Knowledge and Attitude toward Human Papillomavirus among Students at the University of Sulaimani/City Campus

1. INTRODUCTION

Human papillomavirus (HPV) is a common infection that primarily affects the skin and mucous membranes [1], [2]. Its prevalence varies significantly across regions. Historically, the Middle East and North Africa (MENA) region has reported lower rates of HPV infection, largely attributed to more conservative sexual practices [3]. However, recent findings by Obeid et al. [4] indicate a rising trend in HPV infections among women in the region, particularly among individuals aged 10–24 years. Although comprehensive regional data remain limited, approximately 81% of people in the MENA region are considered to have HPV overall. Countries including Bahrain, Kuwait, Oman, Qatar, Saudi Arabia, the United Arab Emirates, and Yemen are among the nations that make up the Gulf Cooperation Council.

Recent studies by Jensen et al. and Petca et al. [5], [6] confirmed that HPV is a prevalent genital virus. There are more than 100 types of HPV that are transmitted through skin-to-skin contact, including sexual contact and other genital contact, such as touching an infected person’s genitalia.

However, HPV cannot be transmitted through contact with inanimate objects, such as toilet seats. The Centers for Disease Control and Prevention [7] confirmed that the majority of HPV infections may resolve spontaneously; however, they can occasionally lead to genital warts, skin lesions, and malignancies, including cervical cancer.

A persistent HPV infection can lead to the development of abnormal cells on the cervix, which, if left untreated, may progress to cervical cancer [8]. While cervical cancer is the most common cancer caused by HPV, both men and women can also develop fewer common cancers, including anal, vulvar, vaginal, oral/throat, and penile cancers, as a result of a persistent infection [9]. The appearance of warts varies depending on the specific type of HPV infection [8]. A genital wart may present as a stem-like protrusion, a flat lesion, or small, cauliflower-shaped growths. Furthermore, multiple viruses or serotypes are associated with HPV, with high-risk HPV serotypes being strongly linked to cervical cancer [10]. High-risk serotypes, such as HPV 16 and HPV 18, are frequently detected and have the potential to cause cancer, as reported by Kombe et al. [11].

Furthermore, most sexually active men and women can become infected with HPV at some time in their lives, and some people may get infected again. Most people acquire the virus early in life, shortly after becoming sexually active [1], [12].

Cervical cancer is the fourth most common cancer in women and the fourth major cause of cancer-related mortality, according to Sung et al. and Bongaerts et al. [13], [14]. It is regarded as the third most prevalent malignancy in women under the age of 45 in almost 79% of nations. The estimated global incidence of cervical cancer in 2018 was 13.1 cases/10,000 women, with significant variations between countries, as reported by Arbyn et al. [15].

The World Health Organization (WHO) recommends HPV vaccination for girls aged 9–14 as a primary preventive measure against cervical cancer [16]. To achieve global elimination, the WHO aims to reduce incidence to fewer than 4 cases/100,000 women [16] through a life-course strategy encompassing primary, secondary, and tertiary prevention. Secondary interventions focus on screening women aged 30, while tertiary measures include palliative care and cancer treatment [17]. By 2030, the goal is for 90% of girls under 15 to be vaccinated, 70% of women aged 35–45 to be screened, and 90% of those with precancerous lesions to receive treatment [18].

Assessing knowledge and attitudes (KAs) about HPV among university students is crucial for several reasons. First, one of the main causes of cervical cancer and other conditions is HPV. Understanding students’ knowledge can help identify gaps and guide the design of educational campaigns to promote awareness about HPV and its prevention. Second, attitudes toward HPV vaccination significantly influence its acceptance. By assessing these attitudes, health authorities can address misconceptions and encourage vaccination, which is essential in reducing HPV-related diseases.

Moreover, university students are forming lifelong health behaviors at a crucial moment. Assessing their attitudes and knowledge about HPV supports larger public health campaigns meant to lower the prevalence of diseases linked to HPV. As university students are at an age where they make independent health decisions, they can significantly benefit from education about HPV. This education encourages healthier lifestyle choices, promotes regular health check-ups, and empowers them to make informed decisions about their well-being, including vaccination, safe sex practices, and regular screenings.

This research provides a unique contribution to the literature by examining university students’ attitudes toward HPV within the context of Sulaimani City, offering culturally specific insights that are currently underrepresented in global research. The central hypothesis is that students’ attitudes toward HPV are influenced by their level of knowledge, cultural beliefs, and exposure to health education, which in turn affects their willingness to engage in preventive behaviors such as vaccination and screening.

These assessments not only help identify gaps in awareness but also inform the development of targeted educational programs and culturally sensitive materials focused on HPV prevention, transmission, and management. By understanding students’ perceptions, the study aims to reduce stigma and misconceptions, ultimately fostering a more supportive environment for individuals affected by HPV.

2. MATERIALS AND METHODS

3. RESULTS

The study sample comprised university students with a mean age of 22.1 years (SD = 1.72), reflecting a relatively homogenous cohort typical of senior undergraduate populations. The majority (85.2%) were aged between 19 and 23 years, suggesting that the findings predominantly represent early adulthood, a developmental stage characterized by increased autonomy and evolving health-related decision-making. A smaller proportion (14.8%) was aged 24–28, indicating limited representation from older students who may have different life experiences or health priorities. Gender distribution showed a slightly higher proportion of female participants (55.7%) compared to males (44.3%). This may reflect enrollment trends in health-related disciplines and could be relevant given the gendered nature of HPV-related health risks and screening behaviors.

Participants were drawn from four academic colleges, with the largest representation from pharmacy (34.3%), followed by nursing (28.1%), education (21%), and Islamic science (16.7%). The predominance of students from health-related fields (pharmacy and nursing) may enhance the relevance of their responses, as these students are more likely to have received formal education on infectious diseases and preventive health measures. A substantial majority (86.7%) were in their 4^th year of study, suggesting a cohort with advanced academic exposure and potential familiarity with public health concepts. This may contribute to more informed perspectives on HPV and related interventions.

Residency data indicated that 64.8% of participants lived in rural areas. This variable is particularly salient, as rural residency may be associated with reduced access to healthcare services and health education, potentially influencing KAs toward HPV prevention and vaccination. Regarding marital status, most participants were single (78.1%), while 21.9% were married. Marital status may intersect with sexual health behaviors and perceptions, which are relevant to HPV-related research, particularly in culturally sensitive contexts.

Finally, parental education levels were relatively high, with 71% of mothers and 82.9% of fathers reported as educated. Parental education is often linked to greater health literacy and may indirectly shape participants’ attitudes and knowledge through familial influence and early exposure to health-promoting behaviors (Table 1).

TABLE 1: Distribution of participants according to sociodemographic characteristics

The results indicate that over half of the participants (51.4%) were unaware of HPV. In addition, there is a lack of understanding about HPV, with the majority of participants (94.3%) unsure of what it is or incorrectly associating it with bacterial infections. The most common source of information regarding HPV among participants was health professionals (23.8%), followed by the Internet (18.6%), friends (13.8%), and television (4.8%). Regarding HPV transmission, the majority of participants (30.5%) reported that it can be transmitted through sexual contact. In comparison, 28.6% believed that it could be transmitted through skin contact, while 12.4% thought that it could be transmitted through sharing personal items.

Over half of the participants (52.4%) were unaware that HPV is a causative agent of cancer. However, 60% recognized its link to oral cancer, while 26% identified its association with anal cancer. In terms of vaccination awareness, 34.3% of respondents correctly indicated that the HPV vaccine is recommended for females and can be administered prior to the age of 12. However, only 29.5% knew that the vaccine can be administered after the age of 18 years old.

With respect to preventive knowledge, there is a lack of awareness about prevention methods. For example, 86.7% of participants demonstrated awareness of the Pap smear test as a preventive screening tool, and 83.3% knew that using condoms can help prevent HPV. Interestingly, the proportion of participants who believed that HPV infection could be asymptomatic was evenly split at 50%. More than two-thirds (68.6%) knew that HPV can affect both genders. Finally, 64.8% of participants expressed interest in receiving more information about HPV, indicating a strong demand for educational resources (Table 2).

TABLE 2: General knowledge toward human papillomavirus of the study sample

The current survey shows that 37.1% of participants strongly agree that receiving an HPV vaccination is necessary, indicating a more positive viewpoint regarding HPV vaccination. Nonetheless, a notable proportion of participants (36.2%) expressed neutrality regarding the recommendation of the HPV vaccine to friends and family. Regarding attitudes toward vaccination, 35.7% of participants believe that getting vaccinated against HPV can prevent certain types of cancer, while a significant number of participants (37.6%) remain neutral. Nearly one-quarter (39.5%) of participants agree or strongly agree that it is crucial for students to be educated about HPV and its potential health risks, reflecting strong support for HPV education. In addition, 45.7% of participants believe that increased awareness of HPV could help reduce its spread. Furthermore, 32.4% of participants agree that discussing HPV openly among students might help reduce the stigma associated with sexually transmitted diseases (STIs), showing a positive attitude toward open communication and education (Table 3).

TABLE 3: Level of Attitude toward human papillomavirus among study participants

The findings reveal that less than half of the participants (45.7%) possessed minimal knowledge about HPV, while only 29.5% possess good knowledge. Furthermore, more than a third of the participants (36.7%) exhibit a poor attitude toward HPV, and 24.8% demonstrate a good attitude. In terms of encouraging positive attitudes toward HPV prevention and education, it shows that although attitudes are slightly better than knowledge levels, considerably more can be performed (Table 4).

TABLE 4: Distribution of knowledge and attitude scores among study participants

The findings from Table 5 indicate that there is an association between certain sociodemographic. Factors such as age, gender, years of study, marital status, and father’s education were statistically significant in relation to knowledge about HPV among the study participants (P < 0.005). Nevertheless, no statistically significant association between mother’s education, residency, and college was found.

TABLE 5: Association between knowledge of human papillomavirus and sociodemographic characteristics among study participants

Table 6 reveals statistically significant associations between participants’ attitudes toward HPV and the variables of age, gender, college affiliation, years of study, and father’s educational level (P < 0.005). In contrast, no significant associations were observed with residency status, marital status, or mother’s education.

TABLE 6: Association between attitude of human papillomavirus and sociodemographic characteristics among study participants

4. DISCUSSION

The purpose of the current study was to evaluate university students’ attitudes and knowledge regarding HPV.

These findings are consistent with those reported by Khan et al. [19] in Pakistan, where the majority of respondents were female (74.9%) and single (79%). The demographic parallels with Khan et al. [19] suggest that young, unmarried women across South Asia may share similar vulnerabilities and openness to HPV prevention. This regional consistency underscores the urgency of culturally sensitive, gender-focused interventions; this population should be a key target for public health efforts. Tailored awareness campaigns and vaccination outreach initiatives are essential to effectively promote HPV prevention within this group. In addition, while pharmacy students comprised the largest academic group in both studies (46.2% in Khan et al.’s study; 34.3% in the present study), the limited representation from non-health disciplines such as arts and humanities underscores a gap in HPV-related education across the broader university population. These findings highlight the need for interdisciplinary educational interventions that extend beyond health faculties, integrating HPV awareness into general curricula and student wellness programs. Such efforts could enhance vaccine uptake, reduce stigma, and promote informed decision-making among diverse student populations.

Another study by Liu et al. [20] conducted in Beijing, China, reported that 56.3% of participants were female and 43% were male. Similarly, Shetty et al. [21] in South India found that 72.3% of participants were female, while 27.7% were male. In Shetty’s study, 50.8% of participants were between the ages of 20 and 22. The largest proportion of participants were enrolled in medical programs (43.5%), followed by those studying dentistry (27. 9%), nursing students (21.1%), and medical laboratory students (7.5%). Regarding marital status, 91% of the participants were single. Most participants were 1^st-year students (32.2%). More than half of the students (55.8%) were from urban areas. In addition, the percentage of fathers’ professions in various fields was higher compared to mothers’ professions, which included healthcare providers, self-employed individuals, and retirees.

The findings of this study were consistent with those of a previous study conducted by Khan et al. [19], which also examined KAs toward HPV among university students in Pakistan. The study confirmed that 57% of students reported having heard about HPV. The participants’ knowledge of HPV infection was 43.6%, whereas their knowledge of the HPV vaccine was 25.3%. Furthermore, almost the same percentage of students said that HPV infects both men and women, and 55% said that HPV causes cervical cancer. According to the vast majority of students (71%), HPV is not a rare disease in Pakistan. Nearly 68% of students, however, disagreed that HPV can cause no symptoms. About 47% of respondents said that HPV causes anal and penile malignancies, while 52% claimed that it causes external genital warts.

Regarding the mechanism of transmission, 40.51% of respondents answered that they were unsure, 34.10% stated that body fluid exchange is the most common way, followed by skin-to-skin contact (44.87%), and coughing or sneezing (5.64%). Less than half (44.87%) of students said that vaccination is the best way to prevent HPV, followed by sexual abstinence (30%), condom use (21.54%), and antibiotic use (5.38%). Unlike prior studies conducted in South and East Asia, this research provides the first comparative insight into HPV knowledge among Iraqi university students. The persistence of misconceptions and low vaccine awareness highlights a critical gap in sexual health education, suggesting the need for national curriculum reform and targeted outreach.

Moreover, reports from previous studies by Khan et al., [19]; Shetty et al., [21]; Patel et al., [22]; Khatiwada et al., [23]; Mekonnen et al., [24] confirmed that the sources of information were varied, including the Internet (37.8%), teachers (31.7%), television (22.1%), healthcare providers (21.9%), brochures (16.7%), posters (14.2%), family (9.4%), social media (67.3%), college education (48.0%), families or friends (41.7%), doctors or health-related workers (37.3%), friends (9.6%), radio (6%), media (49.12%), healthcare professionals (30.97%), and primary care physicians (2.9%). These findings suggest that social media campaigns are effective tools that hold contemporary relevance, indicating that social media campaigns may serve as effective tools for enhancing public knowledge about HPV. In addition, traditional media continues to have a significant impact, and healthcare providers continue to be reliable sources of information. This research highlights how important it is for medical professionals to be informed and initiative-taking in teaching people about HPV. Finally, family and community-based interventions can be very effective in raising awareness about HPV and fostering positive attitudes.

Regarding knowledge on HPV transmission, Chanprasertpinyo et al. [25] confirmed that approximately 65% of participants knew that HPV spreads through sexual contact and causes infection in both men and women. In addition, 52.4% of participants recognized that early sexual activity increases the risk of HPV infection, and 52.8% were aware of its role in causing cervical cancer. However, only 49.7% understood that condom use can help prevent HPV transmission. Notably, over half of the respondents (57%) were unaware that the HPV vaccine offers protection for both males and females In addition, Shetty et al. and Varer et al. [21], [26] found that a small percentage of participants (24.4%) stated that a woman who had previously been infected could receive the HPV vaccine; 21.8% were aware that the HPV vaccine could not cure a current infection. Nonetheless, 64.4% of respondents said that both males and females should have the vaccination, and 61% knew that cervical cancer screening was required for individuals who had already had the vaccination.

Likewise, Kim et al. [27] conducted a study in China assessing knowledge, attitudes, and perceptions associated with HPV vaccination among female Korean and Chinese university students. They found that 21.1% of Chinese female college students and 25.4% of Korean female students had heard of HPV. 15.8% of Korean students thought the immunization was unnecessary in the absence of infection signs, while 17.2% said that it should only be given to females. 52.7% of Chinese students said that HPV vaccinations should be given to both men and women, 31% answered that they were not required if there were no signs of infection, and 16.3% answered that only women should have them.

Furthermore, a study conducted by Shetty et al. [21] in South India revealed that most students (78%) knew the sexual route of HPV transmission, and 25.8% believed that HPV infection could be asymptomatic. While 62.6% of students demonstrated awareness that cervical cancer results from persistent infection with high-risk HPV strains and acknowledged that HPV can affect males, only 37.2% recognized its link to oropharyngeal cancer. In addition, 49.5% of participants reported that condom use offers protection against HPV transmission.

Moreover, Khatiwada et al. [23] in Indonesia confirmed that 90% of students reported that HPV is the leading cause of cervical cancer, and 86.3% agreed that sexual transmission is crucial for the spread of HPV infections among individuals. The participants’ knowledge of the HPV vaccines was slightly greater than two-thirds. Regarding the administration of the HPV vaccine, 35% of students aged 15–20 years had received it. In contrast, 26% of students believed that 9–14 years was the optimal age range for receiving the vaccine, while 28% considered 21–26 years to be ideal.

Similarly, Cheema et al. [28] claimed that the majority (67.6%) of students knew that HPV can infect both males and females, and 58.3% stated that HPV can cause health effects in both men and women. Over half of the participants (53.8%) recognized that HPV is primarily transmitted through sexual intercourse, and 54% acknowledged that practicing safe sex – such as using condoms – can reduce the risk of transmission. In contrast, only 12.6% were aware that HPV infections often resolve spontaneously without medical intervention, and just 11.5% correctly identified the recommended vaccination age as between 11 and 12 years. A significant portion of participants believed that HPV could be transmitted through skin contact or sharing items, which mirrors misconceptions reported in studies from India and China. However, the persistence of these myths in our Iraqi sample may be influenced by limited sexual health education and cultural sensitivities surrounding (STIs). Iraq lacks coordinated national efforts to address HPV knowledge gaps. This suggests a need for culturally tailored educational interventions that respect local norms while promoting accurate information.

Similarly, a study by Khan et al. [19] revealed that approximately 53% of students stated that there is no vaccine against HPV, and 64% disagreed that a vaccine can prevent HPV. In addition, Khatiwada et al. [22] reported that over 70% of participants perceived the HPV vaccine as both safe and highly effective. However, approximately 21% believed that vaccination is unnecessary for individuals who are otherwise healthy.

Furthermore, Cheema et al. [28] reported that 71.5% of students would accept HPV vaccination if recommended by a physician, while Patel et al. [22] found that 90% of participants believed that vaccines were safe and expressed willingness to receive and promote them. Despite this general receptiveness, vaccine hesitancy remains pronounced among nursing students, with 20% expressing safety concerns and fewer than 3% reporting prior vaccination. This discrepancy suggests that professional exposure to healthcare information does not uniformly translate into vaccine confidence, highlighting the need for targeted educational interventions within nursing curricula.

Regarding peer and family influence, Di Giuseppe et al. [29] and Cheema et al. [28] noted that 54.5% of students desired more information before recommending the vaccine to others. This underscores a broader issue: Negative perceptions often stem from misinformation, particularly through social media, and limited understanding of HPV risks and vaccine benefits. Despite robust evidence supporting vaccine safety, concerns about side effects persist, exacerbated by cultural stigma surrounding sexually transmitted infections. Myths such as claim that the vaccine causes infertility or promotes early sexual activity further deter uptake, especially in conservative societies

Significantly, because HPV is spread through sexual contact, conversations about the virus and its vaccine are sometimes frowned upon in some cultures, which causes stigma and discourages people from being vaccinated. Myths and misinformation such as claim that the vaccine causes infertility or encourages early sexual behavior. Apart from safety concerns, other reasons that contribute to vaccine hesitation include cultural beliefs, misinformation, and poor access to reliable health education.

In terms of KA, Chowdhury et al. [30] found that 56.71% of participants had poor HPV knowledge, while Abdelaliem et al. [31] reported moderate attitudes among 57% of nursing students. Cheema et al. [27] similarly observed low knowledge levels, with only 22.4% demonstrating good understanding. Voidazan et al. [32] revealed that 6^th-year medical students in Romania had significantly higher HPV knowledge (62%) compared to 1^st-year students (55.1% with minimal understanding), suggesting that academic progression correlates with awareness. These findings emphasize the importance of integrating HPV education early in university programs to address knowledge gaps and foster informed attitudes.

Sociodemographic factors also influence attitudes. Abdelaliem et al. [30] confirmed a significant association with marital status, while academic year showed a negative correlation with nursing students’ attitudes toward vaccination. In contrast, age and marital status were positively linked to favorable perceptions. These trends suggest that maturity and life experience may enhance receptivity to preventive health measures.

This study has several limitations. First, its findings may not be generalizable beyond the sampled university in Sulaimani city. Future research should adopt multicenter designs to capture broader educational contexts. Second, the cross-sectional nature of the study limits causal inference; longitudinal or experimental approaches are needed to establish temporal relationships. Finally, due to the absence of a standardized global tool for assessing HPV KAs, the questionnaire was adapted from previously validated instruments, which may affect comparability across studies.

5. CONCLUSIONS

The results suggest a gap in KAs regarding HPV among university students. As future healthcare professionals, it is essential for students to possess a foundational understanding of HPV and its vaccine to effectively educate the public and promote preventive health behaviors. Therefore, it is crucial to develop community-based initiatives with a focus on integrating HPV education into school and university health curricula, organizing peer-led workshops, and engaging local healthcare professionals to culturally deliver sensitive and evidence based information. In addition, media campaigns should be strategically designed to correct prevalent misconceptions, particularly the myth that HPV is transmitted through airborne routes or casual contact. Messaging should clearly communicate that since sexual contact is the main way that HPV spreads, it is important to highlight the vaccine’s role in cancer prevention and foster open dialog to reduce stigma associated with sexually transmitted infections.

Moreover, practical outreach efforts could include setting up information booths in public spaces staffed by trained healthcare professionals, distributing educational brochures, and leveraging digital platforms to reach diverse audiences. These interventions should be inclusive and gender sensitive, ensuring that individuals of all backgrounds are equipped with accurate knowledge to make informed decisions about HPV prevention and risk management.

6. ACKNOWLEDGMENT

Gratitude is extended to all of the study participants for their participation and special thanks are given for their great assistance and collaboration in making the data collection process easier.

7. CONFLICTS OF INTEREST

The author affirms that they have no conflicts of interest.