Knowledge, Attitudes, and Practices among Saudi Women regarding Cervical Cancer, Human Papillomavirus (HPV) and Corresponding Vaccine

Reasons why Saudis may or may not accept the human papillomavirus (HPV) vaccine to prevent cervical cancer are unknown and may range from material circumstances and lack of education to cultural beliefs and values. This study explores Saudi women's understanding of the importance of the HPV vaccine through a qualitative and in-depth exploration of the topic. It is hoped that results of this work will enable healthcare providers to develop effective educational materials and interventions tailored to Saudi women.

For the study, 9 focus groups were formed in Riyadh City, Saudi Arabia, for 77 women between the ages of 18 and 45 years old (many of them were either eligible for the HPV vaccine or mothers of young girls), and face-to-face interviews were conducted among 58 healthcare providers - some of whom were non-physicians.

Focus group discussions revealed a lack of knowledge and awareness concerning cervical cancer, HPV, and the HPV vaccine among the Saudi women residing in Riyadh. Only women who initially claimed some knowledge concerning HPV declared knowing about the HPV vaccine. No focus group participants had received the HPV vaccine, and only 2 women (2.6%) mentioned they had been informed about the vaccine by their healthcare provider.

Women from the focus groups expressed that cervical cancer screening was unnecessary because they considered themselves not at risk for developing cervical cancer due to exhibiting no signs and symptoms. After hearing claims about HPV transmission and the HPV vaccine from other participants, many of the conversations among women centred on the fact that the Saudi Arabian population is religious and conservative and that sexually transmitted diseases are less likely to occur. This culturally relevant claim was expressed by one participant who stated "...I don't see the point of vaccinating the girls, when they are not married, and we do not have behaviors and practices that make us need it....we are a conservative society and our religion protects us from having relations before marriage...", and another noted, "...Maybe it is a good idea to give the vaccine immediately before marriage and never for young girls....but we need to know more about it....no one told us anything..."

Barriers to screening for cervical cancer and the HPV vaccine cited by focus group participants included: lack of information about cervical cancer, poor patient-provider communication, and neglect of the pap smear due to lack of time, fear, being a virgin, and/or not wanting to undergo an invasive procedure. One woman said, "many women in our communities go to the doctor only when they are sick....many women need to wait for their husbands or fathers to take them..." On this note, one mother of three girls stated: "...the doctor need[s] to tell my husband about the vaccine, and that the girls need it....I can't make the decision by myself....he has to agree....he will never accept if he knows what I just heard here....it is a problem..."

One common issue was concern about cultural and social factors, including attitudes about prevention from sexually transmitted diseases in a country where such discussions are prohibited, lack of privacy for those requesting the HPV vaccine, and concern about the withholding of information regarding vaccine safety and side effects.

In fact, lack of information regarding the HPV vaccine was a persistent obstacle described throughout the study. However, due to the guided discussions during focus groups, many women reportedly started to listen and understand the information concerning HPV from the few women who knew about it. Women were consistently saying that their healthcare providers need to tell them about such health issues, describe how it affects them, and advise them on what to do.

Approximately half (53.3%) of the healthcare providers - other than physicians - did not know about the causes of cervical cancer, and no more than 16.7% linked it to HPV. Approximately 30% of these healthcare providers did not know about methods of prevention; however, as many as 70% mentioned screenings as a method for early detection. Half of the healthcare providers claimed not having any knowledge regarding HPV, and knowledge concerning the HPV vaccine was very low (36.7%). After hearing few details concerning the HPV vaccine, the most common response to the perceived barriers of its intake among this group of women in healthcare was "...not knowing about it..." (40%), "...unavailability in the healthcare facilities..." (36.7%), and "...lack of guidelines and recommendations for the vaccine..." (26.7%). Approximately 56.7% of healthcare providers insisted that even if the vaccine was available, there is religious and cultural resistance to its administration.

Specifically, one nurse stated, "...there is no need for this kind of vaccine in our culture....this is a conservative society....we have to be careful about what we are preaching....are we encouraging promiscuity by giving the vaccine?". Another healthcare provider said, "I think may be because the topic is sensitive and not easy to talk about, I should have information to read about it or give to my patients, it will be easier to understand and I will be more convinced about the vaccine, and maybe I will give it to my daughters or even recommend it....privacy is a big issue..." When healthcare providers were asked if they would administer the vaccine to their children, approximately half of them said that they would.

None of the physicians who were interviewed has provided counseling regarding HPV, and they attributed this lack in practice due to the sensitivity of the topic in an environment that discourages open discussions about sexually transmitted diseases. Physicians were convinced that the lack of knowledge concerning cervical cancer and HPV among the general population and the healthcare community, in addition to the sensitive nature of the topic, were barriers in their practice. The majority of the physicians (75%) said that education related to cervical cancer and HPV was a necessity among the general population and the healthcare community in Saudi Arabia. A total of 42.9% of physicians suggested that social media could promote cervical cancer screening and foster information dissemination regarding HPV and the HPV vaccine. However, few physicians suggested that printed material could be distributed in healthcare centres and waiting rooms of different clinics and hospitals due to the sensitivity of the topic and cultural bias against publicly discussing sexually transmitted diseases.

Based on these findings, the researchers conclude that it is important to enhance the role of primary healthcare facilities, private practices, and government offices to increase the level of knowledge and awareness of cervical cancer and screening methods among Saudi women and to provide the accepted screening facilities. In many settings, obstetrician and gynaecologists, family medicine practitioners, and nurses are considered the backbone of primary healthcare; thus, they should be at the forefront of making the services available to the communities by informing and encouraging women to make use of cervical cancer screening services.

Future studies could clarify the variation of reasons and attitudes of Saudi women, with a clear correlation of the potential associated factors, such as education, cultural, and religious issues. In addition, a framework for creating targeted educational interventions to improve cervical cancer knowledge and rates of Pap test screening among women could be established. Such interventions would need to address the seriousness and heightened risk of susceptibility to cervical cancer as well as consider the various facilitators, barriers, and cultural and individual beliefs specific to women in this country.