Knowledge and attitudes about HPV infection and prevention methods among medical students in Yemen: a national cross- sectional study

Knowledge and attitudes about HPV infection and prevention methods among medical students in Yemen: a national cross- sectional study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Article Knowledge and attitudes about HPV infection and prevention methods among medical students in Yemen: a national cross- sectional study Mohamed Baklola, Naji Al-bawah, Ehab sharyan, Roa’a Al-ansi, Yousef Alqudaimi, and 8 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7687122/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Human papillomavirus (HPV) is the most common sexually transmitted infection and the primary cause of cervical cancer, as well as other anogenital and oropharyngeal malignancies. Despite proven effectiveness of vaccination, no national HPV immunization program exists in Yemen. Understanding medical students’ knowledge and attitudes is crucial, as they represent future healthcare providers and advocates. Methods A cross-sectional analytical study was conducted from 1 May to 30 July 2025 among undergraduate medical students across Yemen. Data were collected using a structured, self-administered online questionnaire adapted from validated instruments and reviewed by public health experts for contextual relevance. The survey assessed demographics, vaccination history, sources of information, knowledge (11 items; score range 0–11), and attitudes toward HPV vaccination. Statistical analysis was performed using SPSS version 28, employing descriptive statistics, chi-square tests, and logistic regression. Results A total of 2,285 students participated. Although 98.2% had heard of HPV, only 25.8% demonstrated good knowledge, with a median score of 4.0 (IQR 2.0–6.0). Misconceptions were common: only 58.8% recognized the association with multiple cancers, 49.0% identified HPV as the cause of genital warts, and 38.1% were aware that infection may be asymptomatic. In contrast, 58.5% expressed positive attitudes toward vaccination; 72.6% would recommend it to patients and 74.7% to family or friends, but only 56.3% supported nationwide introduction. The most cited barriers to vaccination were lack of knowledge (35.8%) and insufficient governmental support (34.9%). Independent predictors of good knowledge included male gender (AOR = 1.39), rural background (AOR = 1.96), being in the sixth study year (AOR = 1.43), and first hearing about HPV from doctors (AOR = 1.26). Positive attitudes were more likely among males (AOR = 1.50) and those with good knowledge (AOR = 2.41). Conclusion Yemeni medical students showed moderate knowledge but generally favorable attitudes toward HPV vaccination. These findings highlight the need for structured HPV education in medical curricula and underscore the importance of governmental support to facilitate future vaccine introduction in Yemen. Biological sciences/Cancer Health sciences/Diseases Health sciences/Health care Health sciences/Medical research Health sciences/Oncology Human papillomavirus HPV vaccine medical students knowledge Yemen Figures Figure 1 Figure 2 Background Human papillomavirus (HPV) is one of the most prevalent sexually transmitted infections (STIs) worldwide, with an estimated lifetime risk of infection exceeding 80% [ 1 ]. Globally, the prevalence of HPV infection varies considerably, with the highest rates reported in sub-Saharan Africa (24%), followed by Latin America and the Caribbean (16%), Eastern Europe (14%), and Southeast Asia (14%) [ 2 ]. The global pooled prevalence is approximately 17%, with the majority of infections occurring among young people between 15 and 24 years of age [ 2 ]. Although most HPV infections are transient and resolve spontaneously, persistent infection with high-risk HPV genotypes can lead to the development of precancerous lesions and malignant disease [ 3 ]. To date, over 200 HPV genotypes have been identified, which are broadly classified as high-risk or low risk depending on their oncogenic potential. Low-risk genotypes, such as HPV-6 and HPV-11, are primarily associated with benign conditions including genital warts. In contrast, at least 12 genotypes, particularly HPV-16 and HPV-18, are recognized as high-risk types with the potential to cause cervical intraepithelial neoplasia and invasive cancers [ 3 , 4 ]. HPV infection is transmitted predominantly through sexual contact, although perinatal transmission during childbirth and, less commonly, contact with contaminated fomites have also been documented [ 5 ]. The major risk factors for acquisition include multiple sexual partners, early initiation of sexual activity, and co-infection with other STIs [ 5 ]. The public health impact of HPV is profound. Globally, HPV is responsible for more than 660,000 new cancer cases annually [ 6 ]. Cervical cancer remains the most significant HPV-related malignancy, accounting for more than 90% of HPV-attributable cancers in women [ 6 ]. HPV is also linked to cancers of the vulva, vagina, anus, penis, and oropharynx, affecting both sexes [ 6 ]. HPV-related disease burden in Yemen reflects the challenges faced by many low-income countries. According to the International Agency for Research on Cancer (IARC), cervical cancer is the 12th most common cancer among Yemeni women overall and the 8th most frequent among women aged 15–44 years. Each year, an estimated 225 women are diagnosed with cervical cancer and 153 die from the disease [ 7 ]. Despite this burden, Yemen has not yet introduced HPV vaccination into its national immunization program, and there are no official national cervical cancer screening guidelines [ 7 ]. This gap leaves women particularly vulnerable to preventable morbidity and mortality. The introduction of prophylactic HPV vaccines has been a transformative milestone in cancer prevention. Clinical trials and real-world evidence demonstrate that these vaccines prevent more than 90% of HPV-related cancers when administered prior to exposure [ 8 , 9 ]. The World Health Organization (WHO) recommends routine vaccination of girls and boys aged 9–14 years, with catch-up programs extending into early adulthood [ 10 ]. Many high- and middle-income countries, such as Australia, Norway, and Germany, have successfully integrated HPV vaccination into national programs, leading to significant declines in HPV prevalence and related diseases [ 11 ]. However, in regions such as Yemen, barriers including limited resources, lack of awareness, cultural sensitivities, and absence of government prioritization impede vaccine adoption. Medical students, as future healthcare providers, play a pivotal role in shaping community knowledge and promoting preventive practices. Their awareness and attitudes toward HPV and its vaccine directly influence their capacity to educate patients and advocate for public health interventions. Previous studies across diverse contexts, including Turkey, Ukraine, and India, have consistently reported inadequate knowledge and variable attitudes toward HPV among medical students, underscoring the need for improved educational interventions [ 12 – 14 ]. In Yemen, where epidemiological data on HPV are scarce and vaccination remains unavailable, assessing medical students’ understanding is particularly important. Therefore, this study seeks to evaluate the knowledge and attitudes of Yemeni medical students toward HPV infection and its prevention. By identifying gaps in awareness and barriers to vaccine acceptance, the findings may inform both curricular improvements in medical education and policy advocacy for the eventual introduction of HPV vaccination in Yemen. Methods Study design and setting This was a cross-sectional analytical study conducted between 25 July 2025 and 25 August 2025. The study population comprised undergraduate medical students enrolled in faculties of medicine across Yemen. To maximize accessibility to students from different universities and academic years, data collection was conducted online. Participants and eligibility criteria All medical students in Yemen were eligible to participate, irrespective of age, gender, or academic year. Inclusion criteria were enrollment in a Yemeni faculty of medicine and provision of informed consent. Students who declined participation or submitted incomplete responses were excluded from the analysis. Sample size calculation The sample size was determined using MedCalc version 15.8, with the primary outcome set as the proportion of medical students aware of HPV infection. Reference values were derived from international literature, which reported an awareness level of 91.5% among undergraduate students [ 15 ]. Assuming a 5% margin of error, a statistical power of 80%, and a two-sided significance level of 5%, the minimum required sample size was estimated at 135 participants. To account for potential clustering effects and to improve the representativeness of the findings, the calculated sample was inflated by a design effect of 15, resulting in a minimum target of 2,025 students. A total of 2,285 students completed the questionnaire, thereby exceeding the required number and strengthening the statistical power and reliability of the study results. Data collection tool Data were collected using a structured, self-administered questionnaire that was designed after reviewing previously validated instruments from similar HPV knowledge and attitude studies and then adapted to fit the Yemeni context [ 14 – 16 ]. The questionnaire was composed of four main domains. The first section captured socio-demographic information, including age, gender, university, year of study, and place of residence prior to university. The second section explored HPV vaccination history and sources of information, including prior vaccination, intention to be vaccinated, and whether students had attended any educational activities related to HPV. The third section assessed knowledge about HPV infection and vaccination through 11 statements covering modes of transmission, health consequences, and preventive measures; each correct answer was scored as one point, with a total possible score of 0–11. Knowledge levels were categorized as “good” if the total score exceeded the median and “poor” if it was at or below the median. The fourth section assessed attitudes toward HPV vaccination through three items evaluating participants’ willingness to recommend the vaccine to patients, relatives, and friends, as well as their support for implementing vaccination in Yemen. Responses were scored dichotomously (Yes = 1, No = 0), with a total score of 0–3; scores above the median were considered indicative of a positive attitude. To ensure clarity, cultural appropriateness, and contextual relevance, the initial draft of the questionnaire was reviewed by three experts in public health and epidemiology in Yemen. Their feedback led to minor modifications, including rephrasing technical terms into simpler language, adjusting examples to reflect the local healthcare context, and ensuring sensitivity to cultural norms surrounding sexual health discussions. To further establish content validity, the same panel of experts independently evaluated the questionnaire items for clarity and relevance. The content validity index (CVI) was calculated at three levels: item-level CVI (I-CVI), expert-level CVI (E-CVI), and scale-level CVI (S-CVI) [ 17 ]. At the item level, the I-CVI was determined by dividing the number of experts rating an item as clear and relevant (rating ≥ 3 on a 4-point scale) by the total number of experts. Items were considered appropriate if I-CVI was > 0.79, required revision if between 0.70 and 0.79, and were eliminated if < 0.70. The E-CVI was obtained by dividing the number of relevant items by the total number of items assessed by each expert, while the S-CVI was calculated by averaging all I-CVI values across items. An S-CVI ≥ 0.90 indicated strong overall content validity. A pilot test was then conducted with 50 students from different academic years to confirm comprehensibility and acceptability of the survey. Results of the pilot indicated good overall clarity, and Cronbach’s alpha for internal consistency was 0.76, demonstrating acceptable reliability. Sampling and data collection procedure A convenience sampling approach was employed. The survey was hosted on Google Forms and distributed through official university Telegram channels, student WhatsApp groups, and other academic social media platforms. The survey remained open for one month, and reminders were sent weekly to encourage participation. Participation was voluntary, and all responses were anonymous. Statistical analysis Data were analyzed using IBM SPSS Statistics version 28 (IBM Corp., Armonk, NY, USA). Descriptive statistics were presented as frequencies and percentages for categorical variables, and medians with interquartile ranges (IQR) for non-normally distributed continuous variables. The Shapiro–Wilk test was applied to test normality. Associations between categorical variables were examined using Pearson’s chi-square test, while continuous variables were compared using the Mann–Whitney U test. Binary logistic regression analysis was performed to identify independent predictors of good knowledge and positive attitudes. Variables significant at p < 0.20 in univariate analysis were entered into multivariable models using a forward stepwise likelihood ratio method. Adjusted odds ratios (AOR) with 95% confidence intervals (CI) were reported. Multicollinearity was checked using variance inflation factor (VIF), and model adequacy was evaluated using the Hosmer–Lemeshow goodness-of-fit test. A p value < 0.05 was considered statistically significant. Results Participant characteristics A total of 2,285 medical students participated in the study (Table 1 ). The majority were female (56.4%), aged between 20 and 24 years (66.1%), and from urban areas (77.5%). More than one-third of the participants were in their 3rd (24.4%) or 4th (20.3%) year of study. Almost all students (98.2%) had heard about the HPV vaccine, most frequently from doctors (36.3%) or university courses (31.9%). Less than half (45.4%) had attended an educational session about HPV infection or vaccination in the past year, mainly through university lectures (45.7%) or education provided by physicians (40.4%). Only 40.0% reported actively searching for information about HPV in the month preceding the survey. Awareness of vaccine availability in Yemen was limited: nearly half of students (48.4%) reported that they did not know whether HPV vaccines were available. Approximately one-third (32.7%) knew someone who had or had had cervical cancer. Table 1 Sociodemographic, clinical, and health-related characteristics of study participants (N = 2848) Characteristic Level/category N (Percent %) Age (years), Mean ± SD 33.3 ± 10.8 Residence Urban 1980 (69.6) Rural 868 (30.5) Location North 2436 (85.5) South 412 (14.5) Marital Status Married 1869 (65.8) Single 711 (25.0) Widow 165 (5.8) Divorced 95 (3.3) Education Level University degree or higher 758 (26.6) Secondary school 571 (20.0) Preparatory school 288 (10.1) Primary school 343 (12.0) Read and write only 374 (13.1) Non-literate 514 (18.0) Employment Employed 581 (20.4) Unemployed 2267 (79.6) Self-Reported Income Enough with saving 285 (10.0) Enough 1055 (37.0) Not enough 1481 (52.0) Number of Pregnancies, Median (IQR) 2257, 4 (2–6) Number of Children, Median (IQR) 2248, 3 (2–5) Contraceptive Use Yes 1021 (43.1) No 1347 (56.9) Payment for Medical Services Self-Funded 2210 (77.6) Health Insurance 526 (18.5) Government 110 (3.9) Personal History of Any Cancer Yes 118 (4.2) Family History of Cervical Cancer (1st degree) Yes 134 (4.7) Knows Someone Who Died of Cervical Cancer Yes 436 (15.3) Discussed CC Screening with a Physician Yes 131 (4.6) Note : Data are presented as n (%) unless otherwise specified. SD: Standard Deviation; IQR: Interquartile Range. CC: Cervical Cancer. Percentages may not total 100 due to rounding. The 'N' for Number of Pregnancies and Children is based on ever-married women who responded to those specific questions. Knowledge about HPV Overall, knowledge levels were low, with only 25.8% of students demonstrating good knowledge (Table 2 ). The median knowledge score was 4.0 (IQR: 2.0–6.0) out of a possible 11. Misconceptions were common; only 58.8% correctly recognized the association between HPV and cervical, penile, and anal cancers, while less than half (49.0%) identified the link between HPV and genital warts. Knowledge about asymptomatic infection (38.1%) and commonality of HPV infection (41.6%) was also limited. Attendance at HPV-related education was strongly associated with better knowledge. Students who had attended educational sessions had significantly higher correct response rates across nearly all knowledge items, with a higher proportion achieving good knowledge (32.7% vs. 20.1%; P < 0.001) and a higher median knowledge score (5.0 vs. 4.0; P < 0.001). Table 2 Participants' knowledge regarding cervical cancer and screening (N = 2848) Knowledge assessment item Category N (Percent %) Overall knowledge score, Median (IQR) 35 (25–46) Knowledge Level Poor 2833 (99.5) Adequate 15 (0.5) Self-rated knowledge of CC screening (≥ 8/10) Yes 171 (6.0) Correctly identified a benefit of CC screening? Yes 660 (22.7) Correctly identified recommended age for screening? Yes 556 (19.1) Knew the tools used for CC screening? Yes 291 (10.3) Correctly identified the frequency of screening? Yes 175 (6.0) Knew screening should be done without symptoms? Yes 1539 (54.0) Would like more information about CC screening? Yes 2106 (73.9) Note : Data are presented as n (%). IQR: Interquartile Range. CC: Cervical Cancer. In terms of self-assessed knowledge, 61.3% of participants rated their knowledge about HPV infection as sufficient, whereas only 46.0% and 42.0% considered their knowledge about HPV prevention and vaccination sufficient, respectively (Fig. 1 ). Attitudes toward HPV vaccination Most participants expressed favorable attitudes toward HPV vaccination (Table 3 ). Nearly three-quarters reported that they would recommend the HPV vaccine to future patients (72.6%) and to family or friends (74.7%). A smaller proportion stated they would advocate for HPV vaccination in Yemen (56.3%). Overall, 58.5% of students demonstrated positive attitudes, with a median attitude score of 3.0 (IQR: 2.0–4.0). Table 3 Participants' attitudes towards cervical cancer screening and perceived barriers (N = 2848) Attitude assessment item Category N (Percent %) Overall attitude score, Median (IQR) 34 (27–40) Attitude Level Positive 274 (9.6) Neutral 1404 (49.3) Negative 1170 (41.1) Intention and beliefs Will voluntarily seek CC screening Yes 1530 (53.7) Will undergo screening if a doctor recommends Yes 2436 (85.6) Will participate in a mass screening program Yes 2149 (75.5) Doubts the effectiveness of screening Yes 1005 (35.3) Perceived barriers Financial burden Yes 2011 (70.6) Lack of knowledge about screening Yes 1843 (64.7) Lack of knowledge about screening tools Yes 1743 (61.2) Don't know where to go for screening Yes 1596 (56.1) Fear of the results Yes 1563 (54.9) Fear of the procedure Yes 1474 (51.8) Shyness Yes 1022 (35.9) Uncomfortable with doctors Yes 877 (30.8) Lack of time Yes 708 (24.9) Previous bad experience Yes 513 (18.0) Note : Data are presented as n (%). IQR: Interquartile Range. CC: Cervical Cancer. For the "Perceived Barriers" section, participants could report more than one barrier; therefore, percentages do not sum to 100. Barriers to HPV vaccination When asked about perceived barriers to HPV vaccination in Yemen, the most frequently reported obstacle was lack of knowledge about HPV (35.8%), followed closely by lack of government support (34.9%). Fewer participants identified high cost (14.8%) or religious and cultural beliefs (14.5%) as the main barriers (Fig. 2 ). Factors associated with good knowledge Multivariate logistic regression identified several independent predictors of good HPV knowledge (Table 4 ). Male students were more likely to have good knowledge compared with females (AOR = 1.39, 95% CI: 1.14–1.69; P = 0.001). Sixth-year students were significantly more knowledgeable compared with first-year students (AOR = 1.43, 95% CI: 1.03–1.98; P = 0.031). Students from rural backgrounds were also more likely to have good knowledge (AOR = 1.96, 95% CI: 1.58–2.45; P < 0.001). Source of information played a role: those who first heard about HPV vaccines from doctors were more knowledgeable (AOR = 1.26, 95% CI: 1.03–1.55; P = 0.028), while students informed by parents, relatives, or friends were less likely to have good knowledge (AOR = 0.57, 95% CI: 0.41–0.79; P < 0.001). Self-assessed sufficient knowledge of HPV infection was strongly associated with objective good knowledge (AOR = 1.53, 95% CI: 1.22–1.91; P < 0.001). Table 4 Practice of cervical cancer screening among participants (N = 2848) Practice assessment item Category N (Percent %) Overall practice score, Median (IQR) 3 (0–3) Practice Level Good 59 (2.1) Adequate 105 (3.7) Poor 2684 (94.2) Ever been recommended for CC screening? Yes 143 (5.0) No 2704 (95.0) Ever had a CC screening test? Yes 98 (3.5) No 2738 (96.5) Interested in having CC screening in the future? Yes 2069 (72.7) No 778 (27.3) Note : Data are presented as n (%). IQR: Interquartile Range. CC: Cervical Cancer. Factors associated with positive attitudes Multivariate analysis revealed that male gender (AOR = 1.50, 95% CI: 1.14–1.97; P = 0.004) and good objective knowledge of HPV (AOR = 2.41, 95% CI: 1.79–3.26; P < 0.001) were independently associated with positive attitudes toward HPV vaccination (Table 5 ). In contrast, students in the 4th and 5th years of study were significantly less likely to have positive attitudes compared with first-year students (AOR = 0.55, 95% CI: 0.37–0.82; P = 0.003 and AOR = 0.46, 95% CI: 0.31–0.68; P < 0.001, respectively). Students aged ≥ 25 years also demonstrated lower odds of positive attitudes (AOR = 0.44, 95% CI: 0.23–0.84; P = 0.013). Importantly, receiving education from doctors (AOR = 0.58, 95% CI: 0.43–0.77; P < 0.001) or peers (AOR = 0.37, 95% CI: 0.24–0.56; P < 0.001) was associated with less positive attitudes compared with university lectures. Table 5 Association of sociodemographic factors with adequate knowledge and referral for screening Characteristic Category Adequate knowledge n (%) Ever recommended for screening n (%) P-value Residence Urban 3 (0.4%) 112 (5.7%) 0.019 Rural 2 (0.1%) 31 (3.6%) Employment Employed 3 (2.5%) 51 (8.8%) < 0.001 Unemployed 13 (0.5%) 92 (4.1%) Educational Level High (Secondary+) 8 (0.6%) 81 (6.1%) 0.014 Low (Preparatory-) 8 (0.6%) 62 (4.1%) Health insurance Covered 4 (0.7%) 25 (3.9%) < 0.001 Self-funded 9 (0.4%) — Note : P-values were calculated using the Chi-square (χ2) test. Educational Level was categorized for this analysis: 'High' includes secondary school certificate and above; 'Low' includes preparatory school certificate and below. 'MD' refers to a medical doctor. The '—' symbol indicates data was not applicable for that specific comparison. Percentages represent the proportion within each row's category. Discussion This national cross-sectional study assessed knowledge and attitudes regarding HPV infection and vaccination among Yemeni medical students. Although almost all participants (98.2%) had heard of HPV, only one-quarter (25.8%) demonstrated objectively good knowledge based on the scoring system. In contrast, more than half (58.5%) expressed positive attitudes toward HPV vaccination, indicating a notable gap between awareness and understanding. These findings highlight both the deficiencies in knowledge and the opportunities for educational interventions among future healthcare providers in Yemen. The relatively low knowledge observed in our study (median score 4.0/11; only 25.8% classified as having “good” knowledge) is consistent with reports of limited HPV knowledge among medical students in other settings, although absolute levels vary widely for example, 2.1% with good knowledge reported in one Egyptian study and 45% of students in an Indian study correctly identifying HPV as the main cause of cervical cancer [ 14 , 18 ]. In our sample, misconceptions were particularly pronounced: only 58.8% recognized the association between HPV and cervical, penile, and anal cancers, fewer than half (49.0%) knew that HPV can cause genital warts, and only 38.1% were aware that HPV infection can be asymptomatic. These gaps are important because they can perpetuate stigma and hinder effective patient education, a pattern also reported among medical students in other countries [ 16 , 19 ]. Attendance at HPV-related education was strongly associated with improved knowledge in our study. Students who had attended lectures or workshops achieved a higher median score (5.0 vs. 4.0, P < 0.001) and were more likely to be categorized as knowledgeable (32.7% vs. 20.1%, P < 0.001). Comparable effects of structured education have been reported in Croatia and the United States, where targeted sessions significantly improved factual knowledge and increased willingness to vaccinate [ 15 , 20 ]. These findings underscore the importance of incorporating HPV education into the formal medical curriculum rather than leaving students to rely on informal sources. Gender and academic level were also important determinants. Male students were more likely than females to demonstrate good knowledge (AOR = 1.39, 95% CI: 1.14–1.69) and positive attitudes (AOR = 1.50, 95% CI: 1.14–1.97). This contrasts with findings from India and China, where female students often showed better awareness of HPV [ 14 , 21 ]. The reasons for these differences may be cultural; in Yemen, public discourse on cervical cancer is limited, and male students may face fewer barriers in accessing information. With regard to study year, sixth-year students were more knowledgeable than first-year students (AOR = 1.43, 95% CI: 1.03–1.98), consistent with studies in Romania and Serbia that reported higher scores among senior students [ 16 , 19 ]. However, we also observed that fourth- and fifth-year students were less likely than first years to hold positive attitudes toward vaccination (AOR = 0.55 and 0.46, respectively), suggesting that enthusiasm may decline as students’ progress through their training, possibly due to insufficient emphasis on preventive health in later years [ 22 ]. A further noteworthy finding is the discrepancy between self-perceived and actual knowledge. While 61.3% of students rated their knowledge of HPV infection as sufficient, only 25.8% achieved good scores on objective measures. Similar overestimation has been documented in Egyptian and Chinese studies, where students felt confident about their knowledge but performed poorly on factual assessments [ 18 , 21 ]. This mismatch is concerning, as it may lead to overconfidence in clinical counseling without a sound knowledge base [ 23 ]. With respect to barriers, 35.8% of participants cited lack of knowledge and 34.9% cited insufficient governmental support as the main obstacles to HPV vaccination. By contrast, only 14.8% considered cost and 14.5% considered cultural or religious beliefs as barriers. These findings differ from studies in Uganda and Egypt, where cultural stigma and financial constraints were more prominent obstacles [ 18 , 24 ]. The Yemeni results suggest that medical students primarily recognize systemic and informational barriers rather than personal or cultural ones [ 25 ]. Importantly, nearly half of students (48.4%) did not know whether HPV vaccines were available in Yemen, reflecting both the absence of a national program and limited public health communication. This uncertainty is particularly concerning given that medical students are expected to serve as reliable sources of information for patients and the community [ 26 ]. Similar confusion has been reported in studies from Egypt and Uganda, where many students and young adults were unaware of vaccine availability despite its presence in private markets [ 18 , 24 ]. The lack of clarity in Yemen highlights missed opportunities for health authorities to disseminate accurate information about HPV and its prevention [ 27 ]. Even in contexts where vaccines are not yet part of national schedules, transparent communication can help normalize the idea of HPV vaccination, reduce misconceptions, and prepare the population for future implementation. Overall, these findings parallel results from other developing countries, where medical students often display limited knowledge but favorable attitudes toward HPV vaccination. The strong associations between education, knowledge, and attitudes observed in this study support the need for structured curricular interventions. At the same time, the identification of governmental inaction as a barrier highlights the importance of policy-level support for HPV vaccination in Yemen. Limitations This study has several limitations that should be considered when interpreting the findings. First, the use of convenience sampling through online platforms may have introduced selection bias, as students with greater internet access or interest in health topics may have been more likely to participate. Second, the reliance on self-administered questionnaires carries the risk of recall bias and socially desirable responses, particularly on sensitive issues related to sexual health. Third, the cross-sectional design precludes causal inferences between knowledge, attitudes, and associated factors. Finally, although the study included a large and diverse sample of students across Yemen, the findings may not be fully generalizable to all young people or to students in non-medical disciplines. Conclusion This study revealed that Yemeni medical students possess moderate knowledge but generally favorable attitudes toward HPV infection and its prevention. While most students had heard of HPV, only one-quarter demonstrated good objective knowledge, and misconceptions about transmission and disease burden were common. Encouragingly, more than half expressed willingness to recommend HPV vaccination, highlighting a readiness to support future prevention efforts. These findings emphasize the urgent need to strengthen HPV-related education within medical curricula and underscore the importance of governmental commitment to introducing a national HPV vaccination program to reduce the preventable burden of HPV-related diseases in Yemen. Declarations Ethical approval and consent to participate The methods employed in this study adhered to the principles outlined in the Declaration of Helsinki and its subsequent amendments. Ethical approval was obtained from the Institutional Review Board at Amran University (Approval No. 855). Participation in the study was entirely voluntary, anonymous, and without any form of compensation. The objectives of the study were clearly explained on the first page of the online questionnaire. Participants provided electronic informed consent before beginning the survey and were free to withdraw at any point without any consequences. Data availability The datasets used and analyzed during the current study are available from the corresponding author upon reasonable request. Funding None. Competing interest The authors declare that they do not have any potential conflicts of interest concerning the research, authorship, and/or publication of this report. Consent for publication Not Applicable. Clinical trial number Not applicable Acknowledgments The authors would like to express their sincere gratitude to Dr. Mohamed Al-Eryani for his valuable support and guidance during the course of this work. Authors' contributions Mohamed Baklola¹ *† and Naji Al-bawah² *† contributed equally to the conception, design, and supervision of the study. Ehab Sharyan³ contributed to data collection and analysis. Roa’a Al-ansi⁴ contributed to methodology and manuscript preparation. Yousef Alqudaimi⁵ contributed to statistical analysis and validation. Kotoz Al-mansoob⁶ contributed to data acquisition and literature review. Mohammed Al-harogi⁷ contributed to visualization and results interpretation. Fadl Al-Halimi⁸ contributed to resources and data curation. Khairi Alhetari⁹ contributed to formal analysis and manuscript editing. Mohamed Mabrouk Ghonaim¹⁰ contributed to critical revision and technical guidance. Najim Z. Alshahrani¹¹ contributed to supervision and project administration. Omar Hammam Salloum¹² contributed to drafting and reviewing the manuscript. Mohamed Basyouni Helal¹³ contributed to overall review and final approval of the manuscript. References Scott-Wittenborn N, Fakhry C. Epidemiology of HPV Related Malignancies. Semin Radiat Oncol [Internet]. 2021 Oct 1 [cited 2025 Aug 30];31(4):286–96. Available from: https://pubmed.ncbi.nlm.nih.gov/34455984/ Makiani MJ, Minaeian S, Moghaddam SA, Moosavi SA, Moeini Z, Zamani V, et al. 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HPV Vaccine Hesitancy Among Medical Students in China: A Multicenter Survey. Front Public Health [Internet]. 2022 Feb 21 [cited 2025 Aug 30];10:774767. Available from: www.frontiersin.org Schriek J, Carstensen B, Soellner R, Klusmann U. Pandemic rollercoaster: University students’ trajectories of emotional exhaustion, satisfaction, enthusiasm, and dropout intentions pre-, during, and post-COVID-19. Teach Teach Educ [Internet]. 2024 Oct 1 [cited 2025 Aug 30];148:104709. Available from: https://www.sciencedirect.com/science/article/pii/S0742051X24002415 Al-Maghrabi M, Mamede S, Schmidt HG, Omair A, Al-Nasser S, Alharbi NS, et al. Overconfidence, Time-on-Task, and Medical Errors: Is There a Relationship? Adv Med Educ Pract [Internet]. 2024 [cited 2025 Aug 30];15:133. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC10896093/ Bitariho GK, Tuhebwe D, Tigaiza A, Nalugya A, Ssekamatte T, Kiwanuka SN. Knowledge, perceptions and uptake of human papilloma virus vaccine among adolescent girls in Kampala, Uganda; a mixed-methods school-based study. BMC Pediatr [Internet]. 2023 Dec 1 [cited 2025 Aug 30];23(1). Available from: https://pubmed.ncbi.nlm.nih.gov/37461002/ Mohamed NA, Abdel-Aziz HR, Elsehrawy MG. Cultural Influences: Female Students’ Awareness and Perception Regarding Human Papillomavirus Vaccine. SAGE Open Nurs [Internet]. 2025 Jan 4 [cited 2025 Aug 30];11:23779608251363840. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC12326092/ Randall V, Villareal C. “It’s Okay to Say ‘I Don’t Know’”: Medical Students Use Transformative Thinking to Cope with Ambiguity and Uncertainty. MedEdPublish [Internet]. 2020 Jan 15 [cited 2025 Aug 30];9:14. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC10702687/ Ali B, Galbarczyk A, Jasienska G, Ba-Break M, Gül H. Factors related to knowledge, attitudes, and behaviors regarding cervical cancer among Yemeni women. BMC Cancer [Internet]. 2024 Dec 1 [cited 2025 Aug 30];24(1):695. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC11157752/ Additional Declarations No competing interests reported. Supplementary Files Supplementarytables.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7687122","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Article","associatedPublications":[],"authors":[{"id":526480754,"identity":"f12a9925-dcdf-4e04-8fe0-c3cefb586d4c","order_by":0,"name":"Mohamed Baklola","email":"","orcid":"","institution":"Mansoura university hospitals","correspondingAuthor":false,"prefix":"","firstName":"Mohamed","middleName":"","lastName":"Baklola","suffix":""},{"id":526480755,"identity":"cd6f06cc-527f-4629-9280-853c51528073","order_by":1,"name":"Naji Al-bawah","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA/ElEQVRIiWNgGAWjYBACgwMMCQcYCg4AmTyMD0AkHyEtFmAtBmAtzAYgko2QFpsDULtAiiVAbMJajh94eOCHwR15g+Nnj1V+zbGTYWNgfvjoBh4tZmcSEg72GDwz3HAmL+227LZkoMPYjI1z8Gk5kJBwgMfgMOO2AzlmtyW3MQO18LBJ49NifP5BwsE/Boftt51/Y1Ysua2esBbDGwkJh4G2JG67kWPG+HHbYWK0PEg4LGPwLHn/jTfG0ozbjvOwMRPwi8H5nOSPbyru2M7szzH8+HNbtT0/e/PDx/i0AKMjAc5k5gGTeJWDAPsBOJPxB0HVo2AUjIJRMBIBACIFVOLRDxVfAAAAAElFTkSuQmCC","orcid":"","institution":"Sana'a University","correspondingAuthor":true,"prefix":"","firstName":"Naji","middleName":"","lastName":"Al-bawah","suffix":""},{"id":526480756,"identity":"f3a7ac8d-d913-4c2b-aabc-83ddf16d072f","order_by":2,"name":"Ehab sharyan","email":"","orcid":"","institution":"Sana'a University","correspondingAuthor":false,"prefix":"","firstName":"Ehab","middleName":"","lastName":"sharyan","suffix":""},{"id":526480757,"identity":"8b2f079e-8d29-4bd5-9784-20e1191858d1","order_by":3,"name":"Roa’a Al-ansi","email":"","orcid":"","institution":"Sana'a University","correspondingAuthor":false,"prefix":"","firstName":"Roa’a","middleName":"","lastName":"Al-ansi","suffix":""},{"id":526480758,"identity":"2ff300e8-a007-454c-8f6a-f3b93fce69fa","order_by":4,"name":"Yousef Alqudaimi","email":"","orcid":"","institution":"Sana'a University","correspondingAuthor":false,"prefix":"","firstName":"Yousef","middleName":"","lastName":"Alqudaimi","suffix":""},{"id":526480759,"identity":"6a3044be-6b7a-4d8c-a6e4-14bf1f8d9a61","order_by":5,"name":"Kotoz Al-mansoob","email":"","orcid":"","institution":"Jiblah University","correspondingAuthor":false,"prefix":"","firstName":"Kotoz","middleName":"","lastName":"Al-mansoob","suffix":""},{"id":526480760,"identity":"efe9e102-072e-4cf5-9182-5060bc8b8c16","order_by":6,"name":"Mohammed Al-harogi","email":"","orcid":"","institution":"Sana'a University","correspondingAuthor":false,"prefix":"","firstName":"Mohammed","middleName":"","lastName":"Al-harogi","suffix":""},{"id":526480761,"identity":"c84d2fb4-b2bf-4bb8-aa76-9b1d17cafa89","order_by":7,"name":"Fadl Al-Halimi","email":"","orcid":"","institution":"Jiblah University","correspondingAuthor":false,"prefix":"","firstName":"Fadl","middleName":"","lastName":"Al-Halimi","suffix":""},{"id":526480762,"identity":"b32d16af-2b38-4dac-9754-2a8ec3c3972a","order_by":8,"name":"Khairi Alhetari","email":"","orcid":"","institution":"September University for Medical and Applied Sciences","correspondingAuthor":false,"prefix":"","firstName":"Khairi","middleName":"","lastName":"Alhetari","suffix":""},{"id":526480763,"identity":"c9e58037-c082-47a9-876e-34b4fbded8c4","order_by":9,"name":"Mohamed Mabrouk Ghonaim","email":"","orcid":"","institution":"Mansoura university hospitals","correspondingAuthor":false,"prefix":"","firstName":"Mohamed","middleName":"Mabrouk","lastName":"Ghonaim","suffix":""},{"id":526480764,"identity":"fa52778a-248b-4867-8f41-11aebff224e5","order_by":10,"name":"Najim Z. 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02:10:43","extension":"html","order_by":11,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":120285,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7687122/v1/6882e126ae42104089a01e75.html"},{"id":93728188,"identity":"0af42ed3-15cd-4d7e-99ec-a0d78a27aa9f","added_by":"auto","created_at":"2025-10-17 02:10:38","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":74180,"visible":true,"origin":"","legend":"\u003cp\u003eViolin plots showing the distribution of scores for knowledge, attitude, and practice (KAP) towards cervical cancer screening\u003c/p\u003e\n\u003cp\u003eThe figure illustrates a stark contrast in the distribution of scores across the three domains of the study. \u003cstrong\u003eKnowledge\u003c/strong\u003eand \u003cstrong\u003epractice\u003c/strong\u003e scores were overwhelmingly low, with the vast majority of responses concentrated near zero. This indicates a significant deficit in both awareness and the uptake of screening practices. In contrast, \u003cstrong\u003eattitude\u003c/strong\u003escores showed a more normal distribution, with a median of approximately 50%, suggesting that participants hold a moderately neutral to positive attitude towards cervical cancer screening, even in the absence of deep knowledge or practice.\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7687122/v1/45d2eaf2e7d57a23ef29629c.jpeg"},{"id":93728224,"identity":"f85015aa-f0f3-4409-83c8-35d4f772b300","added_by":"auto","created_at":"2025-10-17 02:10:44","extension":"jpeg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":163780,"visible":true,"origin":"","legend":"\u003cp\u003eHeatmap of Pearson correlation coefficients between sociodemographic variables and KAP Scores\u003c/p\u003e\n\u003cp\u003eThis heatmap reveals the relationships between participants' demographic data and their knowledge, attitude, and practice (KAP) scores. As expected, strong positive correlations were found among the demographic variables, particularly between the number of \u003cstrong\u003epregnancies\u003c/strong\u003eand \u003cstrong\u003echildren\u003c/strong\u003e (r = 0.9). Among the main study variables, a moderate positive correlation was observed between \u003cstrong\u003eattitude\u003c/strong\u003e and \u003cstrong\u003epractice\u003c/strong\u003e(r = 0.33), suggesting that women with more positive attitudes were more likely to engage in screening practices. Notably, \u003cstrong\u003eknowledge\u003c/strong\u003e showed no meaningful correlation with any other variable, including attitude, practice, or age.\u003c/p\u003e","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7687122/v1/24e86140ceef53c67b8e621f.jpeg"},{"id":93730010,"identity":"e968c883-c1f5-489f-9153-7568609bedbe","added_by":"auto","created_at":"2025-10-17 02:18:45","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1706679,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7687122/v1/0729fcd3-02fc-44bd-a5a7-6c0fd3c58d2d.pdf"},{"id":93728221,"identity":"2129ef3d-8f6f-4c3e-a382-07ce800034f3","added_by":"auto","created_at":"2025-10-17 02:10:43","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":16392,"visible":true,"origin":"","legend":"","description":"","filename":"Supplementarytables.docx","url":"https://assets-eu.researchsquare.com/files/rs-7687122/v1/a5534c7a4313947c1c067c27.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Knowledge and attitudes about HPV infection and prevention methods among medical students in Yemen: a national cross- sectional study","fulltext":[{"header":"Background","content":"\u003cp\u003eHuman papillomavirus (HPV) is one of the most prevalent sexually transmitted infections (STIs) worldwide, with an estimated lifetime risk of infection exceeding 80% [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Globally, the prevalence of HPV infection varies considerably, with the highest rates reported in sub-Saharan Africa (24%), followed by Latin America and the Caribbean (16%), Eastern Europe (14%), and Southeast Asia (14%) [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. The global pooled prevalence is approximately 17%, with the majority of infections occurring among young people between 15 and 24 years of age [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Although most HPV infections are transient and resolve spontaneously, persistent infection with high-risk HPV genotypes can lead to the development of precancerous lesions and malignant disease [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eTo date, over 200 HPV genotypes have been identified, which are broadly classified as high-risk or low risk depending on their oncogenic potential. Low-risk genotypes, such as HPV-6 and HPV-11, are primarily associated with benign conditions including genital warts. In contrast, at least 12 genotypes, particularly HPV-16 and HPV-18, are recognized as high-risk types with the potential to cause cervical intraepithelial neoplasia and invasive cancers [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. HPV infection is transmitted predominantly through sexual contact, although perinatal transmission during childbirth and, less commonly, contact with contaminated fomites have also been documented [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. The major risk factors for acquisition include multiple sexual partners, early initiation of sexual activity, and co-infection with other STIs [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe public health impact of HPV is profound. Globally, HPV is responsible for more than 660,000 new cancer cases annually [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Cervical cancer remains the most significant HPV-related malignancy, accounting for more than 90% of HPV-attributable cancers in women [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. HPV is also linked to cancers of the vulva, vagina, anus, penis, and oropharynx, affecting both sexes [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eHPV-related disease burden in Yemen reflects the challenges faced by many low-income countries. According to the International Agency for Research on Cancer (IARC), cervical cancer is the 12th most common cancer among Yemeni women overall and the 8th most frequent among women aged 15\u0026ndash;44 years. Each year, an estimated 225 women are diagnosed with cervical cancer and 153 die from the disease [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Despite this burden, Yemen has not yet introduced HPV vaccination into its national immunization program, and there are no official national cervical cancer screening guidelines [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. This gap leaves women particularly vulnerable to preventable morbidity and mortality.\u003c/p\u003e\u003cp\u003eThe introduction of prophylactic HPV vaccines has been a transformative milestone in cancer prevention. Clinical trials and real-world evidence demonstrate that these vaccines prevent more than 90% of HPV-related cancers when administered prior to exposure [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. The World Health Organization (WHO) recommends routine vaccination of girls and boys aged 9\u0026ndash;14 years, with catch-up programs extending into early adulthood [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Many high- and middle-income countries, such as Australia, Norway, and Germany, have successfully integrated HPV vaccination into national programs, leading to significant declines in HPV prevalence and related diseases [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. However, in regions such as Yemen, barriers including limited resources, lack of awareness, cultural sensitivities, and absence of government prioritization impede vaccine adoption.\u003c/p\u003e\u003cp\u003eMedical students, as future healthcare providers, play a pivotal role in shaping community knowledge and promoting preventive practices. Their awareness and attitudes toward HPV and its vaccine directly influence their capacity to educate patients and advocate for public health interventions. Previous studies across diverse contexts, including Turkey, Ukraine, and India, have consistently reported inadequate knowledge and variable attitudes toward HPV among medical students, underscoring the need for improved educational interventions [\u003cspan additionalcitationids=\"CR13\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. In Yemen, where epidemiological data on HPV are scarce and vaccination remains unavailable, assessing medical students\u0026rsquo; understanding is particularly important.\u003c/p\u003e\u003cp\u003eTherefore, this study seeks to evaluate the knowledge and attitudes of Yemeni medical students toward HPV infection and its prevention. By identifying gaps in awareness and barriers to vaccine acceptance, the findings may inform both curricular improvements in medical education and policy advocacy for the eventual introduction of HPV vaccination in Yemen.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eStudy design and setting\u003c/h2\u003e\u003cp\u003eThis was a cross-sectional analytical study conducted between 25 July 2025 and 25 August 2025. The study population comprised undergraduate medical students enrolled in faculties of medicine across Yemen. To maximize accessibility to students from different universities and academic years, data collection was conducted online.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eParticipants and eligibility criteria\u003c/h3\u003e\n\u003cp\u003eAll medical students in Yemen were eligible to participate, irrespective of age, gender, or academic year. Inclusion criteria were enrollment in a Yemeni faculty of medicine and provision of informed consent. Students who declined participation or submitted incomplete responses were excluded from the analysis.\u003c/p\u003e\n\u003ch3\u003eSample size calculation\u003c/h3\u003e\n\u003cp\u003eThe sample size was determined using MedCalc version 15.8, with the primary outcome set as the proportion of medical students aware of HPV infection. Reference values were derived from international literature, which reported an awareness level of 91.5% among undergraduate students [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Assuming a 5% margin of error, a statistical power of 80%, and a two-sided significance level of 5%, the minimum required sample size was estimated at 135 participants. To account for potential clustering effects and to improve the representativeness of the findings, the calculated sample was inflated by a design effect of 15, resulting in a minimum target of 2,025 students. A total of 2,285 students completed the questionnaire, thereby exceeding the required number and strengthening the statistical power and reliability of the study results.\u003c/p\u003e\n\u003ch3\u003eData collection tool\u003c/h3\u003e\n\u003cp\u003eData were collected using a structured, self-administered questionnaire that was designed after reviewing previously validated instruments from similar HPV knowledge and attitude studies and then adapted to fit the Yemeni context [\u003cspan additionalcitationids=\"CR15\" citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. The questionnaire was composed of four main domains. The first section captured socio-demographic information, including age, gender, university, year of study, and place of residence prior to university. The second section explored HPV vaccination history and sources of information, including prior vaccination, intention to be vaccinated, and whether students had attended any educational activities related to HPV.\u003c/p\u003e\u003cp\u003eThe third section assessed knowledge about HPV infection and vaccination through 11 statements covering modes of transmission, health consequences, and preventive measures; each correct answer was scored as one point, with a total possible score of 0\u0026ndash;11. Knowledge levels were categorized as \u0026ldquo;good\u0026rdquo; if the total score exceeded the median and \u0026ldquo;poor\u0026rdquo; if it was at or below the median. The fourth section assessed attitudes toward HPV vaccination through three items evaluating participants\u0026rsquo; willingness to recommend the vaccine to patients, relatives, and friends, as well as their support for implementing vaccination in Yemen. Responses were scored dichotomously (Yes\u0026thinsp;=\u0026thinsp;1, No\u0026thinsp;=\u0026thinsp;0), with a total score of 0\u0026ndash;3; scores above the median were considered indicative of a positive attitude.\u003c/p\u003e\u003cp\u003eTo ensure clarity, cultural appropriateness, and contextual relevance, the initial draft of the questionnaire was reviewed by three experts in public health and epidemiology in Yemen. Their feedback led to minor modifications, including rephrasing technical terms into simpler language, adjusting examples to reflect the local healthcare context, and ensuring sensitivity to cultural norms surrounding sexual health discussions.\u003c/p\u003e\u003cp\u003eTo further establish content validity, the same panel of experts independently evaluated the questionnaire items for clarity and relevance. The content validity index (CVI) was calculated at three levels: item-level CVI (I-CVI), expert-level CVI (E-CVI), and scale-level CVI (S-CVI) [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. At the item level, the I-CVI was determined by dividing the number of experts rating an item as clear and relevant (rating\u0026thinsp;\u0026ge;\u0026thinsp;3 on a 4-point scale) by the total number of experts. Items were considered appropriate if I-CVI was \u0026gt;\u0026thinsp;0.79, required revision if between 0.70 and 0.79, and were eliminated if\u0026thinsp;\u0026lt;\u0026thinsp;0.70. The E-CVI was obtained by dividing the number of relevant items by the total number of items assessed by each expert, while the S-CVI was calculated by averaging all I-CVI values across items. An S-CVI\u0026thinsp;\u0026ge;\u0026thinsp;0.90 indicated strong overall content validity.\u003c/p\u003e\u003cp\u003eA pilot test was then conducted with 50 students from different academic years to confirm comprehensibility and acceptability of the survey. Results of the pilot indicated good overall clarity, and Cronbach\u0026rsquo;s alpha for internal consistency was 0.76, demonstrating acceptable reliability.\u003c/p\u003e\n\u003ch3\u003eSampling and data collection procedure\u003c/h3\u003e\n\u003cp\u003eA convenience sampling approach was employed. The survey was hosted on Google Forms and distributed through official university Telegram channels, student WhatsApp groups, and other academic social media platforms. The survey remained open for one month, and reminders were sent weekly to encourage participation. Participation was voluntary, and all responses were anonymous.\u003c/p\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eStatistical analysis\u003c/h2\u003e\u003cp\u003eData were analyzed using IBM SPSS Statistics version 28 (IBM Corp., Armonk, NY, USA). Descriptive statistics were presented as frequencies and percentages for categorical variables, and medians with interquartile ranges (IQR) for non-normally distributed continuous variables. The Shapiro\u0026ndash;Wilk test was applied to test normality. Associations between categorical variables were examined using Pearson\u0026rsquo;s chi-square test, while continuous variables were compared using the Mann\u0026ndash;Whitney U test. Binary logistic regression analysis was performed to identify independent predictors of good knowledge and positive attitudes. Variables significant at \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.20 in univariate analysis were entered into multivariable models using a forward stepwise likelihood ratio method. Adjusted odds ratios (AOR) with 95% confidence intervals (CI) were reported. Multicollinearity was checked using variance inflation factor (VIF), and model adequacy was evaluated using the Hosmer\u0026ndash;Lemeshow goodness-of-fit test. A \u003cem\u003ep\u003c/em\u003e value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered statistically significant.\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e\u003ch2\u003eParticipant characteristics\u003c/h2\u003e\u003cp\u003eA total of 2,285 medical students participated in the study (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). The majority were female (56.4%), aged between 20 and 24 years (66.1%), and from urban areas (77.5%). More than one-third of the participants were in their 3rd (24.4%) or 4th (20.3%) year of study. Almost all students (98.2%) had heard about the HPV vaccine, most frequently from doctors (36.3%) or university courses (31.9%). Less than half (45.4%) had attended an educational session about HPV infection or vaccination in the past year, mainly through university lectures (45.7%) or education provided by physicians (40.4%). Only 40.0% reported actively searching for information about HPV in the month preceding the survey. Awareness of vaccine availability in Yemen was limited: nearly half of students (48.4%) reported that they did not know whether HPV vaccines were available. Approximately one-third (32.7%) knew someone who had or had had cervical cancer.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eSociodemographic, clinical, and health-related characteristics of study participants (N\u0026thinsp;=\u0026thinsp;2848)\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCharacteristic\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eLevel/category\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eN (Percent %)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eAge (years), Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e33.3\u0026thinsp;\u0026plusmn;\u0026thinsp;10.8\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cb\u003eResidence\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eUrban\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1980 (69.6)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eRural\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e868 (30.5)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cb\u003eLocation\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNorth\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2436 (85.5)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSouth\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e412 (14.5)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003e\u003cb\u003eMarital Status\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMarried\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1869 (65.8)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSingle\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e711 (25.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eWidow\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e165 (5.8)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDivorced\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e95 (3.3)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"5\" rowspan=\"6\"\u003e\u003cp\u003e\u003cb\u003eEducation Level\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eUniversity degree or higher\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e758 (26.6)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSecondary school\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e571 (20.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePreparatory school\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e288 (10.1)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePrimary school\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e343 (12.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eRead and write only\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e374 (13.1)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNon-literate\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e514 (18.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cb\u003eEmployment\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eEmployed\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e581 (20.4)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eUnemployed\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2267 (79.6)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e\u003cb\u003eSelf-Reported Income\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eEnough with saving\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e285 (10.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eEnough\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1055 (37.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNot enough\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1481 (52.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eNumber of Pregnancies, Median (IQR)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2257, 4 (2\u0026ndash;6)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eNumber of Children, Median (IQR)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2248, 3 (2\u0026ndash;5)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cb\u003eContraceptive Use\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1021 (43.1)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1347 (56.9)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e\u003cb\u003ePayment for Medical Services\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSelf-Funded\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2210 (77.6)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eHealth Insurance\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e526 (18.5)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eGovernment\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e110 (3.9)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003ePersonal History of Any Cancer\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e118 (4.2)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eFamily History of Cervical Cancer (1st degree)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e134 (4.7)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eKnows Someone Who Died of Cervical Cancer\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e436 (15.3)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eDiscussed CC Screening with a Physician\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e131 (4.6)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"3\"\u003e\u003cb\u003eNote\u003c/b\u003e: Data are presented as n (%) unless otherwise specified. SD: Standard Deviation; IQR: Interquartile Range. CC: Cervical Cancer. Percentages may not total 100 due to rounding. The 'N' for Number of Pregnancies and Children is based on ever-married women who responded to those specific questions.\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003eKnowledge about HPV\u003c/h2\u003e\u003cp\u003eOverall, knowledge levels were low, with only 25.8% of students demonstrating good knowledge (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). The median knowledge score was 4.0 (IQR: 2.0\u0026ndash;6.0) out of a possible 11. Misconceptions were common; only 58.8% correctly recognized the association between HPV and cervical, penile, and anal cancers, while less than half (49.0%) identified the link between HPV and genital warts. Knowledge about asymptomatic infection (38.1%) and commonality of HPV infection (41.6%) was also limited. Attendance at HPV-related education was strongly associated with better knowledge. Students who had attended educational sessions had significantly higher correct response rates across nearly all knowledge items, with a higher proportion achieving good knowledge (32.7% vs. 20.1%; \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and a higher median knowledge score (5.0 vs. 4.0; \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eParticipants' knowledge regarding cervical cancer and screening (N\u0026thinsp;=\u0026thinsp;2848)\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eKnowledge assessment item\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCategory\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eN (Percent %)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOverall knowledge score, Median (IQR)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003e35 (25\u0026ndash;46)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eKnowledge Level\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePoor\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2833 (99.5)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAdequate\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e15 (0.5)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSelf-rated knowledge of CC screening (\u0026ge;\u0026thinsp;8/10)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e171 (6.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCorrectly identified a benefit of CC screening?\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e660 (22.7)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCorrectly identified recommended age for screening?\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e556 (19.1)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eKnew the tools used for CC screening?\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e291 (10.3)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCorrectly identified the frequency of screening?\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e175 (6.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eKnew screening should be done without symptoms?\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1539 (54.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eWould like more information about CC screening?\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2106 (73.9)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"3\"\u003e\u003cb\u003eNote\u003c/b\u003e: Data are presented as n (%). IQR: Interquartile Range. CC: Cervical Cancer.\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eIn terms of self-assessed knowledge, 61.3% of participants rated their knowledge about HPV infection as sufficient, whereas only 46.0% and 42.0% considered their knowledge about HPV prevention and vaccination sufficient, respectively (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003eAttitudes toward HPV vaccination\u003c/h2\u003e\u003cp\u003eMost participants expressed favorable attitudes toward HPV vaccination (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Nearly three-quarters reported that they would recommend the HPV vaccine to future patients (72.6%) and to family or friends (74.7%). A smaller proportion stated they would advocate for HPV vaccination in Yemen (56.3%). Overall, 58.5% of students demonstrated positive attitudes, with a median attitude score of 3.0 (IQR: 2.0\u0026ndash;4.0).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eParticipants' attitudes towards cervical cancer screening and perceived barriers (N\u0026thinsp;=\u0026thinsp;2848)\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAttitude assessment item\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCategory\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eN (Percent %)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eOverall attitude score, Median (IQR)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003e34 (27\u0026ndash;40)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e\u003cb\u003eAttitude Level\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePositive\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e274 (9.6)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNeutral\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1404 (49.3)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNegative\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1170 (41.1)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eIntention and beliefs\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eWill voluntarily seek CC screening\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1530 (53.7)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eWill undergo screening if a doctor recommends\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2436 (85.6)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eWill participate in a mass screening program\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2149 (75.5)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDoubts the effectiveness of screening\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1005 (35.3)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003ePerceived barriers\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFinancial burden\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2011 (70.6)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLack of knowledge about screening\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1843 (64.7)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLack of knowledge about screening tools\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1743 (61.2)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDon't know where to go for screening\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1596 (56.1)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFear of the results\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1563 (54.9)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFear of the procedure\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1474 (51.8)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eShyness\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1022 (35.9)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eUncomfortable with doctors\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e877 (30.8)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLack of time\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e708 (24.9)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePrevious bad experience\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e513 (18.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"3\"\u003e\u003cb\u003eNote\u003c/b\u003e: Data are presented as n (%). IQR: Interquartile Range. CC: Cervical Cancer. For the \"Perceived Barriers\" section, participants could report more than one barrier; therefore, percentages do not sum to 100.\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003eBarriers to HPV vaccination\u003c/h2\u003e\u003cp\u003eWhen asked about perceived barriers to HPV vaccination in Yemen, the most frequently reported obstacle was lack of knowledge about HPV (35.8%), followed closely by lack of government support (34.9%). Fewer participants identified high cost (14.8%) or religious and cultural beliefs (14.5%) as the main barriers (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\u003ch2\u003eFactors associated with good knowledge\u003c/h2\u003e\u003cp\u003eMultivariate logistic regression identified several independent predictors of good HPV knowledge (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). Male students were more likely to have good knowledge compared with females (AOR\u0026thinsp;=\u0026thinsp;1.39, 95% CI: 1.14\u0026ndash;1.69; \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.001). Sixth-year students were significantly more knowledgeable compared with first-year students (AOR\u0026thinsp;=\u0026thinsp;1.43, 95% CI: 1.03\u0026ndash;1.98; \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.031). Students from rural backgrounds were also more likely to have good knowledge (AOR\u0026thinsp;=\u0026thinsp;1.96, 95% CI: 1.58\u0026ndash;2.45; \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Source of information played a role: those who first heard about HPV vaccines from doctors were more knowledgeable (AOR\u0026thinsp;=\u0026thinsp;1.26, 95% CI: 1.03\u0026ndash;1.55; \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.028), while students informed by parents, relatives, or friends were less likely to have good knowledge (AOR\u0026thinsp;=\u0026thinsp;0.57, 95% CI: 0.41\u0026ndash;0.79; \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Self-assessed sufficient knowledge of HPV infection was strongly associated with objective good knowledge (AOR\u0026thinsp;=\u0026thinsp;1.53, 95% CI: 1.22\u0026ndash;1.91; \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003ePractice of cervical cancer screening among participants (N\u0026thinsp;=\u0026thinsp;2848)\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePractice assessment item\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCategory\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eN (Percent %)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eOverall practice score, Median (IQR)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003e3 (0\u0026ndash;3)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e\u003cb\u003ePractice Level\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eGood\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e59 (2.1)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAdequate\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e105 (3.7)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePoor\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2684 (94.2)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cb\u003eEver been recommended for CC screening?\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e143 (5.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2704 (95.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cb\u003eEver had a CC screening test?\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e98 (3.5)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2738 (96.5)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cb\u003eInterested in having CC screening in the future?\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2069 (72.7)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e778 (27.3)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"3\"\u003e\u003cb\u003eNote\u003c/b\u003e: Data are presented as n (%). IQR: Interquartile Range. CC: Cervical Cancer.\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\u003ch2\u003eFactors associated with positive attitudes\u003c/h2\u003e\u003cp\u003eMultivariate analysis revealed that male gender (AOR\u0026thinsp;=\u0026thinsp;1.50, 95% CI: 1.14\u0026ndash;1.97; \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.004) and good objective knowledge of HPV (AOR\u0026thinsp;=\u0026thinsp;2.41, 95% CI: 1.79\u0026ndash;3.26; \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001) were independently associated with positive attitudes toward HPV vaccination (Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e). In contrast, students in the 4th and 5th years of study were significantly less likely to have positive attitudes compared with first-year students (AOR\u0026thinsp;=\u0026thinsp;0.55, 95% CI: 0.37\u0026ndash;0.82; \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.003 and AOR\u0026thinsp;=\u0026thinsp;0.46, 95% CI: 0.31\u0026ndash;0.68; \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001, respectively). Students aged\u0026thinsp;\u0026ge;\u0026thinsp;25 years also demonstrated lower odds of positive attitudes (AOR\u0026thinsp;=\u0026thinsp;0.44, 95% CI: 0.23\u0026ndash;0.84; \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.013). Importantly, receiving education from doctors (AOR\u0026thinsp;=\u0026thinsp;0.58, 95% CI: 0.43\u0026ndash;0.77; \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001) or peers (AOR\u0026thinsp;=\u0026thinsp;0.37, 95% CI: 0.24\u0026ndash;0.56; \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001) was associated with less positive attitudes compared with university lectures.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eAssociation of sociodemographic factors with adequate knowledge and referral for screening\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCharacteristic\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCategory\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eAdequate knowledge\u003c/p\u003e\u003cp\u003en (%)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eEver recommended for screening\u003c/p\u003e\u003cp\u003en (%)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eP-value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cb\u003eResidence\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eUrban\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e3 (0.4%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e112 (5.7%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.019\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eRural\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e2 (0.1%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e31 (3.6%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cb\u003eEmployment\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eEmployed\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e3 (2.5%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e51 (8.8%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eUnemployed\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e13 (0.5%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e92 (4.1%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cb\u003eEducational Level\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eHigh (Secondary+)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e8 (0.6%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e81 (6.1%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.014\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eLow (Preparatory-)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e8 (0.6%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e62 (4.1%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cb\u003eHealth insurance\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCovered\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e4 (0.7%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e25 (3.9%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSelf-funded\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e9 (0.4%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"5\"\u003e\u003cb\u003eNote\u003c/b\u003e: P-values were calculated using the Chi-square (χ2) test. Educational Level was categorized for this analysis: 'High' includes secondary school certificate and above; 'Low' includes preparatory school certificate and below. 'MD' refers to a medical doctor. The '\u0026mdash;' symbol indicates data was not applicable for that specific comparison. Percentages represent the proportion within each row's category.\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis national cross-sectional study assessed knowledge and attitudes regarding HPV infection and vaccination among Yemeni medical students. Although almost all participants (98.2%) had heard of HPV, only one-quarter (25.8%) demonstrated objectively good knowledge based on the scoring system. In contrast, more than half (58.5%) expressed positive attitudes toward HPV vaccination, indicating a notable gap between awareness and understanding. These findings highlight both the deficiencies in knowledge and the opportunities for educational interventions among future healthcare providers in Yemen.\u003c/p\u003e\u003cp\u003eThe relatively low knowledge observed in our study (median score 4.0/11; only 25.8% classified as having \u0026ldquo;good\u0026rdquo; knowledge) is consistent with reports of limited HPV knowledge among medical students in other settings, although absolute levels vary widely for example, 2.1% with good knowledge reported in one Egyptian study and 45% of students in an Indian study correctly identifying HPV as the main cause of cervical cancer [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. In our sample, misconceptions were particularly pronounced: only 58.8% recognized the association between HPV and cervical, penile, and anal cancers, fewer than half (49.0%) knew that HPV can cause genital warts, and only 38.1% were aware that HPV infection can be asymptomatic. These gaps are important because they can perpetuate stigma and hinder effective patient education, a pattern also reported among medical students in other countries [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eAttendance at HPV-related education was strongly associated with improved knowledge in our study. Students who had attended lectures or workshops achieved a higher median score (5.0 vs. 4.0, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and were more likely to be categorized as knowledgeable (32.7% vs. 20.1%, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Comparable effects of structured education have been reported in Croatia and the United States, where targeted sessions significantly improved factual knowledge and increased willingness to vaccinate [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. These findings underscore the importance of incorporating HPV education into the formal medical curriculum rather than leaving students to rely on informal sources.\u003c/p\u003e\u003cp\u003eGender and academic level were also important determinants. Male students were more likely than females to demonstrate good knowledge (AOR\u0026thinsp;=\u0026thinsp;1.39, 95% CI: 1.14\u0026ndash;1.69) and positive attitudes (AOR\u0026thinsp;=\u0026thinsp;1.50, 95% CI: 1.14\u0026ndash;1.97). This contrasts with findings from India and China, where female students often showed better awareness of HPV [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. The reasons for these differences may be cultural; in Yemen, public discourse on cervical cancer is limited, and male students may face fewer barriers in accessing information. With regard to study year, sixth-year students were more knowledgeable than first-year students (AOR\u0026thinsp;=\u0026thinsp;1.43, 95% CI: 1.03\u0026ndash;1.98), consistent with studies in Romania and Serbia that reported higher scores among senior students [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. However, we also observed that fourth- and fifth-year students were less likely than first years to hold positive attitudes toward vaccination (AOR\u0026thinsp;=\u0026thinsp;0.55 and 0.46, respectively), suggesting that enthusiasm may decline as students\u0026rsquo; progress through their training, possibly due to insufficient emphasis on preventive health in later years [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eA further noteworthy finding is the discrepancy between self-perceived and actual knowledge. While 61.3% of students rated their knowledge of HPV infection as sufficient, only 25.8% achieved good scores on objective measures. Similar overestimation has been documented in Egyptian and Chinese studies, where students felt confident about their knowledge but performed poorly on factual assessments [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. This mismatch is concerning, as it may lead to overconfidence in clinical counseling without a sound knowledge base [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eWith respect to barriers, 35.8% of participants cited lack of knowledge and 34.9% cited insufficient governmental support as the main obstacles to HPV vaccination. By contrast, only 14.8% considered cost and 14.5% considered cultural or religious beliefs as barriers. These findings differ from studies in Uganda and Egypt, where cultural stigma and financial constraints were more prominent obstacles [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. The Yemeni results suggest that medical students primarily recognize systemic and informational barriers rather than personal or cultural ones [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eImportantly, nearly half of students (48.4%) did not know whether HPV vaccines were available in Yemen, reflecting both the absence of a national program and limited public health communication. This uncertainty is particularly concerning given that medical students are expected to serve as reliable sources of information for patients and the community [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. Similar confusion has been reported in studies from Egypt and Uganda, where many students and young adults were unaware of vaccine availability despite its presence in private markets [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. The lack of clarity in Yemen highlights missed opportunities for health authorities to disseminate accurate information about HPV and its prevention [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. Even in contexts where vaccines are not yet part of national schedules, transparent communication can help normalize the idea of HPV vaccination, reduce misconceptions, and prepare the population for future implementation.\u003c/p\u003e\u003cp\u003eOverall, these findings parallel results from other developing countries, where medical students often display limited knowledge but favorable attitudes toward HPV vaccination. The strong associations between education, knowledge, and attitudes observed in this study support the need for structured curricular interventions. At the same time, the identification of governmental inaction as a barrier highlights the importance of policy-level support for HPV vaccination in Yemen.\u003c/p\u003e\u003cdiv id=\"Sec17\" class=\"Section2\"\u003e\u003ch2\u003eLimitations\u003c/h2\u003e\u003cp\u003eThis study has several limitations that should be considered when interpreting the findings. First, the use of convenience sampling through online platforms may have introduced selection bias, as students with greater internet access or interest in health topics may have been more likely to participate. Second, the reliance on self-administered questionnaires carries the risk of recall bias and socially desirable responses, particularly on sensitive issues related to sexual health. Third, the cross-sectional design precludes causal inferences between knowledge, attitudes, and associated factors. Finally, although the study included a large and diverse sample of students across Yemen, the findings may not be fully generalizable to all young people or to students in non-medical disciplines.\u003c/p\u003e\u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study revealed that Yemeni medical students possess moderate knowledge but generally favorable attitudes toward HPV infection and its prevention. While most students had heard of HPV, only one-quarter demonstrated good objective knowledge, and misconceptions about transmission and disease burden were common. Encouragingly, more than half expressed willingness to recommend HPV vaccination, highlighting a readiness to support future prevention efforts. These findings emphasize the urgent need to strengthen HPV-related education within medical curricula and underscore the importance of governmental commitment to introducing a national HPV vaccination program to reduce the preventable burden of HPV-related diseases in Yemen.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthical approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe methods employed in this study adhered to the principles outlined in the Declaration of Helsinki and its subsequent amendments. Ethical approval was obtained from the Institutional Review Board at Amran University (Approval No. 855). Participation in the study was entirely voluntary, anonymous, and without any form of compensation. The objectives of the study were clearly explained on the first page of the online questionnaire. Participants provided electronic informed consent before beginning the survey and were free to withdraw at any point without any consequences.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and analyzed during the current study are available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they do not have any potential conflicts of interest concerning the research, authorship, and/or publication of this report.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot Applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u0026nbsp;\u003c/strong\u003e\u003cbr\u003eThe authors would like to express their sincere gratitude to \u003cstrong\u003eDr. Mohamed Al-Eryani\u003c/strong\u003e for his valuable support and guidance during the course of this work.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors' contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMohamed Baklola¹\u003c/strong\u003e*† and\u0026nbsp;\u003cstrong\u003eNaji Al-bawah²\u003c/strong\u003e*† contributed equally to the conception, design, and supervision of the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEhab Sharyan³\u003c/strong\u003e contributed to data collection and analysis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRoa’a Al-ansi⁴\u003c/strong\u003e contributed to methodology and manuscript preparation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eYousef Alqudaimi⁵\u003c/strong\u003e contributed to statistical analysis and validation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eKotoz Al-mansoob⁶\u003c/strong\u003e contributed to data acquisition and literature review.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMohammed Al-harogi⁷\u003c/strong\u003e contributed to visualization and results interpretation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFadl Al-Halimi⁸\u003c/strong\u003e contributed to resources and data curation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eKhairi Alhetari⁹\u003c/strong\u003e contributed to formal analysis and manuscript editing.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMohamed Mabrouk Ghonaim¹⁰\u003c/strong\u003e contributed to critical revision and technical guidance.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eNajim Z. Alshahrani¹¹\u003c/strong\u003e contributed to supervision and project administration.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eOmar Hammam Salloum¹²\u003c/strong\u003e contributed to drafting and reviewing the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMohamed Basyouni Helal¹³\u003c/strong\u003e contributed to overall review and final approval of the manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eScott-Wittenborn N, Fakhry C. Epidemiology of HPV Related Malignancies. Semin Radiat Oncol [Internet]. 2021 Oct 1 [cited 2025 Aug 30];31(4):286\u0026ndash;96. Available from: https://pubmed.ncbi.nlm.nih.gov/34455984/\u003c/li\u003e\n\u003cli\u003eMakiani MJ, Minaeian S, Moghaddam SA, Moosavi SA, Moeini Z, Zamani V, et al. Relative frequency of human papillomavirus genotypes and related sociodemographic characteristics in women referred to a general hospital in Tehran, 2014-2015: A cross-sectional study. 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Available from: https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0284542\u003c/li\u003e\n\u003cli\u003eAbdelaziz MN, Hefnawy A, Azzam H, Reisha O, Hamdy O. Knowledge and attitude among Egyptian medical students regarding the role of human papillomavirus vaccine in prevention of oropharyngeal cancer: a questionnaire-based observational study. Sci Rep [Internet]. 2025 Dec 1 [cited 2025 Aug 30];15(1):1\u0026ndash;12. Available from: https://www.nature.com/articles/s41598-025-86853-8\u003c/li\u003e\n\u003cli\u003eDu EY, Adjei Boakye E, Taylor DB, Kuziez D, Rohde RL, Pannu JS, et al. Medical students\u0026rsquo; knowledge of HPV, HPV vaccine, and HPV-associated head and neck cancer. Hum Vaccin Immunother [Internet]. 2022 [cited 2025 Aug 30];18(6). Available from: https://pubmed.ncbi.nlm.nih.gov/36070503/\u003c/li\u003e\n\u003cli\u003eBelavic A, Pavic Simetin I. 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Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC11157752/\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Human papillomavirus, HPV vaccine, medical students, knowledge, Yemen","lastPublishedDoi":"10.21203/rs.3.rs-7687122/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7687122/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eHuman papillomavirus (HPV) is the most common sexually transmitted infection and the primary cause of cervical cancer, as well as other anogenital and oropharyngeal malignancies. Despite proven effectiveness of vaccination, no national HPV immunization program exists in Yemen. Understanding medical students\u0026rsquo; knowledge and attitudes is crucial, as they represent future healthcare providers and advocates.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eA cross-sectional analytical study was conducted from 1 May to 30 July 2025 among undergraduate medical students across Yemen. Data were collected using a structured, self-administered online questionnaire adapted from validated instruments and reviewed by public health experts for contextual relevance. The survey assessed demographics, vaccination history, sources of information, knowledge (11 items; score range 0\u0026ndash;11), and attitudes toward HPV vaccination. Statistical analysis was performed using SPSS version 28, employing descriptive statistics, chi-square tests, and logistic regression.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eA total of 2,285 students participated. Although 98.2% had heard of HPV, only 25.8% demonstrated good knowledge, with a median score of 4.0 (IQR 2.0\u0026ndash;6.0). Misconceptions were common: only 58.8% recognized the association with multiple cancers, 49.0% identified HPV as the cause of genital warts, and 38.1% were aware that infection may be asymptomatic. In contrast, 58.5% expressed positive attitudes toward vaccination; 72.6% would recommend it to patients and 74.7% to family or friends, but only 56.3% supported nationwide introduction. The most cited barriers to vaccination were lack of knowledge (35.8%) and insufficient governmental support (34.9%). Independent predictors of good knowledge included male gender (AOR\u0026thinsp;=\u0026thinsp;1.39), rural background (AOR\u0026thinsp;=\u0026thinsp;1.96), being in the sixth study year (AOR\u0026thinsp;=\u0026thinsp;1.43), and first hearing about HPV from doctors (AOR\u0026thinsp;=\u0026thinsp;1.26). Positive attitudes were more likely among males (AOR\u0026thinsp;=\u0026thinsp;1.50) and those with good knowledge (AOR\u0026thinsp;=\u0026thinsp;2.41).\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003eYemeni medical students showed moderate knowledge but generally favorable attitudes toward HPV vaccination. These findings highlight the need for structured HPV education in medical curricula and underscore the importance of governmental support to facilitate future vaccine introduction in Yemen.\u003c/p\u003e","manuscriptTitle":"Knowledge and attitudes about HPV infection and prevention methods among medical students in Yemen: a national cross- sectional study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-10-17 02:09:21","doi":"10.21203/rs.3.rs-7687122/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"4537bbf2-8288-44cb-885f-9ec14986f508","owner":[],"postedDate":"October 17th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":55957974,"name":"Biological sciences/Cancer"},{"id":55957975,"name":"Health sciences/Diseases"},{"id":55957976,"name":"Health sciences/Health care"},{"id":55957977,"name":"Health sciences/Medical research"},{"id":55957978,"name":"Health sciences/Oncology"}],"tags":[],"updatedAt":"2025-10-17T02:10:10+00:00","versionOfRecord":[],"versionCreatedAt":"2025-10-17 02:09:21","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7687122","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7687122","identity":"rs-7687122","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}