vaccine to protect from cervical cancer?1 386 (76.6 118 (23.4)
2
8. Does the vaccine protect against all cervical cancer? 332 (65.9) 172 (34.1)
9. Girls who have been vaccinated will need to attend for 359 (71.2) 145 (28.8)
cervical cancer screening1
Mean % score = 55.2% ± 25.9%
Knowledge about HPV
10. Is HPV responsible for a wide range of diseases 455 (90.3) 49 (9.7)
including cervical cancer?1
11. Transmission of HPV 448 (88.9) 56 (11.1)
12. The Technique available for HPV detection
- Pap smear 376 (74.6) 128 (25.4)

(continued on next page)

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 Table 2 (continued)
Question Correct answer Wrong answer
N (%) N (%)
- Biopsy 169 (33.5) 335 (66.5)
- PCR 218 (43.3) 286 (56.7)
- Blood (False)* 390 (77.4) 114 (22.6)
13. HPV subtypes 6 and 11 are commonly associated with 328 (65.1) 176 (34.9)
Genital warts1
14. HPV subtypes 16 and 18 are commonly associated with 355 (70.4) 149 (29.6)
Cervical carcinoma1
Mean % score = 67.9% ± 21.5%
Overall % Knowledge score = 63.0% ± 12.9%
Notes.
1
Yes.
2
No.
*Student get one point if the answer for this statement is false.

The association of socioeconomic factors with knowledge score was assessed using t -test
and analysis of variance and there was a significant difference between the mean knowledge
score for male students 20.6 ± 4.7 compared to female students 22.0 ± 4.0 (p-value =
0.001). The knowledge score was significantly associated with the year of study with the
highest mean score among students in the sixth year with 23.6 ± 3.5 (p-value < 0.001)
and the least mean score among third-year students 18.4 ± 4.2. There was no significant
association between family income, place of living, or nationality and knowledge score
(p-value >0.05).

Awareness about HPV vaccine and acceptance

Regarding student’s awareness about the HPV vaccine, only 40.5% knew about the
availability of the HPV vaccine in Jordan, 71.4% were aware that the HPV vaccine should
be given at an age between 11 and 29, and about half (54.0%) knew that it could be given
to boys also. There were 21.0% that were familiar that girls or women do not need to
be screened for HPV before getting vaccinated and that CC protection provided by the
HPV vaccine is 70%. Less than one third of the students (30.8%) were aware that the HPV
vaccine cannot be given to a woman already having HPV infection while 19.0% of students
knew that three doses are required for protection in women. The mean awareness score
of students about the HPV vaccine was 5.7 ± 2.8 with a range 0-13 which is classified as
average awareness (Table 3).
The awareness score about the HPV vaccine was significantly associated with the year
level of study as there was a significant difference between the mean awareness score for
students in the sixth year with 6.3 ± 2.8 (p-value < 0.001). On the other hand, the awareness
score was not associated with all other demographic data (p-value > 0.05) as shown in
Table 4.
There were 332 students (65.9%) that accepted the idea that it is essential to introduce
the HPV vaccine for schoolgirls in Jordan. The association of demographic data with the
acceptance of introducing the HPV vaccine was assessed using chi-square analysis, and it
was higher among students in the sixth year at 71.1% (p-value = 0.005). On the other hand,

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 Table 3 Participant’s awareness and acceptance of HPV vaccination (n = 504).

Question Correct answer Wrong answer

N (%) N (%)
1. Is the HPV vaccine available in Jordan?1 204 (40.5) 300 (59.5)
-Yes (2 points) 204 (40.5)
-No 64 (12.7)
-Don’t know 236 (46.8)
2. Which age group HPV vaccine should be given? 443 (87.9)* 51 (12.1)
-(0–10) Years 48 (9.5)
-(11–29) Years (2 points) 360 (71.4)
-(30–50) Years (1 point) 83 (16.5)
-(51) years and above 13 (2.6)
3. Can HP vaccine be given to boys?1 272 (54.0) 132 (46.0)
-Yes (2 points) 272 (54.0)
-No 50 (9.9)
-Don’t know 182 (36.1)
4. Do girls/women need to be screened 109 (21.6) 395 (78.4)
for HPV before getting vaccinated?2 237(47.0)
-Yes 109 (21.6)
-No (2 points) 158 (31.4)
-Don’t know
5. Can HP vaccine be given to a 155 (30.8) 349 (69.2)
woman already having HPV infection?2 141 (28.0)
-Yes 155 (30.8)
-No (2 points) 208 (41.2)
-Don’t know
6. How many doses of HPV vaccine 96 (19.0) 408 (81.0)
are required for protection in women? 49 (9.7)
-One 70 (13.9)
-Two 96 (19.0)
-Three (2 points) 8 (1.6)
-Four 281 (55.8)
-Don’t Know
7. Cervical cancer protection provided by HPV vaccine is: 275 (54.6)* 263 (45.4)
-100% 21(4.2)
-90% (1 points) 135(26.8)
-70% (2 point) 106 (21.0)
-50% (1 point) 34 (6.7)
-Don’t know 208 (41.3)
Overall % awareness score = 40.5% ± 19.8% 332 (65.9) 172 (34.1)
Notes.
1
Yes.
2
No.
*Number of students who had a score of 1 or 2 points.

the acceptance of introducing the vaccine was not associated with all other demographic
data nor with the knowledge score or awareness score (p-value > 0.05).

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Alsous et al. (2021), PeerJ, DOI 10.7717/peerj.11611

Table 4 Knowledge and awareness about HPV vaccine scores and acceptance stratified by participants’ characteristics (n = 504).

Knowledge score Awareness score Acceptance of the vaccine

Variable N (%) Mean SD P-value Mean SD P-value Yes No Don’t know P-value
N (%) N (%) N (%)
Gender
213 (42.3) 20.6 4.7 <0.001* 5.6 2.7 0.626 138 (64.8) 39 (18.3) 36 (16.9) 0.389
Male
291 (57.7) 22.0 4.0 5.7 2.8 194 (66.7) 60 (20.6) 37 (12.7)
Female
Place of living
395 (78.4) 21.5 4.2 0.266 5.7 2.8 0.959 261 (66.1) 80 (20.2) 54 (13.7) 0.551
Urban
109 (21.6) 21.0 5.0 5.7 2.7 71 (65.1) 19 (17.4) 19 (17.4)
Rural
Nationality
454 (90.1) 21.5 4.4 0.596 5.6 2.7 0.431 297 (65.4) 94 (20.7) 63 (13.9) 0.140
Jordanian
50 (9.9) 21.1 4.6 6.0 3.0 35 (70.0) 5 (10.0) 10 (20.0)
Non-Jordanian
Know someone with
22 (4.4) 21.9 5.2 0.638 6.2 3.5 0.373 12 (54.6) 3 (13.6) 7 (31.8) 0.060
Cervical Cancer
482 (95.6) 21.4 4.4 5.6 2.7 320 (66.4) 96 (19.9) 66 (13.7)
Yes
No
University
168 (33.3) 21.8 4.3 <0.001* 5.9 2.9 0.272 116 (69.0) 30 (17.9) 22 (13.1) 0.644
Yarmouk University
81 (16.1) 22.4 4.4 5.7 2.6 54 (66.7) 15 (18.5) 12 (14.8)
University of Jordan
32 (6.3) 21.4 4.5 5.2 2.6 20 (62.5) 7 (21.9) 5 (15.6)
Mutah University
126 (25.0) 20.4 4.4 5.4 2.8 82 (65.1) 26 (20.6) 18 (14.3)
The Jordan University of
29 (5.8) 18.7 4.0 5.2 2.6 13 (44.8) 8 (27.6) 8 (27.6)
Science and Technology
68 (13.5) 21.4 4.0 6.1 2.8 47 (69.1) 13 (19.1) 8 (11.8)
Albalqa University
The Hashemite University
Year Level
131 (26.0) 18.3 4.2 <0.001* 5.1 2.6 <0.001* 90 (68.7) 16 (12.2) 25 (19.1) 0.005*
Third year
63 (12.5) 20.0 3.1 5.3 2.6 39 (61.9) 12 (19.0) 12 (19.0)
Fourth year
113 (22.4) 22.1 4.3 5.4 2.8 63 (55.7) 30 (26.6) 20 (17.7)
Fifth year
197 (39.1) 23.6 3.5 6.3 2.8 140 (71.1) 41 (20.8) 16 (8.1)
Sixth year
Family Income
33 (6.5) 22.0 5.4 0.502 6.2 3.0 0.587 19 (57.6) 5 (15.2) 9 (27.3) 0.411
<500
128 (25.4) 21.0 4.4 5.6 2.9 87 (68.0) 26 (20.3) 15 (11.7)
501–1000
111 (22.0) 21.1 4.5 5.5 2.8 77 (69.4) 22 (19.8) 12 (10.8)
1001–1499
94 (18.7) 21.7 4.4 5.9 2.7 62 (65.9) 20 (21.3) 12 (12.8)
1500–2000
138 (27.4) 21.8 4.0 5.6 1.7 87 (63.0) 26 (18.8) 25 (18.1)
>2000
Notes.
*P<0.05.
10/17
 Figure 1 Obstacle preventing form receiving or advice taking HPV vaccination.
Full-size DOI: 10.7717/peerj.11611/fig-1

Figure 2 Sources of knowledge and information on HPV vaccination.

Full-size DOI: 10.7717/peerj.11611/fig-2

Among the obstacles that prevent the receipt of the vaccine or advice about taking HPV
vaccination were high cost (53.8%) and inadequate information about the vaccine (62.5%)
as shown in Fig. 1.
Figure 2 presents the sources of information about HPV vaccination which were
reported by students as medical school teaching being the main source of information
(87.7%) followed by internet sources (33.3%) and books (23.2%).

DISCUSSION
In the current study, general CC and HPV knowledge was moderate which was similar to
the result of a study done with medical, dental, and nursing students in South India (Shetty
et al., 2019). Most of participants in the present study were aware that CC is caused by
an infection and that the HPV infection can lead to CC. These results show adequate
knowledge about CC epidemiology and are similar to other studies conducted with health
care professionals (Sherman et al., 2020; Almazrou, Saddik & Jradi, 2019).

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 In our study, most medical students were able to recognize that infection and risky sexual
practices are common risk factors for CC; these results were similar to other studies (Jolly et
al., 2017; Melan et al., 2017; Goldsmith et al., 2007). However, some students had incorrect
information that old age and nulliparity were among the risk factors of CC. In the current
study, a high percentage of participants were unaware that lower pelvic pain and anemia
are common clinical features of CC, and some of them wrongly thought that fever, itching,
and swelling of the cervix were symptoms of CC. This highlights the need to increase
the consciousness about CC among physicians who act as the main source of health
information to their patients.
Less than half of students correctly reported PCR as a test used for the detection of HPV
infection and knew the appropriate frequency of CC screening in women (i.e., women aged
25–44 years should be screened every three years and women aged 45–60 years should be
screened every 5 years). This showed an inadequacy of knowledge which is important as a
preventive measure for CC. In addition, the knowledge score was significantly associated
with gender and year of study and this was consistent with other studies where the score
was higher among female students (Hussain et al., 2014; Ngwenya & Huang, 2018) and
higher level of study (Tesfaye et al., 2019).
The HPV vaccine offers a major breakthrough to limit the global burden of
CC (Santhanes et al., 2018). Many studies have been conducted worldwide recently on the
knowledge, attitude, beliefs, and awareness about the HPV vaccine (Sherman et al., 2020;
Almazrou, Saddik & Jradi, 2019; Jradi & Bawazir, 2019; Maness et al., 2016; Kasymova,
Harrison & Pascal, 2019). In the current study, only 40.5% of medical students were aware
of the availability of the HPV vaccine in Jordan which protects from CC and about 20.0%
were aware that there is no need to screen girls before getting vaccinated. Also, 70% were
aware that CC protection is provided by the HPV vaccine. This could be due to the lack
of awareness and guidance campaigns in Jordan to shed light on the importance of this
vaccine, and it has not been introduced officially in the national vaccination program in
Jordan. In addition, topics about cervical cancer and the HPV vaccine are not sufficiently
addressed in the curricula of medical schools.
Less than one third of students were aware that the HPV vaccine cannot be given to a
woman already having the HPV infection, and 19% of students knew that the appropriate
number of doses of the HPV vaccine is three with an overall awareness score of 5.7 ± 2.8.
This indicates an inadequate awareness about the HPV vaccine which was similar to a
result from a study of university students in India (Gollu & Gore, 2021).
In the current study, about two thirds of students (65.9%) thought that it is important
to introduce the vaccine in school girls in Jordan which indicates a favorable acceptance
of using the vaccine in Jordan. Hoque (2016) indicated that most of the physicians in their
study reported that they intended to prescribe the HPV vaccine to patients as they expected
an important advantage from HPV vaccination.
In the present study, more than half of the students (62.5%) reported inadequate
information about CC and the HPV vaccine as an obstacle preventing the receipt of the
vaccine or advice about taking HPV vaccination. Our results were similar to a study
on medical students in India (Pandey et al., 2012). Therefore, it is recommended that

Alsous et al. (2021), PeerJ, DOI 10.7717/peerj.11611 12/17

 physicians should receive information about HPV from educational campaigns to improve
their communication practices for recommending HPV vaccination (Hswen et al., 2017).

STRENGTH AND LIMITATIONS OF THE STUDY

The high response rate and the inclusion of all medical colleges in Jordan enhance the
generalizability of our results. However, this is a cross sectional study and therefore causal
relationships between variables cannot be established. We could also not detect the response
rate as the questionnaire was distributed electronically. In addition, a systematic sampling
method must be used to identify respondents from each level, but a convenient sampling
method was used in the current research to reach the determined sample number. Our
study is considered a starting point for future studies on this sensitive topic exploring the
attitudes and barriers to vaccination among women in Jordan.

CONCLUSION
This study highlights insufficient knowledge about CC and its screening among medical
students in Jordan. Despite the limited awareness about the HPV vaccine among the
study’s participants, there is a favorable opinion towards the introduction of the vaccine
in school girls in Jordan. More emphasis should be placed on the medical curriculum
taught in undergraduate education. Suitable educational campaigns should be stratified
at hospitals along with workshops and seminars which highlight the importance of CC
screening in women and increase the awareness about HPV among physicians. Medical
students who are the future health care providers can educate their patients, address their
sensitive cultural concerns, and later increase the health seeking behavior in women in
Jordan especially if they are properly aware of CC and hence its burden reduced.

ACKNOWLEDGEMENTS
Thanks to all the members of the medical students who participated in this study.

ADDITIONAL INFORMATION AND DECLARATIONS

Funding
The authors received no funding for this work.

Competing Interests
The authors declare there are no competing interests.

Author Contributions
• Mervat M. Alsous conceived and designed the experiments, performed the experiments,
analyzed the data, prepared figures and/or tables, authored or reviewed drafts of the
paper, and approved the final draft.
• Ahlam Ali, Sayer Al-Azzam, Reema Karasneh and Haneen Amawi conceived and
designed the experiments, performed the experiments, authored or reviewed drafts of
the paper, and approved the final draft.

Alsous et al. (2021), PeerJ, DOI 10.7717/peerj.11611 13/17

 Human Ethics
The following information was supplied relating to ethical approvals (i.e., approving body
and any reference numbers):
The Institutional Review Board (IRB) of Jordan University of Science and Technology
(JUST) and King Abdulla University Hospital (KAUH), Irbid, Jordan approved this
research (13/128/2019).

Data Availability
The following information was supplied regarding data availability:
The data are available in the Supplemental Files.

Supplemental Information
Supplemental information for this article can be found online at http://dx.doi.org/10.7717/
peerj.11611#supplemental-information.

REFERENCES
Aljuwaihel A, Al-Jarallah A, Al-Busairi H, El-Shazly MK. 2013. Awareness of HPV and
cervical cancer vaccine among PHC physicians in Kuwait. Greener Journal of Medical
Sciences 3(4):152–159 DOI 10.15580/GJMS.2013.4.031813528.
Almazrou S, Saddik B, Jradi H. 2019. Knowledge, attitudes, and practices of Saudi
physicians regarding cervical cancer and the human papilloma virus vaccine. Journal
of Infection and Public Health 13(4):584–590.
Chawla PC, Chawla A, Chaudhary S. 2016. Knowledge, attitude & practice on human
papillomavirus vaccination: a cross-sectional study among healthcare providers. The
Indian Journal of Medical Research 144(5):741–749 DOI 10.4103/ijmr.IJMR_1106_14.
Franco E, Harper DM. 2005. Vaccination against human papillomavirus in-
fection: a new paradigm in cervical cancer control. Vaccine 23:2388–2394
DOI 10.1016/j.vaccine.2005.01.016.
Gargano J, Meites E, Watson M, Unger E, Markowitz L. 2017. Manual for the surveil-
lance of vaccine-preventable diseases. In: Chapter 5: Human Papillomavirus. Atlanta,
GA: Centers for Disease Control and Prevention.
Goldsmith MR, Bankhead CR, Kehoe ST, Marsh G, Austoker J. 2007. Information
and cervical screening: a qualitative study of women’s awareness, understanding
and information needs about HPV. Journal of Medical Screening 14(1):29–33
DOI 10.1258/096914107780154459.
Gollu AN, Gore CA. 2021. Knowledge, awareness and attitude of medical students
regarding HPV infection and HPV vaccination. Asian Pacific Journal of Cancer Care
6(1):41–46 DOI 10.31557/apjcc.2021.6.1.41-46.
Goussous S. 2016. 13,000 Jordanian studying medicine abroad. Jordan Times.
https://www.jordantimes.com/news/local/13000-jordanians-studying-medicine-
abroad%E2%80%99.

Alsous et al. (2021), PeerJ, DOI 10.7717/peerj.11611 14/17

 Hoque ME. 2016. Factors influencing the recommendation of the Human Papillomavirus
vaccine by South African doctors working in a tertiary hospital. African Health
Sciences 16(2):567–575 DOI 10.4314/ahs.v16i2.26.
Hswen Y, Gilkey MB, Rimer BK, Brewer NT. 2017. Improving physician recom-
mendations for HPV vaccination: the role of professional organizations. Sexually
Transmitted Diseases 44(1):42–47.
Hussain S, Nasare V, Kumari M, Sharma S, Khan MA, Das BC, Bharadwaj M.
2014. Perception of human papillomavirus infection, cervical cancer and
HPV vaccination in North Indian population. PLOS ONE 9(11):e112861
DOI 10.1371/journal.pone.0112861.
ICO/IARC Information Centre on HPV and Cancer. 2018. Jordan Human Papillo-
mavirus and Related Cancers, Fact Sheet. 2018. https://hpvcentre.net/statistics/reports/
JOR_FS.pdf.
Jolly PE, Mthethwa-Hleta S, Padilla LA, Pettis J, Winston S, Akinyemiju TF, Turner
HJ, Ejiawoko A, Brooks R, Preko L, Preko PO. 2017. Screening, prevalence, and
risk factors for cervical lesions among HIV positive and HIV negative women in
Swaziland. BMC Public Health 17(1):218 DOI 10.1186/s12889-017-4120-3.
Jradi H, Bawazir A. 2019. Knowledge, attitudes, and practices among Saudi women
regarding cervical cancer, human papillomavirus (HPV) and corresponding vaccine.
Vaccine 37(3):530–537 DOI 10.1016/j.vaccine.2018.11.065.
Jumaan AO, Ghanem S, Taher J, Braikat M, Al Awaidy S, Dbaibo GS. 2013.
Prospects and challenges in the introduction of human papillomavirus vaccines
in the extended Middle East and North Africa region. Vaccine 31:G58–G64
DOI 10.1016/j.vaccine.2012.06.097.
Kasymova S, Harrison SE, Pascal C. 2019. Knowledge and awareness of human papillo-
mavirus among college students in South Carolina. Infectious Diseases: Research and
Treatment 12:1178633718825077.
Lee A, Chan PKS. 2012. Interim result for school based cervical cancer education and
prevention programme. In: 50th anniversary multidisciplinary conference, The Hong
Kong paediatric society, Hong Kong. 17–19.
Leung SOA, Akinwunmi B, Elias KM, Feldman S. 2019. Educating healthcare providers
to increase human papillomavirus (HPV) vaccination rates: a qualitative systematic
review. Vaccine 100037.
Maness SB, Reitzel LR, Watkins KL, McNeill LH. 2016. HPV awareness, knowledge and
vaccination attitudes among church-going African-American women. American
Journal of Health Behavior 40(6):771–778 DOI 10.5993/AJHB.40.6.9.
Melan K, Janky E, Macni J, Ulric-Gervaise S, Dorival MJ, Veronique-Baudin J, Joachim
C. 2017. Epidemiology and survival of cervical cancer in the French West-Indies:
data from the Martinique Cancer Registry (2002–2011). Global Health Action
10(1):1337341 DOI 10.1080/16549716.2017.1337341.
Munoz N, Bosch FX, De Sanjose S, Herrero R, Castellsague X, Shah KV, Snijders PJF,
Meijer CJM. 2003. Epidemiologic classification of human papillomavirus types

Alsous et al. (2021), PeerJ, DOI 10.7717/peerj.11611 15/17

 associated with cervical cancer. New England Journal of Medicine 348:518–527
DOI 10.1056/NEJMoa021641.
Ngwenya D, Huang SL. 2018. Knowledge, attitude and practice on cervical cancer
and screening: a survey of men and women in Swaziland. Journal of Public Health
40(3):e343–e350 DOI 10.1093/pubmed/fdx174.
Pandey D, Vanya V, Bhagat S, Vs B, Shetty J. 2012. Awareness and attitude towards
human papillomavirus (HPV) vaccine among medical students in a premier medical
school in India. PLOS ONE 7:e40619.
Pereira JEG, Gomes JM, Costa ADS, Figueiredo FWDS, Adami F, Santos EFDS,
Sorpreso ICE, De Abreu LC. 2019. Knowledge and acceptability of the human
papillomavirus vaccine among health professionals in Acre state, western Amazon.
Clinics 74:e1166.
Riedesel JM, Rosenthal SL, Zimet GD, Bernstein DI, Huang B, Lan D, Kahn JA. 2005.
Attitudes about human papillomavirus vaccine among family physicians. Journal of
Pediatric and Adolescent Gynecology 18(6):391–398 DOI 10.1016/j.jpag.2005.09.004.
Santhanes D, Yong CP, Yap YY, San Saw P, Chaiyakunapruk N, Khan TM. 2018.
Factors influencing intention to obtain the HPV vaccine in South East Asian and
Western Pacific regions: a systematic review and meta-analysis. Scientific Reports
8(1):1–11.
Schiffman M, Castle PE. 2003. Human papillomavirus: epidemiology and public health.
Archives of Pathology & Laboratory Medicine 127:930–934
DOI 10.5858/2003-127-930-HPEAPH.
Sherman SM, Cohen CR, Denison HJ, Bromhead C, Patel H. 2020. A survey of
knowledge, attitudes and awareness of the human papillomavirus among healthcare
professionals across the UK. European Journal of Public Health 30(1):10–16.
Shetty S, Prabhu S, Shetty V, Shetty AK. 2019. Knowledge, attitudes and factors
associated with acceptability of human papillomavirus vaccination among under-
graduate medical, dental and nursing students in South India. Human Vaccines &
Immunotherapeutics 15(7–8):1656–1665 DOI 10.1080/21645515.2019.1565260.
Tesfaye ZT, Bhagavathula AS, Gebreyohannes EA, Tegegn HG. 2019. Knowledge and
awareness of cervical cancer and human papillomavirus among female students in
an Ethiopian University: a cross-sectional study. International Journal of Preventive
Medicine 10:198 DOI 10.4103/ijpvm.IJPVM_181_17.
Trottier H, Franco EL. 2005. The epidemiology of genital human papillomavirus
infection. Vaccine 24:S1–S15.
Warner EL, Ding Q, Pappas L, Bodson J, Fowler B, Mooney R, Kirchhoff AC, Kepka
D. 2017. Health care providers’ knowledge of HPV vaccination, barriers, and
strategies in a state with low HPV vaccine receipt: mixed-methods study. JMIR
Cancer 3(2):e12 DOI 10.2196/cancer.7345.
World Health Organization. 2009. WHO position on HPV vaccines Vaccine.
27(52):7236–7237.

Alsous et al. (2021), PeerJ, DOI 10.7717/peerj.11611 16/17

 World Health Organization. 2019. Human papillomavirus (HPV) and cervical cancer.
https://www.who.int/news-room/fact-sheets/detail/human-papillomavirus-(hpv)-and-
cervical-cancer.
World Health Organization. 2020. Cervical cancer. https://who.int/cancer/prevention/diagnosis-
screening/cervical-cancer/en/.

Alsous et al. (2021), PeerJ, DOI 10.7717/peerj.11611 17/17