PONE-D-25-02990Human Papilloma Virus Vaccination uptake and Associated Factors among Adolescent Girls in Merab Abaya District, Gamo Zone, Southern Ethiopia: Mixed MethodsPLOS ONE

Dear Dr. Milkano,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Please submit your revised manuscript by Apr 10 2025 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org . When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

• A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
• A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
• An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols . Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols .

We look forward to receiving your revised manuscript.

Kind regards,

Morufu Olalekan Raimi, Ph.D

Academic Editor

PLOS ONE

Journal Requirements:

1. When submitting your revision, we need you to address these additional requirements. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf 2. We note that your Data Availability Statement is currently as follows: All relevant data are within the papers and its supporting information files. But the qualitative parts of the study, the participants were not consented to share their audio. Please confirm at this time whether or not your submission contains all raw data required to replicate the results of your study. Authors must share the “minimal data set” for their submission. PLOS defines the minimal data set to consist of the data required to replicate all study findings reported in the article, as well as related metadata and methods (https://journals.plos.org/plosone/s/data-availability#loc-minimal-data-set-definition). For example, authors should submit the following data: - The values behind the means, standard deviations and other measures reported;- The values used to build graphs;- The points extracted from images for analysis. Authors do not need to submit their entire data set if only a portion of the data was used in the reported study. If your submission does not contain these data, please either upload them as Supporting Information files or deposit them to a stable, public repository and provide us with the relevant URLs, DOIs, or accession numbers. For a list of recommended repositories, please see https://journals.plos.org/plosone/s/recommended-repositories. If there are ethical or legal restrictions on sharing a de-identified data set, please explain them in detail (e.g., data contain potentially sensitive information, data are owned by a third-party organization, etc.) and who has imposed them (e.g., an ethics committee). Please also provide contact information for a data access committee, ethics committee, or other institutional body to which data requests may be sent. If data are owned by a third party, please indicate how others may request data access. 3. One of the noted authors is a group or consortium. In addition to naming the author group, please list the individual authors and affiliations within this group in the acknowledgments section of your manuscript. Please also indicate clearly a lead author for this group along with a contact email address.

Additional Editor Comments:

Dear Authors,

Thank you for submitting your manuscript titled "Human Papilloma Virus Vaccination Uptake and Associated Factors among Adolescent Girls in Merab Abaya District, Gamo Zone, Southern Ethiopia: Mixed Methods" (PONE-D-25-02990). Your study addresses an important public health issue, particularly in the context of HPV vaccination among adolescent girls in Ethiopia. The mixed-methods approach is a strength, as it provides both quantitative and qualitative insights into factors influencing vaccine uptake. However, the manuscript requires major revisions to address several methodological, structural, and language-related issues before it can be considered for publication.

The reviewers have provided detailed and constructive feedback, which I encourage you to address thoroughly. Key areas for improvement include:

Language and Grammar: The manuscript contains numerous grammatical and structural errors, which hinder readability. Professional proofreading and language editing are strongly recommended.

Methodological Clarity: Please provide a clearer justification for the mixed-methods design, elaborate on sampling techniques, and ensure transparency in statistical analyses. The qualitative component, in particular, requires more detail regarding participant selection and data saturation.

Integration of Findings: The qualitative and quantitative findings are currently presented separately, leading to a lack of cohesion. A more integrated discussion would enhance the manuscript’s narrative and impact.

Ethical Considerations: While ethical approval and informed consent are mentioned, the section needs to be expanded to include details on confidentiality and parental consent for minors.

Policy and Practical Implications: The discussion and conclusion should more explicitly connect the findings to Ethiopia’s national HPV vaccination strategy and propose targeted interventions to improve uptake.

We recommend that you address these concerns thoroughly and resubmit the manuscript for further evaluation. With the suggested revisions, your study has the potential to make a meaningful contribution to the literature on HPV vaccination strategies in low-resource settings.

Thank you for considering these comments. We look forward to receiving your revised manuscript.

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Partly

**********

2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

**********

3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

**********

4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

**********

5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1:  Key Comments & Suggested Revisions:

1. Abstract

� Strengths:

• Clearly outlines the study’s background, objective, methods, results, and conclusion.

• Highlights the main statistical findings concisely.

� Areas for Improvement:

• Language & Grammar: The abstract contains multiple grammatical and structural errors. Needs proofreading for better readability.

• Methodology Clarification: The mention of “two-stage sampling” and “purposive sampling” should be slightly elaborated for clarity.

• Qualitative Findings Integration: The abstract heavily focuses on quantitative results. Briefly summarizing key qualitative barriers would strengthen the abstract.

� Suggestion:

• Improve clarity and grammar.

• Include qualitative findings concisely.

• Clarify key methodological aspects.

2. Introduction

� Strengths:

• Provides a strong rationale for the study with a global and regional perspective on HPV vaccination.

• Discusses the burden of cervical cancer and vaccination strategies.

� Areas for Improvement:

• Ethiopian Context: Needs more statistics specific to Ethiopia’s HPV vaccination program coverage.

• Study Gap & Justification: The gap in school vs. community-based adolescent girls is a key contribution but should be emphasized more clearly.

• Policy Relevance: How can findings inform Ethiopia’s national HPV vaccination strategy?

� Suggestion:

• Add national data on HPV vaccination rates.

• Explicitly state how this study fills the research gap.

• Connect findings to national health policy implications.

3. Methods

� Strengths:

• Provides a structured explanation of study design, population, and sampling.

• The two-stage sampling approach and use of mixed methods are appropriate.

� Areas for Improvement:

• Study Design Justification: The choice of a mixed-methods design should be explicitly justified.

• Qualitative Methods Weakness:

o Lack of details on how qualitative participants were selected and how data saturation was determined.

o The qualitative component is not well-integrated with quantitative findings.

• Statistical Analysis Clarity:

o The rationale for using logistic regression should be briefly explained.

o Define statistical assumptions (e.g., multicollinearity check, goodness-of-fit test).

• Ethical Considerations:

o Ethical approval and informed consent are mentioned, but there is no discussion on how participant confidentiality was maintained.

o Parental consent for minors should be explicitly stated.

� Suggestion:

• Clarify why a mixed-methods approach was chosen.

• Improve details on qualitative data collection and analysis.

• Provide more details on statistical validity checks.

• Strengthen the ethical considerations section.

4. Results

� Strengths:

• Clearly presents both descriptive and inferential statistics.

• Tables and figures effectively summarize key findings.

� Areas for Improvement:

• Inconsistent Data Presentation:

o The qualitative findings are summarized separately, making it difficult to integrate with the quantitative results.

o The qualitative barriers should be incorporated within the quantitative discussion to create a cohesive narrative.

• Confidence Intervals & p-values:

o Some tables lack confidence intervals for adjusted odds ratios.

o Ensure all variables in multivariate models have their respective p-values reported.

• Missing Effect Sizes for Key Findings:

o Instead of just stating associations, include an interpretation of effect sizes (e.g., "Family support increases the odds of HPV uptake by sevenfold").

Suggestion:

• Integrate qualitative and quantitative findings for a more coherent discussion.

• Ensure consistent reporting of confidence intervals and p-values.

• Interpret effect sizes meaningfully.

5. Discussion

� Strengths:

• Findings are compared with other studies.

• Practical recommendations are given.

� Areas for Improvement:

• Thematic Integration Weakness:

o The discussion mostly focuses on quantitative results, with minimal integration of qualitative themes.

o The qualitative findings should be used to explain why certain factors influence HPV uptake.

• Study Limitations Section is Weak:

o It should include potential biases (e.g., self-reporting bias, recall bias).

o Acknowledge limitations in the generalizability of findings.

• Policy & Practice Implications Need Strengthening:

o How can these findings inform vaccination strategies in Ethiopia?

o What targeted interventions can improve uptake?

Suggestion:

• Improve qualitative-quantitative integration.

• Expand the limitations section.

• Strengthen the practical and policy implications.

6. Conclusion

� Strengths:

• Summarizes key findings concisely.

• Provides recommendations.

� Areas for Improvement:

• Should explicitly connect findings to policy recommendations.

• Needs to acknowledge study limitations more clearly.

Suggestion:

• Strengthen connection to policy and public health strategies.

• Mention study limitations.

Language & Formatting Issues

Major concerns:

• Numerous grammatical and typographical errors throughout the manuscript.

• Sentence structure and wording need improvement for clarity and readability.

Suggestion:

• Professional proofreading & language editing is strongly recommended.

• Consider restructuring certain paragraphs for better flow.

Final Decision:

Major Revisions Required

Key Actions Needed Before Resubmission:

1. Improve language clarity & proofreading.

2. Enhance integration of qualitative and quantitative findings.

3. Clarify statistical methodology and reporting.

4. Strengthen ethical considerations, limitations, and policy implications.

5. Improve discussion depth and coherence.

**********

6. PLOS authors have the option to publish the peer review history of their article (what does this mean? ). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy .

Reviewer #1: No

**********

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/ . PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org . Please note that Supporting Information files do not need this step.

Attachments

Attachment

Submitted filename: Reviewers comments(HG).docx

PONE-D-25-02990R1Human Papilloma Virus Vaccination uptake and Associated Factors among Adolescent Girls in Merab Abaya District, Gamo Zone, Southern Ethiopia: Mixed MethodsPLOS ONE

Dear Dr. Milkano,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Please submit your revised manuscript by Aug 07 2025 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org . When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

• A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
• A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
• An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols . Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols .

We look forward to receiving your revised manuscript.

Kind regards,

Morufu Olalekan Raimi, Ph.D

Academic Editor

PLOS ONE

Journal Requirements:

Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

Additional Editor Comments:

After reviewing the manuscript and the authors' responses to the reviewers' comments, here is my assessment and recommendation:

Strengths of the Manuscript:

1. The mixed-methods approach (quantitative and qualitative) provides a robust analysis of HPV vaccine uptake and associated factors, enhancing the depth of understanding.

2. The study aims to assess HPV vaccine uptake among adolescent girls in a specific region, addressing a gap in existing literature.

3. The sampling technique, data collection, and analysis are well-described, ensuring reproducibility.

4. The study identifies key factors influencing vaccine uptake (knowledge, attitude, health worker recommendations, family support) and barriers (mistrust, irregular provision, lack of information).

5. Ethical approval and consent procedures are documented, and confidentiality measures are highlighted.

Areas Addressed in Revisions:

• The authors state that the manuscript underwent professional proofreading and language editing.

• Additional details on sampling techniques, qualitative data saturation, and statistical validity checks were provided.

• The discussion now better integrates qualitative and quantitative results.

• Expanded details on confidentiality and parental consent for minors were included.

• The discussion now explicitly connects findings to Ethiopia’s national HPV vaccination strategy.

Remaining Concerns:

1. The qualitative audio data are not shared due to consent issues, which may limit transparency. However, the authors offer to provide it if mandatory.

2. The study’s focus on one district may limit broader applicability, though this is acknowledged as a limitation.

3. While proofreading was done, some minor grammatical or structural errors may persist.

Recommendation:

Accept the Manuscript with Minor Revisions

The manuscript is well-structured, addresses an important public health issue, and has incorporated most reviewer feedback. The remaining concerns are minor and do not detract from the study's overall quality and contributions.

Justification for Acceptance:

• The study provides valuable insights into HPV vaccine uptake in a low-resource setting, with practical recommendations for improving vaccination rates.

• The mixed-methods approach strengthens the findings.

• Ethical and methodological rigor is demonstrated.

• The revisions have adequately addressed the reviewers' comments.

Proceed with acceptance, pending these minor checks.

Final Decision: Accept with Minor Revisions

[Note: HTML markup is below. Please do not edit.]

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/ . PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org . Please note that Supporting Information files do not need this step.

Human Papilloma Virus Vaccination uptake and Associated Factors among Adolescent Girls in Merab Abaya District, Gamo Zone, Southern Ethiopia: Mixed Methods

PONE-D-25-02990R2

Dear Authors Dr.

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

An invoice will be generated when your article is formally accepted. Please note, if your institution has a publishing partnership with PLOS and your article meets the relevant criteria, all or part of your publication costs will be covered. Please make sure your user information is up-to-date by logging into Editorial Manager at Editorial Manager®  and clicking the ‘Update My Information' link at the top of the page. For questions related to billing, please contact billing support .

If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

Kind regards,

Morufu Olalekan Raimi, Ph.D

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

After all necessary corrections has been made. This manuscript meets the high standards of scientific rigor, original contribution, and public health relevance expected by PLOS ONE. Its mixed-methods approach enriches understanding of HPV vaccine uptake barriers in a critical region, providing evidence to guide effective interventions.

Therefore, the manuscript should be accepted for publication to advance global efforts in cervical cancer prevention and adolescent health promotion.

Kind regards

Prof. Morufu Olalekan Raimi

Reviewers' comments: