-->PONE-D-25-55196

From Global to Local: Developing a Context-Specific BeSD-HPV Tool through Cultural and Linguistic Adaptation in Pakistan

PLOS One

Dear Dr. Noor,

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PLOS One

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Additional Editor Comments:

PLOS ONE Editorial Decision

Manuscript Number: PONE-D-25-55196

Title: From Global to Local: Developing a Context-Specific BeSD-HPV Tool through Cultural and Linguistic Adaptation in Pakistan

Corresponding Author: Dr. Mehreen Noor

Decision: Major Revision Required

Dear Dr. Noor and Co-authors,

Thank you for submitting your manuscript to PLOS ONE. We have now received comments from two reviewers, both of whom recognize the importance and relevance of your work in addressing HPV vaccine hesitancy in Pakistan through cultural adaptation of the WHO BeSD framework. While the reviewers find the study promising, they have raised substantial methodological, conceptual, and presentational concerns that must be adequately addressed before the manuscript can be considered for publication. As the handling editor, I have conducted a detailed assessment of the manuscript and concur with the reviewers’ critiques. The study has strong potential to contribute to the literature on culturally informed vaccine implementation, but several critical issues undermine its current scholarly rigor and clarity.

Below, I outline the core concerns that must be addressed in a revised submission:

Major Concerns Requiring Substantive Revision

1. Conceptual Clarity and Justification

• The Introduction does not sufficiently justify why Pakistan is a distinct context requiring a unique adaptation of the BeSD framework. The sociocultural, religious, and gendered nuances must be explicitly detailed with supporting literature.

• The added domain “Cultural Integration” lacks clear conceptual distinction from the existing BeSD domains (e.g., Social Processes, Thinking & Feeling). You must provide a rigorous theoretical and empirical justification for why this domain is necessary rather than integrating these constructs into existing domains. Overlap must be explicitly addressed.

• The target population (adolescent girls) and the rationale for excluding boys from HPV vaccination discussions need clarification, especially given global recommendations for gender-neutral HPV vaccination.

2. Methodological Rigor and Transparency

• Participant characteristics: Vaccination status of participants is missing. This is critical for interpreting perspectives on hesitancy vs. acceptance.

• Interview guides: The four qualitative guides are mentioned but not described. You must detail how each guide was tailored to different stakeholder groups and how they operationalized the BeSD domains.

• Focus Group Discussions: The composition of the fourth FGD is unspecified. Provide participant numbers and group demographics for all FGDs.

• Analytical process: While Braun & Clarke’s thematic analysis is cited, the manuscript lacks detail on coder agreement, resolution of discrepancies, and translation verification processes.

• Sampling justification: Purposive sampling is noted, but the rationale for selecting specific districts and stakeholders needs elaboration regarding representativeness and transferability.

3. Structural and Presentation Issues

• Tables are excessively large and disrupt narrative flow. Consider moving detailed tables (e.g., Tables I-V) to supplementary materials and retaining summarized versions in the main text.

• Figure clarity: Figures (e.g., methodological framework) require improved labeling and integration with the described process. Legends must be self-contained and clearly referenced.

• Language and flow: Several sections contain repetitive phrases, grammatical errors, and unclear syntax. A thorough language edit by a native English speaker or professional editing service is strongly recommended.

4. Discussion and Interpretation

• The Discussion does not sufficiently synthesize key findings or explicitly link back to the Results. A concise summary of main themes is needed.

• Comparative analysis with other BeSD adaptation studies (e.g., Nigeria, Bangladesh) is superficial. Strengthen this to highlight the unique contributions of your work.

• The implications of the “Cultural Integration” domain for policy and practice are overstated without validation. Frame conclusions more cautiously and emphasize the need for future quantitative validation of the adapted tool.

5. Compliance with Journal Guidelines

• Ensure all supplementary materials are clearly labeled and referenced.

• Abbreviations (e.g., BeSD, LMICs) must be defined at first use.

• Ethical approval details are included but should be clearly stated in the Methods section as per PLOS ONE requirements.

Recommendations for Revision

1. Restructure the Introduction to clearly articulate the gap in cultural adaptation of BeSD in Pakistan, supported by local data on HPV burden, vaccination coverage, and sociocultural barriers.

2. Clarify methodological steps in a dedicated subsection, detailing adaptation procedures, coder consistency, translation approach, and participant recruitment.

3. Refine the conceptual framework to explicitly distinguish the new “Cultural Integration” domain and justify its addition with qualitative evidence.

4. Condense and reorganize results: Use summary tables in the main text and provide extensive tables as supplementary files.

5. Strengthen the Discussion with a clear summary of findings, comparative context, limitations, and future research directions, particularly tool validation.

6. Undergo thorough language editing to improve clarity, coherence, and academic tone.

Revision Deadline: We expect to receive your revised manuscript within 90 days. Please submit a detailed point-by-point response to all reviewer and editor comments, noting changes made in the manuscript.

If you are unable to address these concerns within this timeframe, we will consider the manuscript withdrawn.

We appreciate your contribution to PLOS ONE and look forward to receiving a revised manuscript that meets the journal’s standards for publication.

Sincerely,

Dr. Morufu Olalekan Raimi

Editor, PLOS ONE

Deputy Director, Niger Delta Institute for Emerging and Re-emerging Infectious Diseases, Federal University Otuoke.

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Reviewers' comments:

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Reviewer #1: Yes

Reviewer #2: Partly

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Reviewer #1: Yes

Reviewer #2: N/A

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Reviewer #1: Yes

Reviewer #2: No

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Reviewer #1: Yes

Reviewer #2: No

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Reviewer #1: Thank you for submitting this important qualitative study focused on the cultural and linguistic adaptation of the WHO BeSD-HPV tool for Pakistan. The manuscript addresses a clear public health gap, is methodologically sound, and provides a well-articulated adaptation process grounded in rigorous qualitative inquiry.

The study employs a descriptive qualitative design that is appropriate for cultural adaptation work.

Use of Braun & Clarke’s six-step thematic analysis is well described and correctly implemented.

The data (verbatim quotes, themes, emergent domain) clearly support the conclusions.

Addition of a new domain, Cultural Integration, is strongly grounded in participant narratives.

Transparency in coding, construct development, and translation strengthens credibility.

Clear use of both deductive and inductive coding.

Trustworthiness is addressed comprehensively using Lincoln and Guba’s criteria (credibility, dependability, confirmability, transferability).

Reflexivity is described adequately.

Triangulation through IDIs and FGDs strengthens internal validity.

Minor Suggestion:

Indicate coder agreement or how discrepancies were resolved (e.g., consensus meetings, intercoder reliability).

Clarity and English Language Quality

The manuscript is clear, intelligible, and written in acceptable standard English, but minor language and formatting issues should be addressed.

Examples of recommended improvements:

Remove repeated words (e.g., “that that”, “includees”).

Areas for Strengthening Before Publication

Include a brief paragraph on the limitations, such as:

geographic focus on Punjab,

potential social desirability bias,

reliance on purposive sampling.

In the Discussion, more explicitly compare findings to other adaptation studies of BeSD tools globally.

Improve the clarity of tables some are extremely large for the main text.

Reviewer #2: Thank you for submitting your manuscript “From Global to Local: Developing a Context-Specific BeSD-HPV Tool through Cultural and Linguistic Adaptation in Pakistan” to PLOS One.

The study offers insights into the cultural, social, and gendered factors influencing HPV vaccine hesitancy in Pakistan, while important methodological and conceptual clarifications are needed to fully support the proposed adaptation of the BeSD framework.

Some revisions are suggested as follows:

Introduction: Please strengthen the Introduction by clearly defining the BeSD-HPV framework, explicitly justifying why Pakistan is the appropriate context, and explaining why the WHO Behavioral and Social Drivers of Vaccination (BeSD) framework is the most suitable approach for addressing HPV vaccination in this setting.

The Introduction does not adequately describe how behavioral, social, and cultural factors specific to Pakistan influence HPV vaccination decisions, nor does it report current HPV vaccination coverage, clarify the target population (female, male, or both, given that HPV vaccination is not limited to cervical cancer prevention), or present sex-specific HPV disease burden and vaccination patterns.

Key terms such as “low-resource environments” are also insufficiently described, and prior HPV prevention or vaccination approaches in Pakistan, along with their limitations related to behavioral and cultural factors, are not clearly described. Addressing these gaps is essential to establish a coherent rationale for the proposed framework development.

The figure Methodological Framework for a Culturally Adapted HPV Vaccine Acceptance Study in Pakistan partially reflects the WHO BeSD framework; however, several core BeSD components are incompletely specified, and conceptual boundaries between domains are unclear. In particular, the addition of a “Cultural Integration” domain appears to overlap with existing BeSD constructs without sufficient justification. Please clarify the conceptual rationale for this domain and explicitly describe how it differs from, extends, or integrates with existing BeSD domains.

Please report participants’ HPV vaccination status and indicate whether vaccination experience was considered in sampling or analysis, as the absence of this information limits interpretation of the findings.

Although 4 qualitative interview guides are mentioned, the Methods do not clearly describe how these guides differ in content, what domains each covers, or how they were aligned with the WHO BeSD framework. Please clarify these distinctions and provide sufficient detail to assess how the interview guides operationalized the framework.

Please clarify the composition of all 4 focus group discussions, including the participant group for the fourth session and the approximate number of participants per group.

Please provide greater analytic detail by clarifying how Braun and Clarke’s six-step thematic analysis was applied, how coding consistency was ensured across multiple coders, how transcript translation was conducted and verified, and what analytic criteria justified the creation of the additional “Cultural Integration” domain rather than integration within existing BeSD domains.

It seems that the Methods and Results do not sufficiently demonstrate how qualitative findings were systematically synthesized into a distinct, culturally adapted BeSD-HPV framework. In particular, the process for preserving the conceptual integrity of the original BeSD domains and the analytic justification for introducing an additional domain are not clearly articulated, limiting confidence that the stated framework development objective was achieved.

The Discussion partially addresses the Results and the stated study purpose. While it interprets key cultural and social drivers of HPV vaccine hesitancy and reiterates the rationale for adapting the WHO BeSD framework, it lacks a clear, concise summary of the main findings and does not consistently link interpretations back to the reported Results. Comparison with prior BeSD-based studies is limited, and the conceptual contribution of the added “Cultural Integration” domain remains insufficiently articulated. It could be helpful to strengthen the Discussion by improving alignment with the Results, adopting a more cautious framing of the implications, and explicitly addressing future validation and application of the adapted framework.

Please spell out the full term at first mention and use the abbreviation thereafter.

Please clearly identify all supplementary materials and provide complete legends for all figures.

Please review and revise the manuscript to ensure that all components comply with the journal’s submission guidelines.

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Reviewer #1: No

Reviewer #2: No

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Submitted filename: Review notes.pdf

-->PONE-D-25-55196R1-->-->From Global to Local: Developing a Context-Specific BeSD-HPV Tool through Cultural and Linguistic Adaptation in Pakistan-->-->PLOS One

Dear Dr.  Noor,

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 May 15 2026 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 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.

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As the corresponding author, your ORCID iD is verified in the submission system and will appear in the published article. PLOS supports the use of ORCID, and we encourage all coauthors to register for an ORCID iD and use it as well. Please encourage your coauthors to verify their ORCID iD within the submission system before final acceptance, as unverified ORCID iDs will not appear in the published article. Only  the individual author can complete the verification step; PLOS staff cannot  verify ORCID iDs on behalf of authors.

We look forward to receiving your revised manuscript.

Kind regards,

Morufu Olalekan Raimi, Ph.D

Academic Editor

PLOS One

Journal Requirements:

1. If the reviewer comments include a recommendation to cite specific previously published works, please review and evaluate these publications to determine whether they are relevant and should be cited. There is no requirement to cite these works unless the editor has indicated otherwise.

2. 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:

PLOS ONE Editorial Decision

Manuscript Number: PONE-D-25-55196R1

Title: From Global to Local: Developing a Context-Specific BeSD-HPV Tool through Cultural and Linguistic Adaptation in Pakistan

Corresponding Author: Dr. Mehreen Noor

Editor: Dr. Morufu Olalekan Raimi

Decision: Minor Revision Required

Date: March 31, 2026

Dear Dr. Noor and co-authors,

Thank you for submitting your revised manuscript and for the detailed, point-by-point response to the previous round of reviews. I have carefully evaluated the revised manuscript, the original reviewer comments, and your responses. You have made substantial efforts to address the major conceptual, methodological, and presentation concerns raised by the reviewers and myself as the handling editor. The manuscript has significantly improved. The introduction now more clearly justifies Pakistan’s distinct sociocultural context, the methods section provides greater transparency regarding coder agreement, FGD composition, and interview guide operationalization, and the discussion offers a more cautious framing of the “Cultural Integration” domain while calling for future quantitative validation. The relocation of extensive tables to supplementary files and the professional language editing have also enhanced readability. However, despite these improvements, a careful re-reading of the revised manuscript (including the clean and marked-up versions) reveals several residual issues that prevent me from accepting the manuscript in its current form. These are not as fundamental as the previous major concerns, but they require attention to meet PLOS ONE’s standards for clarity, consistency, and scientific rigor.

I therefore invite you to submit a minor revision of your manuscript, addressing the following points:

1. Inconsistent Terminology and Redundancy (Throughout)

Despite the language edit, several redundant or inconsistent terms persist, suggesting incomplete proofreading.

• Example (Abstract, Line 29-31): “Table cell colors are indicative of the domain thinking and feeling, social processes, motivation, practical issues, and emergent new theme cultural Integration as per colors aligned with the WHO BeSD Framework.” This sentence is convoluted. Consider: “Table cell colors correspond to the WHO BeSD domains (Thinking and Feeling, Social Processes, Motivation, Practical Issues) and the emergent theme, Cultural Integration.”

• Example (Page 13, Line 279-281): “Deeply committed constructs of BeSD” – “Deeply committed” is unclear. Did you mean “Core constructs” or “Original constructs”?

• Example (Page 15, Line 311-313): The phrase “The transcripts were coded using the six steps of thematic analysis, as developed by Braun and Clarke, by researchers KN, SM, and MN, who also coded them independently” is awkwardly structured. Simplify.

Action: Please conduct a final, line-by-line review to eliminate redundancy, correct unclear phrasing, and standardize terminology (e.g., consistently use “Thinking and Feeling” not “thinking and feeling” without capitalization when referring to the domain).

2. Figure Quality and Self-Contained Legends

You have replaced copyrighted images and improved figure resolution. However, the legends for Figures 1, 2, and 3 are not fully self-contained.

• Figure 1 (Methodological Framework): The legend currently (Page 10, Line 209-210) is minimal. A reader should understand the figure without referring to the main text. Please add a brief legend that explains each step (e.g., “Step 1: Study Design & Setting; Step 2: Sampling & Recruitment; Step 3: Data Collection; Step 4: Analysis; Step 5: Final Outcome”).

• Figure 3 (Cultural Adaptation Process Aligned with TPB): The legend (Page 23, Line 488) simply states the title. Add 1-2 sentences explaining how TPB constructs map to BeSD domains (e.g., “Attitudes → Thinking & Feeling; Subjective Norms → Social Processes; Perceived Behavioral Control → Practical Issues; Intention → Motivation; with Cultural Integration as a cross-cutting domain”).

Action: Revise all figure legends to be fully descriptive and self-contained. Ensure each figure file is high-resolution (TIFF, ≥300 dpi) as previously requested.

3. Missing Supplementary File Legend for S1 and Inconsistent Referencing

In the main text (Page 12, Line 247), you state that “Adapted Interview guides are also attached as supplementary file no 1.” However, in the “Supporting Information” section at the end of the manuscript (Page 53, Line 703-708), you list “S1: Four qualitative interview guides” without a descriptive legend. PLOS ONE requires a brief legend for each supporting file.

Action: Immediately after the References section, provide a clear, numbered legend for each supplementary file. For example:

• S1. Qualitative interview guides for caregivers, healthcare providers, community influencers, and program managers (adapted from WHO BeSD).

• S2. De-identified interview transcripts.

• S3. Coding tree from thematic analysis.

• S4. Final 70-item BeSD-HPV tool (English and Urdu versions).

• Table S1. Thinking and Feeling domain – item mapping, quotes, and rationale.

• (Continue for S2–S5 and all supplementary tables)

Also, ensure that every supplementary file is cited in the main text at least once.

4. Minor Ethical and Data Availability Clarifications

• Ethics Statement (Page 52, Line 698-702): You state the study adhered to the Declaration of Helsinki. Please add the date or version of the Declaration (e.g., “as revised in 2013”) for precision.

• Data Availability (Page 17, Line 13 of the editorial section): You state “All relevant data are within the manuscript and its Supporting Information files.” However, the coding tree (S3) and transcripts (S2) are provided as supplementary files. Confirm explicitly that no additional raw data (e.g., NVivo project files) are required for replication, and that the de-identified transcripts contain no direct identifiers (names, specific dates, locations below district level). A one-sentence confirmation in the cover letter during resubmission will suffice.

5. Overstated Claim in the Conclusion (Still Present)

You have toned down implications, but the conclusion (Page 52, Line 672-678) still states: “This study provides evidence for the cultural adaptation of BeSD framework to develop a context-specific and linguistically appropriate tool… to support the successful launch of the HPV vaccine in Pakistan.”

The phrase “to support the successful launch” implies predictive effectiveness. Given that the tool has not been quantitatively validated, revise to: “to inform the development of strategies for the planned introduction of the HPV vaccine in Pakistan” or “to provide a foundation for future implementation research.”

Action: Minor rewording to align with the cautious framing you correctly adopted in the Discussion (Page 50, Line 632-634).

________________________________________

Summary of Required Revisions (Minor)

Category Specific Action

Language & consistency Eliminate redundancy, clarify awkward phrasing, standardize domain capitalization.

Figure legends Make Figures 1, 2, and 3 legends self-contained (2-3 sentences each).

Supporting information Add descriptive legends for all supplementary files (S1–S5, Tables S1–S5).

Ethics statement Include version/date of Declaration of Helsinki.

Data availability Confirm no additional raw data needed and transcripts are fully de-identified.

Conclusion Replace “to support the successful launch” with more cautious wording.

________________________________________

Final Editorial Comment

This work addresses a critical gap in HPV vaccine implementation science for culturally complex, low-resource settings. The theoretical integration of TPB with the WHO BeSD framework and the empirically grounded “Cultural Integration” domain are potentially valuable contributions. However, the manuscript’s current clarity and presentation must meet PLOS ONE’s publication standards. I am confident that the remaining issues are minor and can be resolved within 14 days. Please submit your revised manuscript along with a point-by-point response to this decision letter, clearly indicating where each change has been made (page and line numbers).

I look forward to receiving your prompt revision.

Sincerely,

Dr. Morufu Olalekan Raimi

Editor, PLOS ONE

Deputy Director, Niger Delta Institute for Emerging and Re-emerging Infectious Diseases, Federal University Otuoke, Nigeria

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-->PONE-D-25-55196R2-->-->From Global to Local: Developing a Context-Specific BeSD-HPV Tool through Cultural and Linguistic Adaptation in Pakistan-->-->PLOS One

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Additional Editor Comments:

REVIEWER'S REPORT

Title: From Global to Local: Developing a Context-Specific BeSD-HPV Tool through Cultural and Linguistic Adaptation in Pakistan

Recommendation: Minor Revision

Editor: Dr. Morufu Olalekan Raimi, PLOS ONE Academic Editor

Review Date: April 17, 2026

EDITORIAL DECISION

Dear Authors,

Thank you for submitting your revised manuscript and for the detailed, point-by-point response to the previous reviews. You have addressed the major conceptual, methodological, and structural concerns raised in the prior round substantively and professionally. The manuscript is now considerably stronger: the introduction better justifies Pakistan's distinct context, the "Cultural Integration" domain is more clearly distinguished from existing BeSD constructs, the methodological transparency has improved, and the discussion is appropriately cautious about the need for future quantitative validation. However, after a thorough review of the revised manuscript and your response letter, several minor but necessary issues remain. These do not require major re-analysis or additional data collection, but they must be corrected before the manuscript is ready for publication.

REQUIRED MINOR REVISIONS

1. Incomplete Correction of Abstract Wording (Page 4, Lines 29-30)

In your response letter, you revised the abstract sentence to: “Table cell colors correspond to the WHO BeSD domains (Thinking and Feeling, Social Processes, Motivation, Practical Issues) and the emergent theme, Cultural Integration.” However, the manuscript file (page 4, lines 29-30) still contains the original convoluted wording. The revised version appears in the response letter but was not carried over to the manuscript file.

Action: Replace the current abstract sentence with the corrected version as shown in your response letter.

2. Redundant Sentence in Introduction (Page 6, Lines 121-129 and Lines 130-134)

You have two nearly identical paragraphs describing the target population (adolescent girls) and the rationale for excluding boys. The first paragraph (lines 121-129) is sufficient. The second paragraph (lines 130-134) begins "To provide a theoretically grounded basis..." and repeats TPB framing already covered elsewhere.

Action: Delete the second redundant paragraph (lines 130-134). Keep the first paragraph as the sole justification.

3. Typographical Error in Methods (Page 11, Line 226)

The text reads: “Islamabad is the Capital Territory, and Rawalpindi comprises towns and urban areas with greater higher level of exposure...”

Action: Change “greater higher level” to “greater level” or “higher level” (not both).

4. Incomplete Sentence in Methods (Page 13, Line 274)

The text reads: "This process helped in the following phenomenon to identify topics that require modification..."

Action: This sentence is incomplete. Revise to: “This process helped to identify topics requiring modification in terms of rephrasing and contextual probing to enhance cultural relevance.”

5. Duplicate Phrase in Thematic Analysis Section (Page 17, Lines 346-348)

The text reads: “In the first coding stage, all transcripts were initially looked at deductively to find out whether the narratives by the participants could be meaningfully and conceptually placed within the already established BeSD constructs and in- alignment with the corresponding TPB constructs. The Coding decisions in coding were determined by the theoretical purpose of each domain...”

Action: Change “The Coding decisions in coding” to “Coding decisions” (remove redundancy).

6. Missing Space in Figure 3 Reference (Page 24, Line 490)

The text reads: “Figure 03 showillustrates the theoretical basis...”

Action: Change to “Figure 3 illustrates the theoretical basis...”

7. Inconsistent Capitalization of “Cultural Integration”

Throughout the manuscript, “Cultural Integration” is sometimes capitalized as a proper domain name (correct) and sometimes written in lowercase. Examples:

• Page 4, line 30: “emergent theme, Cultural Integration” (correct)

• Page 26, line 540: “emergent domain 'cultural integration'” (incorrect, should be capitalized)

Action: Standardize to “Cultural Integration” (capitalized) throughout the manuscript.

8. Missing Supporting File Citations in Main Text

You have added descriptive legends for supplementary files at the end of the manuscript. However, several supplementary tables (S1-S5) are not cited in the main text. The journal requires that every supplementary file be cited at least once in the body of the manuscript.

Action: Add brief citations for Tables S1-S5 in the Results or Methods section (e.g., "Detailed item mapping for each domain is provided in Supplementary Tables S1-S5").

9. Minor Language Improvements (Optional but Recommended)

Location Current Text Suggested Revision

Page 5, line 88 “family setups is are mainly largely male-dominated” “family structures are predominantly male-dominated”

Page 8, line 157 “BeSD domains eorrespond- closely align withe TPB's constructs” “BeSD domains align closely with TPB's constructs”

Page 26, line 528 “participants' perceptions about of HPV vaccinations is are not just limited” “participants' perceptions of HPV vaccination are not limited”

Page 29, line 613 “a reasonably opportunity” “a reasonable opportunity”

STRENGTHS OF THE REVISED MANUSCRIPT

The authors deserve credit for several substantive improvements:

1. Clearer justification for Pakistan as a distinct context - The introduction now explicitly details sociocultural, religious, and gendered barriers with supporting literature.

2. Improved conceptual distinction of “Cultural Integration” - The revised framework clarifies how this domain differs from (and interacts with) existing BeSD constructs, particularly through the TPB alignment.

3. Enhanced methodological transparency - The addition of coder agreement procedures, translation verification, and detailed FGD composition strengthens credibility.

4. Appropriately cautious conclusions - The discussion now emphasizes the need for future quantitative validation and tones down overstatements about policy impact.

5. Responsive to all reviewer concerns - The point-by-point response is thorough and professional.

RECOMMENDATION

Minor Revision

The manuscript is now methodologically sound and makes a meaningful contribution to the cultural adaptation of global health frameworks. The remaining issues are minor and can be corrected without additional review. Once the 9 items listed above are addressed, the manuscript will be suitable for publication.

SUBMISSION INSTRUCTIONS

Please prepare a revised manuscript addressing the required corrections. In your cover letter, provide a brief point-by-point response to each of the 9 items, citing page and line numbers. Use tracked changes or a colored font to highlight revisions.

Respectfully,

Dr. Morufu Olalekan Raimi

Academic Editor, PLOS ONE

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From Global to Local: Developing a Context-Specific BeSD-HPV Tool through Cultural and Linguistic Adaptation in Pakistan

PONE-D-25-55196R3

Dear Authors,

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.

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Kind regards,

Morufu Olalekan Raimi, Ph.D

Academic Editor

PLOS One

Additional Editor Comments (optional):

PLOS ONE Editorial Decision

Manuscript Number: PONE-D-25-55196R3

Title: From Global to Local: Developing a Context-Specific BeSD-HPV Tool through Cultural and Linguistic Adaptation in Pakistan

Authors: Khola Noreen, Mehreen Noor, Saba Maryam, Mukhtiar Baig

Academic Editor: Dr. Morufu Olalekan Raimi

Decision: Accept

Summary of Evaluation

The authors have thoroughly and systematically addressed all required minor revisions from the previous round. Each of the nine specific issues raised in my prior decision (abstract wording, redundant paragraph, typographical error, incomplete sentence, duplicate phrase, missing space, inconsistent capitalization of “Cultural Integration,” missing supplementary file citations, and minor language improvements) has been corrected in the manuscript. The revised text is now clear, consistent, and compliant with journal standards.

Key Confirmations

1. Abstract – Corrected wording now appears on page 2, lines 29-30 as specified.

2. Introduction – Redundant paragraph removed; justification for adolescent girls as the target population is now concise and non-repetitive.

3. Methods – Typographical error (“greater higher level” → “higher level”) and incomplete sentence have been fixed; supporting file citations (S1–S5) are now included in the main text (page 23, lines 483-484).

4. Thematic Analysis – Duplicate phrasing (“Coding decisions in coding” → “Coding decisions”) resolved.

5. Capitalization – “Cultural Integration” is now consistently capitalized throughout as a proper domain name.

6. Figure reference – Corrected to “Figure 3 illustrates…”

7. Language – Minor grammatical improvements incorporated as recommended.

No further revisions are required.

The manuscript meets PLOS ONE’s criteria for publication: it presents methodologically sound qualitative research, offers a meaningful cultural adaptation of a global health framework, and is reported with sufficient transparency (COREQ guidelines, trustworthiness criteria, supplementary materials). The added “Cultural Integration” domain is conceptually justified, and the authors appropriately acknowledge the need for future quantitative validation.

Final Recommendation

Accepted in current form.

I congratulate the authors on a well-executed study and a responsive revision process.

Sincerely,

Dr. Morufu Olalekan Raimi

Academic Editor, PLOS ONE

Reviewers' comments: