Abstract
Introduction:
Cervical cancer is expected to become the second leading cause of female cancer mortality in low- and middle-income countries, with the majority of critical cases projected to occur in these regions by 2050. This study aimed to identify the prevalence and determinants of knowledge and attitudes toward cervical cancer prevention, including Pap smear uptake and human papillomavirus (HPV) vaccination, while highlighting actionable gaps for intervention.
Methods:
A cross-sectional study was conducted using an online structured questionnaire, administered to Lebanese women aged 18–50 years. A knowledge score (KS) was calculated from true-or-false questions on risk factors, symptoms, and prevention. An attitude score (AS) assessed the proportion of women with a positive attitude toward cervical cancer prevention.
Results:
Participants had a mean age of 28.5 years. The prevalence of women who had ever had a Pap smear was 18.6%, and HPV vaccination coverage was 17.9%. Bivariate analysis showed that HPV vaccination was significantly associated with younger age, being single, having a graduate degree, being a health care student/professional, perceiving income as sufficient, and never smoking. Binary logistic regression analysis indicated that only a KS above the mean and an AS above the mean remained significant predictors after adjustment. Physicians were the most influential incentive for vaccination, while lack of knowledge was the primary barrier.
Conclusion:
To improve HPV vaccination rates and reduce cervical cancer incidence in developing countries, strategies should focus on enhancing health care access and physician–patient communication. Targeted awareness campaigns addressing misconceptions and negative attitudes toward HPV vaccination are warranted to improve preventive practices and reduce disease burden.
Introduction
Cervical cancer remains a leading cause of death among women globally, with an estimated 604,000 new cases annually, more than half of which result in death. 1 It is the second leading cause of female cancer mortality in developing countries. 2 It is well known that cervical cancer caused by human papillomavirus (HPV) can be effectively prevented through regular screening for precancerous lesions and vaccination. 3 Even though 80% of HPV infections occur in high-income countries nowadays, it is in low- and middle-income countries that invasive cervical cancer is expected to rise by 2050 due to lack of screening and prevention. 4 Despite historically low HPV infection rates in developing countries, due to cultural conservatism, recent increases in premarital sexual activity among younger populations have led to higher infection rates. 5 This trend, compounded by cultural stigma surrounding screening and vaccination, inadequate health care infrastructure, political instability, and financial constraints, contributes to rising cervical cancer rates. 6
This situation also applies to Lebanon, where an increase in sexual activity has not been matched by a corresponding rise in HPV vaccination or screening rates. Screening remains a low priority and is predominantly “opportunistic,” with a reported rate of only 25%.7,8 Literature on HPV infection, cervical cancer knowledge, attitudes, and practices among Lebanese women is scarce, and available studies are often limited to specific population groups.9,10
This study aimed to assess knowledge related to cervical cancer, attitudes, and practices regarding Pap smear screening and HPV vaccination among Lebanese women. The relationship of relevant associated sociodemographic characteristics and lifestyle factors were also explored. Identifying gaps and misconceptions in current knowledge and attitudes will provide actionable recommendations to enhance prevention and improve HPV vaccination rates in Lebanon.
Materials and Methods
Study design
A cross-sectional study targeting Lebanese women aged between 18 and 50 years in the general population was conducted. Data were collected through a self-administered anonymous online questionnaire, adapted from previous questionnaires and disseminated in English and Arabic.10,11 The questionnaire was distributed via social media channels (WhatsApp, LinkedIn, Facebook, Instagram, etc.) to eligible participants and was shared on the different platforms via snowball sampling. The data collection took place from January 2023 until June 2024. Informed consent was obtained at the beginning of the survey. The study was approved by the LAU IRB committee (LAU.SOM.AF.24/Mar/2022).
The questionnaire consisted of 50 questions divided into a total of four sections. The first section inquired about age, socioeconomic status, education level, current residence, marital status, physical activity, smoking, and alcohol consumption. The second part included knowledge questions related to HPV infection and cervical cancer, risk factors, modes of transmission of the HPV infection, and its presentation, in addition to the awareness of the Pap smear test as a screening tool for cervical cancer and the HPV vaccines for its prevention. The third section focused on the attitude of the participants regarding screening and prevention of cervical cancer through the Pap smear test and the HPV vaccine. In the last section, questions were related to uptake of the Pap smear test and HPV vaccination, as well as identifying barriers and incentives for vaccination.
A knowledge score (KS) was calculated that consisted of a total of 29 questions inquiring about cervical cancer risk factors (6 questions), symptoms (7), prevention (7 questions), HPV mode of transmission, and HPV vaccination (9 questions). Each knowledge question had a score of 1 for the correct response and 0 for incorrect and “I don’t know” responses. The KS was further categorized as below the mean and above the mean.
The attitude score (AS) was calculated using seven Likert scale questions assessing women’s attitudes toward cervical cancer, Pap smear uptake, and HPV vaccination. Each question was scored from 1 to 5: 1 = strongly disagree, 2 = disagree, 3 = neutral, 4 = agree, and 5 = strongly agree. The “agree” and “strongly agree” depict a woman’s positive attitude. To calculate AS, we added the numerical value checked by the respondents for each attitude question.
Statistical analysis
The data were analyzed using the Statistical Package for Social Sciences (SPSS) Version 28.0 (IBM Corporation, Armonk, USA). A t-test or ANOVA was used to determine the association between women’s characteristics (age, marital status, education level, place of residence, occupation status, professional health care, perceived income, smoking, alcohol drinking, and physical activity) and the outcome variables KS and AS. The relationship of Pap smear and HPV vaccination uptake by relevant categorical variables was analyzed using the chi-square test. All explanatory variables that were significant at the bivariate analysis for the study’s four outcome variables, KS (above the mean vs. below the mean), AS (above the mean vs. below the mean), ever had a Pap smear or an HPV vaccination (yes vs. no), were entered into four separate multivariate binary logistic regressions. A p value <0.05 indicated statistical significance (in bold in tables).
Results
The study included 585 women residing in various Lebanese regions, with a mean age of 28.5 ± 7.9 years. The majority were single (80%), had a university degree (79.5%), were university students (52.5%), while 26.7% were either enrolled or working in a health-related field (Table 1). Social media and the internet were the primary sources of cervical cancer information (45.3%) (Supplementary Table S1).
Distribution of Women Who Ever Heard of Cervical Cancer and Pap Smear by Sociodemographic Variables
Statistically significant p-value is bolded.
aTotal does not add up to 585 due to missing data.
Detailed demographic characteristics are described in Supplementary Table S1.
Awareness and knowledge of cervical cancer risk factors, symptoms, and prevention
Among the 585 women participants, 82.7% had heard of cervical cancer and 61.9% of the Pap smear test. Being older, married (89.7% vs. singles 80.8%, p = 0.025), economically active, either a health care student or professional, and having a university degree was associated with greater awareness of cervical cancer and the Pap smear. Participants 31 years and older were more aware than those aged 18–20 years (p < 0.001). Awareness was higher among university graduates (88.8%) compared with high school/technical school students (73.7%, p = 0.002) (Table 1).
The proportion of women who were familiar with the Pap smear test was 80% in the age group 41–50 years compared with 30.9% of those aged 18–20 years (p < 0.001). Married women had higher awareness than singles (p < 0.001), and university graduates were more aware than high school/technical school students (72.4% vs. 43.9%, respectively; p < 0.001) (Table 1).
Knowledge of cervical cancer risk factors is summarized in Figure 1. Among participants, 76.0% identified sexually transmitted infections (STIs), 60.7% recognized having multiple sexual partners, and 65.5% identified smoking as risk factors for cervical cancer. Notably, 66.7% either believed or were unsure whether unsanitary toilets posed a risk for HPV infection.
Distribution of knowledge questions related to risk factors, symptoms, and prevention of cervical cancer.
Preventive measures were recognized correctly by the majority of women: regular screening (89.0%), vaccination (76.2%), and condom use (57.4%). However, 47.1% incorrectly believed regular genital washing with antiseptic could prevent cervical cancer.
Knowledge of HPV mode of transmission and its vaccine is detailed in Figure 2. Most participants (78.8%) correctly identified vaginal sex as a mode of transmission, followed by anal sex (49.7%) and oral sex (39.5%).
Distribution of knowledge questions related to HPV and HPV vaccine.
Prevalence and determinants of awareness related to HPV and its vaccine are described in Supplementary Table S1.
Women’s attitudes toward cervical cancer, Pap smear, and HPV vaccination
Attitudes toward cervical cancer showed that the vast majority agreed that it is a serious medical condition (81.4%). Additionally, 73.3% would recommend Pap smear testing, while 61.2% endorsed the HPV vaccine’s efficacy (Fig. 3).
Distribution of women’s attitudes toward cervical cancer, Pap smear, and HPV vaccination.
Knowledge and attitude scores
The calculated KS ranged from 0 to 27 with a mean KS of 13.8 ± 7.3. Those in the age group 21–25 years had a higher mean KS (15.3) than those aged 18–20 years (11.3; p < 0.001). Mean scores among university graduates and high school students were 15.4 and 10.1, respectively (p < 0.001). Women who had a health care background either as students or as professionals had a mean knowledge of 19.4 compared with 11.5 among women with no health care–related exposure (p < 0.001). Participants who were past or current alcohol drinkers had higher mean KS (14.4) compared with never drinkers (12.8; p = 0.03) (Table 2).
Mean Score of Knowledge and Attitude by Sociodemographic Variables
Statistically significant p-value is bolded.
SD, standard deviation.
AS ranged from 7 to 35 with a mean of 27.6 ± 7.7. Having a university degree, being a student/currently unemployed, and being a health care professional were significantly associated with an AS above the mean (Table 2).
The binary logistic regression revealed that the four variables that remained significant predictors of KS above the mean versus KS below the mean were having a graduate education, being a former or current alcohol drinker, being a health care student or professional, and having an AS above the mean (Table 3).
Logistic Regression of Knowledge and Attitude Score by Selected Participants Characteristics
Statistically significant p-value is bolded.
CI, confidence interval; OR, odds ratio.
A KS above the mean was the only significant predictor of an AS above versus below the mean (odds ratio [OR] 3.24, confidence interval [CI]: [2.16–5.53], p < 0.001) in the adjusted multivariate analysis (Table 3).
Prevalence of Pap smear and HPV vaccine uptake
The prevalence of women who reported having ever had a Pap smear was 18.6%. Older age, being married, having a university graduate degree, residing in Mount Lebanon, being unemployed, being a health care student or professional, being a current smoker, and being an alcohol drinker were significantly correlated with ever having had a Pap smear. The two variables that were not associated were perceived income and physical exercise.
While 17.9% of women received at least one HPV vaccination dose, the vaccination rate varied by age group, with the highest rates among those aged 21–25 years (43.2%) and the lowest (9.3%) in the age group 41–50 (p < 0.001). Other women’s characteristics associated with vaccination against HPV were being single, having a graduate degree, being a health care student or professional, perceiving income as sufficient, and those who never smoked (Table 4).
Distribution of Women Who Ever Had a Pap Smear and an HPV Vaccine
Statistically significant p-value is bolded.
HPV, human papillomavirus.
Incentives and barriers related to HPV vaccination
Most vaccinated women reported receiving the vaccine following recommendations from a gynecologist or physician (81.9%). Additional sources included relatives/friends and awareness campaigns. Among unvaccinated participants, 57.1% attributed their status to a lack of knowledge and 16.5% because of perceived young age. Other barriers included limited health care access, high cost, and concerns about side effects or safety (Fig. 4).
Incentives for taking the HPV vaccine and barriers for not taking the HPV vaccine as reported by the participants (%).
Multivariate binary logistic regression
The multivariate analysis showed that women residing in Mount Lebanon were 2.45 times more likely to be vaccinated compared with those living in Beirut (CI: [1.16–5.16]). AS above the mean and KS above the mean were also strong predictors of HPV vaccination (OR: 2.00, CI: [1.14–3.50]; OR: 2.26, CI: [1.19–4.29], respectively).
The only two variables that remained significant were age and KS. Women in age groups 26–30, 31–40, and 41–50 were more likely to have had a Pap smear compared with those aged 18–20. The odds of having had a Pap smear among those with a KS above the mean were 3.66 (CI: [1.64–8.18], p = 0.002) compared with those who had KS below the mean (Table 5).
Variables Associated with Ever Having Received an HPV Vaccine and/or a Pap Smear
Statistically significant p-value is bolded.
Discussion
This study aimed to assess determinants of cervical cancer prevention practices among Lebanese women. It is particularly relevant within the context of the Middle East, where HPV burden can reach up to 25% in low-risk women with normal cytology. 12 KS and AS were the most significant predictors of HPV vaccine uptake, while both age and KS above the mean were associated with increased likelihood of Pap smear screening. These findings are consistent with previous studies showing that women with adequate knowledge and a positive attitude were more likely to have received the vaccine, even in different settings.13–15 While this study demonstrated generally a KS above the mean about HPV and its vaccine among our participants, who largely represent an educated subgroup engaged in health care, substantial gaps remain. Many women lacked knowledge of HPV risk factors, symptoms, prevention, and specific transmission pathways. Similar to findings from other regional studies, the Lebanese women captured in this study appear to have a general understanding of the main known risk factors associated with cervical cancer but are limited in knowledge regarding the smaller nuances of the topic.9,11 While a study by Dany et al. found that 66.5% of college-aged female participants correctly identified all three transmission modes (vaginal, anal, and oral sex), fewer than half recognized oral and anal intercourse as modes of HPV transmission in our cohort. 10 This might be because these modes of transmission were grouped into one survey question, making it easier for respondents to answer accurately. Higher educational levels and health care–related employment were positively associated with greater KS, an association consistently reported in the literature.14,16,17 Therefore, this underscores the need for public health initiatives to bridge the educational gap, such as the dissemination of accessible and jargon-free information to ensure equitable awareness. Successful methods for information dissemination involve culture-friendly and audience-targeted campaigns (adolescents vs. parents). 18 Despite most participants acknowledging cervical cancer as a serious and preventable condition, vaccination rates among participants remained low, even among the younger age group, with insufficient knowledge identified as the principal barrier. This explains the positive correlation of greater knowledge of vaccine benefits and safety with vaccine uptake.14,19 Older vaccination age found in this study could reflect the societal belief that vaccination is relevant only after the onset of sexual activity, often post-marriage. Even if still proven efficient and approved by the FDA for women aged 27–45 years, this misconception undermines the vaccine’s preventive intent, as the development of immunity requires approximately 6 months and is most effective when administered before exposure to the virus.13,20 While alcohol consumption is associated with risky sexual behaviors, this study showed it was associated with higher KS s. This could possibly reflect greater engagement in discussions about sexual health within this subgroup. 21 As for Pap smear screening, the reported AS in our cohort was notably higher than in neighboring countries, such as Kuwait (30.6%) and the UAE (28%). This may be attributable to Lebanon’s relatively liberal sociocultural environment and greater accessibility to health-related information, in addition to the characteristics of our study population, which was predominantly younger and overrepresented by individuals studying or working in the health care field.22,23 Physicians, family members, and social media were the main sources of HPV-related information, making them key targets for interventions to increase awareness and boost vaccine uptake. Physicians play a pivotal role, as their recommendations were the most frequently cited motivators for vaccination.18,24,25 Social media presents an effective tool to reach broader and younger audiences. However, it also poses challenges, as it can easily spread misinformation or relay incomplete content, potentially leading to increased skepticism and confusion among targeted audiences. 26 Vaccinated participants identified close friends or relatives as key influencers, emphasizing the role of social support in vaccination decisions.13,18 A study by Abou El Ola et al. reports only 34% of mothers being aware of the HPV vaccine, a finding supported by recent research highlighting widespread parental misconceptions.24,27 This underscores the need to expand awareness campaigns to include caregivers. Efforts to improve HPV vaccine awareness must also address cost and accessibility, which Lebanese gynecologists report as a significant barrier to vaccination. 28 The absence of a national HPV vaccination program in Lebanon remains a significant barrier.9,10 Successful partnerships with nongovernmental organizations or the Ministry of Health, as implemented in the UAE, have increased vaccination rates and demonstrated the effectiveness of national programs. 29 However, Lebanon’s unstable political and economic situation poses significant challenges to implementing similar initiatives, leaving the responsibility largely to the private sector. In addition, improving access to vaccination through initiatives such as mobile clinics or walk-in services has been reported to increase patient motivation. 18
The strengths of this study lie in its comprehensive assessment of knowledge, attitudes, and practices related to HPV, cervical cancer, and HPV vaccination among a subset of Lebanese women of all ages, drawn from diverse regions across the country, and involving a good sample size. It provides updated and contemporary data on knowledge and attitudes toward cervical cancer screening and HPV vaccination in the current context. However, the results should be interpreted in light of several limitations. First, the data collection process relied on a convenient sample selection using the snowball method. The sample may not be representative of Lebanese women overall, as the online survey predominantly captured younger and more educated participants. Additionally, the use of a self-administered, 50-item survey introduces the potential for response and completion biases, including social desirability bias, and may have resulted in selection bias favoring participants who were more motivated, health-aware, or interested in cervical cancer screening and HPV vaccination. Despite this, substantial knowledge gaps and misconceptions were still observed. The study being cross-sectional will not allow us to infer causality. Despite these limitations, the study offers critical insights into a largely underexplored area, laying the groundwork for targeted public health strategies.
Conclusion
Cervical cancer continues to be a significant public health challenge in Lebanon, with gaps in awareness and prevention efforts contributing to its burden. The health care promotion campaigns should target societal knowledge, enhancing positive attitudes toward HPV vaccination. Effective prevention strategies, such as enhanced access to health care and financial support for vaccines, could reduce stigma and increase participation in screening and vaccination programs. Addressing these issues is essential to improve overall health outcomes.
Authors’ Contributions
A.C.: Conceptualization, writing—original draft (lead), and review and editing (equal). J.P.: Conceptualization, writing—original draft (lead), and review and editing (equal). M.R.: Conceptualization and writing—original draft. M.B.: Conceptualization and writing—original draft. M.F.: Conceptualization and review. J.M.: Writing—original draft. M.E.D.: Software (lead), methodology (lead), and writing—review and editing (equal). A.F.: Writing—review and editing (equal). Authors contributed equally to this work and share co-authorship.
Footnotes
Acknowledgments
Pamela Fakhry, Marc Ghattas.
Author Disclosure Statement
No competing financial interests exist.
Funding Information
This research received no specific grant from a funding agency in the public, commercial, or not-for-profit sectors.