Introduction

Human papillomavirus (HPV) is the most common sexually transmitted viral infection worldwide, affecting any age, sex, or geographic location1, 2. HPV has over 150 subtypes, about 40 of which infect the genital tract. Among these, high-risk types (16, 18, 31, 33, 35, 45) are linked to cancers, while low- to medium-risk types (6, 11, 42, 44) are mainly associated with anogenital warts3. Since its discovery in the early twentieth century, HPV has garnered significant attention due to its role in several malignancies, particularly cervical and penile cancer, as well as cancers of the uterus, vagina, vulva, and oropharynx4.

The incidence of HPV infection varies worldwide, with around 14 million new cases annually2. Transient infections are most common among adolescents, especially females aged 11–15, highlighting the urgent need for early preventive measures5. High-risk HPV 16/18 prevalence is about 3% in Egypt and around 2.5% in Jordan, Yemen, and Syria6, 7, 5. HPV spreads primarily through sexual activity, with increased risk among young women, those with multiple partners, and immunocompromised individuals4. High-risk HPV, often asymptomatic, may progress to cervical cancer (CC), which accounts for over 80% of worldwide cases according to The World Health Organization (WHO)8.

Cervical cancer, caused mainly by persistent HPV infection alongside cofactors such as HIV, is the 13th most common malignancy and the fourth leading cause of cancer death in women worldwide, with about 600,000 new cases and 340,000 deaths each year9. In Saudi Arabia, CC remains a concern, with 350 new cases and around 170 deaths annually10, 11. Screening strategies such as Pap smears and HPV testing have been established as cost-effective tools, allowing early detection of precancerous lesions and reducing both incidence and mortality12.

Because of its asymptomatic course, HPV requires a dual approach: vaccination (primary prevention) and screening (secondary prevention), both considered cost-effective and complementary13. In 2006, the U.S. Food and Drug Administration (FDA) approved the HPV vaccine, now in use in more than 117 countries, including the studied Arab countries. The vaccine is most effective when given before sexual debut, a recommendation strongly endorsed by WHO as the optimal strategy for preventing cervical cancer14. However, HPV vaccination coverage remains lower than for other vaccines due to limited awareness, cultural influences, healthcare access, and variation in national screening programs15,16,17,18.

By 2030, the WHO Global Strategy for Cervical Cancer Elimination aims to achieve 90% HPV vaccination coverage among girls by age 15, 70% of women screened at ages 35 and 45, and 90% treatment coverage for diagnosed cases19, 20. In Arab countries, cultural and religious contexts, along with relatively low levels of high-risk behaviors, underscore the importance of developing context-specific national strategies.

Tailored guidelines will ensure optimal allocation of resources for prevention and treatment, supporting either elimination of CC or reduction of the broader disease burden. Therefore, our goal was to integrate these factors and generate robust evidence to better understand human papillomavirus (HPV) transmission and its associated risk factors for cervical cancer (CC). This knowledge is crucial for guiding public health interventions and strengthening national prevention strategies. The study aimed to: (1) Determine CC-related risk factors and knowledge; (2) Assess HPV-related awareness and vaccination attitudes using the Vaccination Attitudes Examination (VAX) Scale; (3) Examine broader adult vaccination behaviors, including those for measles, influenza, coronavirus, respiratory syncytial virus (RSV), and shingles; and (4) Evaluate risky and preventive health behaviors and their determinants among adults in the participating countries.

Methods

Study design, and duration

This study employed a multinational, cross-sectional design conducted between March and May 2025. It aimed to generate evidence to inform cervical cancer (CC) prevention strategies in the Middle East by assessing participants’ knowledge, associated risk factors, and vaccination attitudes. The design allowed for the simultaneous evaluation of behavioral, demographic, and perceptual determinants influencing HPV transmission and prevention within the studied populations.

Study setting

The study was implemented in four Middle Eastern countries: Egypt, Syria, Jordan, and Yemen.

Participants (selection criteria)

The study targeted adult men and women aged 18–50 years representing various educational and occupational backgrounds. Exclusion criteria included illiteracy, mental unfitness, autoimmune diseases, or a history of severe medical or psychological disorders that could interfere with self-administration of the questionnaire. Participants were recruited through voluntary participation, ensuring regional diversity and representativeness across both sexes.

Sample size calculation

The minimum sample size was estimated using the single population proportion formula: n = (Z2 × p × (1 – p))/d2 where n = required sample size, Z = 1.96 (for 95% confidence level), p = 0.538 (expected prevalence of adequate knowledge21), and d = 0.05 (margin of error). Substituting the values: n = (1.962 × 0.538 × (1–0.538))/0.052 ≈ 430.

As this was a multinational study using a multistage cluster sampling design, a design effect of 3 was applied to account for heterogeneity across countries and intra-cluster correlation. This increased the required sample size to approximately 1,290 participants. After data cleaning and exclusion of incomplete responses, 1,174 valid questionnaires were included in the final analysis, which exceeded the minimum effective sample size.

Sampling frame and techniques

A multistage sampling technique was employed. Using a facility-based approach, participants were recruited from primary health care centers (PHCCs). From each country, four PHCCs (two rural and two urban) were randomly selected from different governorates. Within each PHCC, every fifth registered participant was approached, informed about the study, and invited to self-complete the questionnaire on a smart device or tablet. A minimum of 30 participants per PHCC and at least 60 per region were targeted. Recruitment continued in the same manner until the required sample size was achieved.

Development and validation of the questionnaire

The questionnaire was developed based on previous studies21–29. It was initially drafted in English, translated into Arabic by a bilingual panel (two healthcare professionals and one certified medical translator), and back translated by two independent translators. The back-translated version was reviewed for accuracy against the original English draft.

To ensure cultural appropriateness and reliability across all four countries, the instrument was reviewed by three physicians in each country (family medicine, public health, obstetrics/gynecology). A pilot study with 30 participants per country was conducted to evaluate clarity and comprehension; these responses were included in the final dataset. Internal consistency was strong, with Cronbach’s alpha = 0.87.

Structure of the questionnaire

The final questionnaire consisted of four sections:

  • Consent page: Written informed consent outlining objectives, voluntary participation, and confidentiality.

  • Section I – Sociodemographic characteristics: age, sex, residence, marital status, education, occupation, and monthly income Insufficient,” “Sufficient,” or “More than Sufficient (.” was collected as a self-reported variable based on participants’ perceptions of their income in relation to their living expenses and responsibilities, rather than on fixed monetary thresholds To transparency and acknowledges variability across countries.

  • Section II – Risky practices and risk factors: family history of cervical cancer, HPV vaccination status, smoking, dietary habits, age at first sexual relationship, multiple partners, prior HPV history, and cervical cancer screening. Coding: good practice = 1 (recommended behavior), poor practice = 2 (less than recommended), neutral = 0. “Good practice” referred to participants who had undergone CC screening at least once. Lower scores indicated better behavior; scores below the mean denoted good practice.

  • Section III – Knowledge of HPV and CC: 29 items on causes, risk factors, clinical presentation, screening, and prevention. Responses were coded Yes = 2, Don’t know = 1, No = 0, with reverse scoring for negatively worded items. The total score ranged from 0–32. Participants scoring ≥ the mean were classified as having good knowledge.

Section IV – HPV vaccine-related attitudes and experiences

  1. o

    The Vaccination Attitudes Examination (VAX) Scale, a validated 12-item tool covering mistrust of benefits, worries about unforeseen effects, concerns about profiteering, and preference for natural immunity. Items were rated on a 5-point Likert scale. Positively worded items were reverse scored so that higher scores indicated greater hesitancy.

  2. o

    General vaccination attitudes among adults (measles, flu, coronavirus, RSV, and shingles vaccines)

  3. o

    Reasons for not being HPV vaccinated.

  4. o

    Reported adverse events among HPV vaccinated participants.

Data analysis

Data was coded and analyzed using SPSS version 26.0 (IBM Corp., Armonk, NY, USA). A p-value < 0.05 was considered statistically significant. Continuous variables were summarized as mean, standard deviation (SD), and range, while categorical variables were described as frequencies and percentages. The Shapiro–Wilk test was used to assess normality. As most continuous variables were not normally distributed, the Mann–Whitney U test was applied for two-group comparisons.

Associations between categorical variables (e.g., vaccination attitudes vs. sociodemographic factors) were examined using the Chi-square test or Fisher’s exact test (for small cell sizes). For continuous outcomes (knowledge and VAX scores), comparisons across groups were made using t-tests or ANOVA, as appropriate.

Multivariate regression analysis was not performed due to the exploratory nature of the study, the large number of potential predictors, and the very low HPV vaccine uptake, which would limit model stability. Instead, results are presented using descriptive and bivariate analyses, with limitations acknowledged in the discussion.

Results

Demographic characteristics (Table 1 )

Table 1 Demographics, and clinical characteristics of participants and their relationship with the total knowledge, practice of risky behaviors score and VAX scale.
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The study included 1172 participants with a mean age of 34.1 years. More than half were female (54.2%), university-educated (59.6%), and urban residents (67.9%). Most were married (57.7%), reported no comorbidities (92.4%), and rated their health as excellent or very good (55%). Nearly half (48.4%) reported insufficient monthly income, and the majority (56.7%) worked outside the medical field. The mean age at first marital or sexual relationship was 29.3 ± 8.6 years, with an average of 2.9 ± 1.7 children among those who had any. Regarding confidence in the health system, 18.9% reported excellent confidence, whereas 10.8% reported weak confidence.

Risk factors (Table 2 )

Table 2 Risk factor assessment.
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Among the participants, 489 (41.7%) were smokers, and 385 (32.8%) exceeded recommended sugar or salt intake. Risky sexual relations with infected partners were reported by 283 (24.1%), while low intake of vegetables (35.2%), protein (33.3%), and dairy (36.8%) was also frequent. Only 60 participants (9.5%) had undergone cervical screening, and 23 (2.0%) reported a prior HPV infection. Less common risk factors included herpes history in 84 (7.2%), family history of reproductive cancers in 81 (6.9%), immunosuppressive drug use in 66 (5.6%), immunodeficiency in 63 (5.4%), multiple sexual partners in 29 (2.5%), personal history of reproductive cancer in 12 (1.0%), and genital tattoo or cosmetic procedures in 9 (0.8%). Overall, 524 participants (44.7%) demonstrated poor practice of risky behaviors.

Knowledge of HPV and cervical cancer (Table 3 ; Figs. 1–2 )

Table 3 Measuring knowledge level about HPV and cancer cervix.
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Fig. 1
figure 1

Classification of the total knowledge score regarding human papillomavirus (HPV), cervical cancer (CC), and both combined.

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Fig. 2
figure 2

Association between nationality and (a) total knowledge score, (b) total practice of risky behaviour, (c) Vaccine Attitudes Examination (VAX) scale, and (d) receipt of HPV vaccination.

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HPV Knowledge was limited. Less than half correctly recognized that HPV infection results from sexual contact (45.6%), may present with genital warts (44.7%), and can cause cancer in both men and women (43.3%). Misconceptions were frequent, with 32.7% believing HPV could be transmitted through contaminated surfaces, 28.5% attributing it to respiratory symptoms, 24.5% considering it genetic, 22.5% believing it affects only women, and 21.9% believing vaccination treats infection. Knowledge of vaccine characteristics was particularly poor, as over half did not know about co-administration (53.7%), booster requirements (53.2%), or strain coverage (50.9%). In total, only 46.6% achieved a “good knowledge” score about HPV.

Cervical cancer knowledge

Knowledge of cervical cancer was also suboptimal, with only 33.5% demonstrating “good knowledge.” Although 44.7% recognized HPV infection as the primary cause and 48.6% acknowledged the role of screening, awareness of risk factors varied. Nearly half identified multiple sexual partners (48.9%) and early sexual activity (44.8%) as risks, but fewer recognized increased parity (34.3%) or smoking (41.9%). Symptom awareness was modest: 37.6% recognized abnormal bleeding and 39.1% abnormal discharge, while fewer identified abdominal or back pain, rectal bleeding, or leg swelling. Misconceptions were also frequent, as 42.2% believed a single exam was sufficient, 37.9% thought the disease affects only women, and 32.5% considered it genetic.

Associations with knowledge score

Knowledge was significantly associated with age (r = −0.350, p < 0.001), with younger participants scoring higher. Education level (p < 0.001), residency (urban > rural, p < 0.001), occupation (medical > unemployed/non-medical, p< 0.001), and marital status (single > married/divorced/widowed, (p < 0.001) were also significant. Interestingly, higher income was inversely associated with knowledge (p < 0.001). The age at first marital/sexual relationship (r = −0.207, p < 0.001) and number of children (r = −0.095,  p= 0.012) were negatively correlated with knowledge. Nationality was also significant (p < 0.001), with Syrians and Yemenis scoring highest and Egyptians lowest (Fig. 2).

Vaccine attitudes (Tables 4–5 ; Fig. 3 )

Table 4 Vaccination history and HPV vaccine related context.
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Table 5 Human Papilloma Virus Vaccine attitude examination (VAX) scale.
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Fig. 3
figure 3

The correlation between the VAX scale towards HPV and (total knowledge score, The total practice of risky behaviour).

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General vaccine acceptance varied by type. The highest uptake was for coronavirus (38.1%), followed by flu (24.9%), while hesitancy was notable for both flu (24.1%) and coronavirus (16.9%). Acceptance of measles (6.9%), RSV (3.5%), and shingles (3.0%) vaccines was minimal, with over 83% reporting no intention to receive the latter two.

For HPV specifically, 83.3% had not received the vaccine and did not intend to, 8.1% were very hesitant, 6.6% intended to vaccinate, and just 2.0% had been vaccinated. Almost half of respondents (49.3%) reported not knowing the disease at all. Among those participants, the main information sources were lectures/research (25.2%), social media (17.1%), websites (13.5%), and healthcare providers (10.9%). Most participants (58.1%) did not know if the Ministry of Health provides vaccine information, and 23.5% stated it does not.

Among the 16 vaccinated participants, the most frequent side effects were allergic reactions (58.8%) and dizziness/fainting (56.3%), followed by injection-site pain (50%), muscle/joint pain (47.1%), fever/fatigue (43.8%), nausea (37.5%), and headache (25%). Reasons for not receiving the HPV vaccine included insufficient information (24.2%), perceived lack of risk (22.2%), adherence to prevention standards (22.2%), unavailability (18.3%), fear of side effects (16.9%), and lack of conviction (13.5%).

The VAX scale indicated generally neutral attitudes, with ~ 60% of responses reflecting uncertainty rather than strong rejection. Concerns about profiteering had the highest mean (3.49), reflecting distrust in authorities, while mistrust of benefits and worries about future effects scored around 3.15. Preference for natural immunity was less strongly endorsed (3.1). The mean total VAX score (38.3 ± 8.04) indicated a moderate level of vaccine hesitancy.

The HPV vaccine attitudes examination (VAX) scale

Demonstrated that responses were largely neutral across all four domains, with varying levels of hesitancy.

Mistrust of vaccine benefits

Across the three items in this domain, approximately one-third of participants expressed neutrality (27–34%), while a sizable proportion disagreed or strongly disagreed that the vaccine would provide safety or protection (≈20–23%). Only a minority strongly agreed with the protective benefits (14–16%). The mean scores (3.08–3.25 ± 1.49–1.54) indicated moderate confidence in vaccine efficacy but with marked uncertainty.

Worries about unforeseen future effects

Concerns about long-term or unknown side effects were highly prevalent. Nearly one-quarter (23–28%) expressed agreement, while another 27–31% selected neutral responses. Approximately 20–24% disagreed with these concerns. The mean scores (3.13–3.17 ± 1.47–1.55) suggest that potential long-term harms remain a dominant source of hesitancy.

Concerns about commercial profiteering

Most participants (59–61%) reported neutral views regarding the perception that vaccines mainly serve commercial rather than health purposes. Nonetheless, 14% agreed that vaccines profit drug companies without benefiting ordinary people, and 10–12% agreed that vaccination programs were financially motivated or even a “scam.” Mean scores were slightly higher (3.11–3.49 ± 1.12–1.22), reflecting skepticism about the role of pharmaceutical companies and authorities.

Preference for natural immunity

Neutral responses dominated this domain (≈59–61%). However, 9–15% agreed that natural immunity provides stronger or safer protection compared with vaccination. Around 13–16% disagreed, rejecting the notion of natural immunity superiority. Mean scores ranged between 3.01 and 3.27 ± 1.10–1.17, indicating mixed attitudes but with a tilt toward neutrality.

The overall total VAX score was 38.30 ± 8.04, which falls within the moderate range, reflecting a general tendency toward hesitancy and neutrality rather than strong pro-vaccine attitudes. Taken together, these findings suggest that mistrust, safety concerns, and neutrality dominate vaccine perceptions, with fewer participants expressing strong acceptance or strong rejection.

Associations with vaccine attitudes

Demographic determinants showed significant associations with VAX scores. More favorable attitudes were found among medical professionals (p = 0.001), participants with higher income (p = 0.010), those reporting excellent health (p = 0.018), and individuals with excellent confidence in the health system (p = 0.002). Marital status (married > single/divorced, p = 0.005) and later age at first marital/sexual relationship (r = 0.110, p = 0.004) were also associated with higher VAX scores. Nationality was significant (p < 0.001), with Egyptians and Yemenis showing the highest hesitancy, while Jordanians showed the lowest (Fig. 2). Finally, total VAX scores were significantly correlated with knowledge scores and risky practices (p < 0.001), as shown in Fig. 3.

Discussion

Demographic characteristics

Our findings revealed clear demographic patterns influencing HPV knowledge and vaccine attitudes. Younger age, higher education, urban residence, and employment in the medical field were consistently associated with greater awareness and more positive vaccine attitudes, whereas lower income, non-medical occupations, and marital status (married/widowed) correlated with poorer knowledge and higher hesitancy. These trends align with regional studies, including data from Saudi Arabia, which identified education level and credible information sources as key determinants of parental acceptance of HPV vaccination30,31,32.

Risk factors

Smoking (41.7%) and risky sexual behavior (24.1%) were the most prevalent behavioral risk factors, both well-documented cofactors in HPV-related carcinogenesis33,34. Although multiple sexual partners were reported by only 2.5%, such practices remain strongly linked with HPV-16/18 infections35. Genital laser hair removal (8%) emerged as a noteworthy and novel risk factor, echoing reports of lesion aggravation through repeated micro-trauma36. A recent study demonstrated a positive association between genital laser hair removal and HPV positivity (OR = 4.35, 95% CI 3.16–5.99), suggesting possible epithelial disruption37. Although evidence is limited, further longitudinal research is needed to determine whether this represents an independent risk factor for HPV infection or cervical cancer. Meanwhile, HPV vaccines continue to show sustained efficacy exceeding 90% against infection and precancerous lesions, with an excellent safety record spanning > 15 years38,39,40.

Screening services

Across participating countries, cervical cancer screening remains largely opportunistic and uneven. In Egypt, Pap-smear testing is limited to tertiary and teaching hospitals, and HPV vaccination is not yet part of the national schedule. Only 9.5% of women (60/635) had ever undergone screening—consistent with regional estimates (< 10%) from the Eastern Mediterranean41,42,43. Similar patterns occur in Jordan, Syria, and Yemen, where services are confined mainly to private or urban clinics. These figures underscore the fragmented nature of preventive services and their limited accessibility.

Knowledge of HPV and cervical cancer

Overall knowledge levels were poor: 53.4% and 66.5% of participants demonstrated low awareness of HPV and cervical cancer, respectively, and nearly half (49.3%) had never heard of HPV. Misconceptions—such as genetic causation or transmission via surfaces—were widespread. Symptom recognition was weak, and many believed a single cervical exam sufficed. These findings mirror previous Egyptian studies43,44,45 and extend to healthcare providers, where knowledge gaps and negative vaccination attitudes persist46.

HPV Vaccine uptake and hesitancy

HPV vaccination uptake was extremely low (2.0%), with 6.6% intending to vaccinate, 8.1% hesitant, and 83.3% unwilling. Main reasons included insufficient information (24.2%), perceived lack of risk (22.2%), and fear of side effects (16.9%). Among the vaccinated, adverse events were mild and consistent with global safety data. These results reflect previous reports from Egypt (2% coverage)20 and Saudi Arabia, where education strongly predicts acceptance35. Despite robust evidence of safety and efficacy, HPV vaccine hesitancy remains common worldwide30,31.

General Vaccine Attitudes

Low acceptance extended to other adult vaccines: RSV (3.5%) and shingles (3.0%), whereas coronavirus vaccination reached 38.1%. For measles and influenza, refusal or hesitancy predominated, indicating broad skepticism toward adult immunization. Only 2.0% received at least one HPV dose, suggesting that general vaccine hesitancy—rather than HPV-specific concerns—largely determines cervical-cancer-related prevention behaviors. Inclusion of multiple vaccine types in this survey situates HPV hesitancy within the broader immunization context.

Vaccine attitudes and the VAX scale

Assessment using the Vaccination Attitudes Examination (VAX) scale revealed moderate hesitancy, dominated by neutrality and concerns over profiteering, mistrust of benefits, and long-term safety—patterns paralleling international experiences31,47,48,49. Reported barriers aligned with the four VAX domains: mistrust of benefits (low perceived risk), worries about unforeseen effects (fear of side effects), concerns about commercial motives (profit-driven views), and preference for natural immunity (reliance on general prevention measures).

HPV related adverse events

Among vaccinated participants (n = 16), adverse events were predominantly mild to moderate and comparable to international reports28,30: allergic reactions (58.8%), dizziness/fainting (56.3%), injection-site pain (50%), muscle/joint pain (47.1%), fever/fatigue (43.8%), nausea (37.5%), and headache (25%). Despite fear of side effects being common, actual events were tolerable and consistent with the vaccine’s established safety profile.

Regional and global context

Similar barriers are documented regionally: in Saudi Arabia, education and trusted information sources are key predictors of acceptance32, 50; in Egypt, awareness and Pap-smear uptake remain minimal44,46; in Jordan and Oman, hesitancy stems mainly from safety fears and misinformation48. Outside the region, global reviews highlight stigma, misinformation, and accessibility as principal obstacles44,46,50,51,52,53,54. Collectively, these findings confirm that HPV vaccine hesitancy in the Middle East arises from both individual attitudes (mistrust, safety concerns, preference for natural immunity) and systemic barriers (stigma, misinformation, and limited access)55,56. Addressing these challenges demands educational interventions and structural reforms to ensure equitable vaccine delivery.

Strengths and limitations

This study’s strengths include a large, diverse, multinational sample (both sexes, four MENA countries) and comprehensive assessment of 13 risk behaviors. Inclusion of men and older adults broadens understanding of secondary vaccination targets. Limitations include variable sample sizes due to regional instability, potential selection bias inherent to online surveys, and self-reporting bias in sensitive behaviors. The exploratory design and low vaccination rate (2.0%) limited use of multivariate modeling; future larger studies are warranted.

Public health implications

The very low HPV vaccination rate and persistent hesitancy highlight critical gaps in awareness, service accessibility, and public trust. Expanding HPV vaccination into national immunization schedules, implementing culturally tailored education campaigns, and empowering healthcare providers to recommend vaccination are urgent priorities. Integrating vaccination and screening into routine reproductive health services will enhance access and coverage. These strategies align with the WHO Global Strategy for Cervical Cancer Elimination and are pivotal to reducing the regional burden of HPV-related disease.

Conclusion

This study revealed that most participants had limited knowledge of HPV and cervical cancer, including poor awareness of risk factors and symptoms. Uptake of HPV vaccination and cervical screening was extremely low, while vaccine hesitancy was widespread. Risk behaviors such as smoking, unhealthy dietary patterns, and unsafe sexual practices were common, and novel practices such as genital laser hair removal were also reported. Sociodemographic characteristics—including age, education, occupation, residency, income, and nationality—were significantly associated with knowledge, risky practices, and vaccine attitudes.

The overall total VAX scale falls within the moderate range, reflecting a general tendency toward hesitancy and neutrality rather than strong pro-vaccine attitudes. These findings suggest that mistrust, safety concerns, and neutrality dominate vaccine perceptions, with fewer participants expressing strong acceptance or strong rejection.

Recommendations

Based on the current findings, several coordinated actions are required to strengthen HPV and cervical cancer prevention efforts in the Middle East. National awareness campaigns should deliver culturally sensitive education to correct misconceptions, enhance recognition of risk factors, and build trust in vaccination programs, particularly through schools and workplaces. Healthcare providers must be actively engaged through continuous professional training to serve as credible advocates for HPV vaccination and screening. Integration of HPV vaccination into national immunization schedules should focus on adolescents aged 9–14 years, with consideration for older women and men when feasible and cost-effective.

Expanding access to affordable cervical screening services, including Pap smears and HPV testing, is equally vital to ensure early detection, especially among high-risk or underserved populations. Public health programs should also address modifiable behaviors such as smoking, sexual health practices, and elective genital procedures through tailored counseling and education. Equity in access must remain a guiding principle, prioritizing low-resource and politically unstable settings. Moreover, awareness efforts should encompass both traditional and emerging risk behaviors while promoting HPV vaccination for both sexes as a cornerstone of prevention. Finally, interventional and longitudinal research is needed to evaluate educational and community initiatives, monitor behavioral shifts, and sustain long-term improvements in vaccination coverage and screening uptake across diverse populations.