The World Health Organization (WHO) reports that cervical cancer is the fourth most common cancer among women and the ninth leading cause of cancer-related deaths worldwide [1, 2]. Even though this type of cancer remains one of the most life-threatening, especially in low and middle-income countries, it is also one of the most preventable ones [3].

HPV infection is frequently detected in the anogenital tract of both men and women, regardless of the presence of clinical lesions. HPV infection can lead to a range of cervical morphological changes, such as various stages of precancerous lesions (CIN-1, minor dysplasia; CIN-2, moderate dysplasia; CIN-3/CIS, severe dysplasia or carcinoma in situ) and invasive cervical cancer [4].

Recognizing the critical need to address the rising incidence of cervical cancer and to accelerate the elimination, WHO in November 2020 launched the Global Strategy for Cervical Cancer Elimination by setting concrete goals to be achieved by 2030 [5]. In this context, all countries are required to reduce cervical cancer incidence to less than four cases per 100,000 women [6].

HPV vaccines are the most effective measure for preventing HPV infections and lowering the lifetime risk of developing cervical cancer. The vaccination against HPV promotes herd immunity, reducing the overall prevalence of HPV and the risk of infections from high-risk HPV types that may lead to cancer.

Five HPV vaccines are currently prequalified by WHO, namely Cecolin^® (2vHPV/ bivalent HPV vaccine, manufactured by Xiamen Innovax Co.Ltd), Cervarix™ (2vHPV, manufactured by GlaxoSmithKline Biologicals), Walrinvax^® (2vHPV, manufactured by Walvax Biotechnology Co. Ltd), Gardasil^® (4vHPV/ quadrivalent HPV vaccine, manufactured by Merck Vaccines), and Gardasil-9^® (9vHPV/ nonavalent HPV vaccine, manufactured by Merck Vaccines). The safety of these vaccines has been ensured by the WHO prequalification process and by the Global Advisory Committee on Vaccine Safety (GACVS) [7]. In addition, one more HPV vaccine (Cervavac^®) is nationally licensed but not yet WHO-prequalified.

Since 2006, the Advisory Committee on Immunization Practices (ACIP) has recommended routine HPV vaccinations for females, expanding the recommendation to include males in 2011 [8]. Moreover, in April 2022, the Strategic Advisory Group of Experts (SAGE) on Immunization, WHO’s principal advisory group for vaccines and immunization, reported that a one-dose HPV vaccine schedule provides comparable protection against HPV compared to a two or more regimen [9].

The latest statistics indicate that cervical cancer ranks as the fifth most frequent cancer among women in Albania and the second most common cancer among women between 15 and 44 years of age [10]. Despite several significant actions and public health policy reforms implemented in Albania during the past decade, providing the opportunity for primary prevention of cervical cancer was clearly the most crucial advancement. In this context, on November 2022, a significant milestone was achieved in Albania with the inclusion of the quadrivalent recombinant HPV vaccine (Gardasil^®) in the National Immunization Program (NIP). Unlike in many other countries where the HPV vaccine is routinely recommended for both males and females, in Albania, the HPV vaccine is provided free of charge exclusively to young women aged 13 years old. Recently, the Institute of Public Health in Albania launched an important initiative aiming to temporarily extend free vaccination eligibility to the age group of 14-20 years old young women. This effort was initiated in January 2024 and aims to increase vaccine coverage and reduce the prevalence of HPV-related diseases [11]. Based on the evaluation of the National Committee of Experts on Immunization and SAGE recommendations, the HPV vaccine in Albania is administered as a single dose.

Since HPV vaccination in Albania has been recently included in the NIP, official data regarding the HPV vaccination coverage are not available yet. On the other hand, a poor understanding of the risks associated with HPV infection, combined with the perception of not being at risk of contracting HPV, significantly contributes to vaccination hesitancy, negative attitudes, and ineffective vaccination programs [12, 13].

This study aims to assess awareness, knowledge, and attitudes toward the HPV vaccine among Albanian women and to examine how these vary across different age groups and socio-demographic characteristics.

Despite global efforts to reduce cervical cancer through HPV vaccination, challenges in awareness and accessibility persist, particularly in specific populations. The uncertainty about vaccination among one-third (34.7%) of the participants in this study may be attributed to the recent introduction of the HPV vaccine into Albania's immunization program, as well as significant barriers, including widespread misconceptions about the vaccine. However, nearly half of the participants reported a willingness to receive the vaccine and recommend it to others. Notably, those aged 18-30 years were more likely to undergo vaccination. This is consistent with findings from other studies reporting similar positive attitudes toward vaccination among this subgroup [19-21].

On a global scale, HPV vaccine coverage among adolescent girls was just 15% in 2019, underscoring persistent challenges despite varied healthcare systems among countries [22, 23]. However, recent WHO data report a gradual improvement in coverage, increasing from 20% in 2022 to 27% in 2023 [24].

A study conducted in China from 2017 to 2022 found consistently low HPV vaccination rates (below 7%) across all age groups of females aged 9–45, despite evidence from other studies indicating that most participants were willing to get vaccinated if the vaccine was offered at no cost [25, 26].

Interesting results were also reported by a study conducted among young females in Jakarta, Indonesia, indicating a strong willingness for vaccination (95%), particularly when parental permission was granted [27]. This highlights the crucial role of parental influence in shaping health behaviors. Studies in behavioral science and public health consistently show that parental attitudes and education level strongly influence adolescents’ health decisions [28]. Given this, efforts to promote HPV vaccination in Albania should not only target adolescents but also actively involve their parents (especially those of young women aged 13–20) by providing them with accurate information about the vaccine’s benefits and importance.

In the present study, more than half of the respondents correctly identified the HPV vaccine eligible population, although awareness varied significantly across socio-demographic groups. A similar study conducted in Poland found that only 31.9% of adults were aware of the HPV vaccine-eligible population, highlighting the considerable gap in awareness even within European contexts [29]. Only one third of our participants aged 15–17 recognized that the vaccine is intended for individuals prior to sexual activity, likely due to limited or a lack of targeted information campaigns. In contrast, adult women, especially those over 31 years old, exhibited higher awareness, which may be attributed to their accumulated life experience, greater access to health information, and more consistent involvement with healthcare services throughout their lives. On the other hand, consistent with other studies, we observed that higher education levels (university attenders and postgraduates) are generally associated with increased awareness of the HPV vaccine [30-35].

Recent studies in Albania have explored HPV-related knowledge and attitudes among university students, revealing gender-based discrepancies in awareness. For instance, Merkuri et al. reported that only 18.9% of the participants enrolled in the survey (female university students) recognized the HPV vaccine as a preventive method, while Bakiri et al. found that 45.3% of male students were aware of the protection provided by the HPV vaccine [36, 37]. Moreover, various studies have shown that women are more likely to accept HPV vaccination than men, even when both genders have access to free vaccination [38-40]. Effectively addressing this gender disparity is essential to reducing HPV transmission and the associated burden of HPV-related diseases.

Another key finding of this study was that older women (ages 18-30 and 31+) demonstrated an acceptable level of knowledge about the Pap test, likely due to increased awareness from life experiences or indirect exposure to information about cervical cancer. Although a small proportion of participants had undergone a Pap test, it is encouraging that 20.8% did so based on personal awareness, suggesting a hopeful trend for the future. Previous studies have found that women often experience feelings of shame and embarrassment, or a perception of not being at risk, which contributes to a generally negative attitude towards cervical cancer screening methods [41-43]. Additionally, previous research has shown that factors such as high poverty levels and the absence of free national screening services negatively impact women's attitudes toward screening methods [44].

To meet the WHO Cervical Cancer Elimination strategy's goal of achieving 90% immunization coverage among adolescent girls by 2030, targeted and effective interventions are essential to raise HPV awareness and vaccine acceptance [45]. These require a comprehensive strategy including education, healthcare provider engagement, supportive policies, and ongoing research. Healthcare providers should receive training and resources to effectively convey the importance of HPV vaccination to parents, address common questions, and manage vaccine hesitancy. Additionally, it is crucial to understand and mitigate socioeconomic barriers, including cultural beliefs, that hinder access to vaccines. Addressing these barriers may require community involvement, such as organizing workshops and seminars, and involving community leaders in awareness campaigns to foster trust and acceptance of the HPV vaccine.

Future research should focus on identifying and addressing specific factors related to HPV infection and vaccine knowledge, as well as implementing long-term research to monitor the impact of vaccination programs on HPV infection rates and cervical cancer incidence. These interventions can improve vaccination coverage and reduce the global burden of cervical cancer.

The recent implementation of an immunization program in Albania provided an opportunity to explore the multifaceted factors that could influence its success. The present study used a comprehensive questionnaire, which was carefully developed and pilot-tested to ensure clarity and relevance. Moreover, this study provides valuable insights across different age groups to better understand their familial roles in the decision-making process regarding the HPV vaccine.

However, this study has a few limitations. Firstly, the use of an online survey may have excluded individuals without internet access, potentially introducing bias by favoring more technologically skilled and urban participants. Secondly, self-reporting could introduce reporting biases, such as social desirability bias or inaccurate recall, which may have led to overreporting of positive behaviors or inaccuracies in participants' responses. Lastly, the cross-sectional design limits the ability to draw causal conclusions.

This study provides a timely and comprehensive overview of knowledge, attitudes, and practices related to HPV vaccination and cervical cancer screening among Albanian women. Knowledge about HPV vaccination varied significantly by age, educational background, marital status, and employment sector. Importantly, age, education level, and employment status emerged as predictors of willingness to receive the HPV vaccine. Although nearly half of the participants expressed a willingness to get vaccinated, the variation across demographic groups underscores the need for targeted public health and educational interventions.

Notably, the willingness to recommend the HPV vaccine was higher among urban residents, university students, and healthcare professionals, indicating the need for targeted educational campaigns aimed at less-informed subgroups, especially adolescents and rural populations. Although Pap smear awareness was widespread, the actual participation rate remained low, prompting a need to enhance both access to and motivation for cervical cancer screening. Overall, these findings highlight the need for specific and tailored public health interventions. Expanding community education, improving access to services, and engaging trusted healthcare professionals can play a critical role in improving HPV vaccine uptake and screening rates, ultimately contributing to the prevention of HPV-related diseases in Albania.