-->PONE-D-26-17339-->-->Understanding factors influencing HPV vaccine uptake among caregivers in Kwara state, Nigeria: A qualitative study-->-->PLOS One

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Additional Editor Comments:

Manuscript Number: PONE-D-26-17339

Title: Understanding factors influencing HPV vaccine uptake among caregivers in Kwara state, Nigeria: A qualitative study

Recommendation: Minor Revision

Reviewer: Morufu Olalekan Raimi, PhD (Chief Editor, PLOS One – Vaccine Acceptance & Global Health)

Review Date: 2026-04-30

Reviewer Comments

Dear Authors,

Thank you for submitting this qualitative study on HPV vaccine uptake among caregivers in Kwara State, Nigeria. The manuscript addresses a critically important public health issue: why HPV vaccination coverage remains suboptimal in Nigeria despite free provision. The qualitative approach is appropriate for exploring the complex, context-specific factors influencing caregiver decisions, and the findings, particularly around multi-level trust, historical medical mistrust, and implementation gaps, offer valuable insights for policy and programme improvement. The manuscript is well-written, methodologically sound in most respects, and makes a meaningful contribution to the literature on vaccine acceptance in low- and middle-income settings. However, several issues require attention before the manuscript meets PLOS ONE standards. These are moderate in scope and focus on data availability, methodological clarity, interpretation of findings, and presentation.

Recommendation: Minor Revision – The manuscript is suitable for publication after addressing the issues below.

Major Concerns

1. Data Availability – Non-Compliant with PLOS ONE Policy

The Data Availability Statement (page 7) states: “Participants in this study did not consent to the public sharing of their raw transcripts. Due to the sensitive nature of the qualitative interviews and the risk of re-identification, data are available upon request from the corresponding author for researchers who meet the criteria for access to confidential data.”

While this is a common approach for qualitative data, PLOS ONE requires that data underlying the findings be fully available without restriction or a clear explanation of why restrictions are necessary. The current statement is vague (“researchers who meet the criteria” – what criteria?) and does not specify who will review requests or on what basis they might be denied.

Required action:

• Specify the exact conditions under which data will be shared (e.g., “Data will be shared with researchers who provide a methodologically sound research proposal and sign a data access agreement prohibiting re-identification and onward sharing.”)

• OR, if ethical approval explicitly prohibits data sharing, state this clearly and provide the relevant ethics committee approval letter as supporting information.

• Additionally, provide anonymized transcripts (with all identifiable information removed) as supporting information if possible. If not possible, explain why.

Acceptable revision:

“Raw transcripts cannot be shared publicly because participants did not consent to public data sharing. Anonymized transcripts (with names, locations, and other identifiers removed) are available from the corresponding author for researchers who submit a methodologically sound research proposal and sign a data access agreement. Requests will be reviewed by the University of Nottingham Faculty of Medicine and Health Sciences Research Ethics Committee.”

2. Limited Representation of Vaccine Decliners – Potential Bias

The study includes 35 acceptors (five FGDs? Actually: four FGDs with acceptors, n=35) and only 6 decliners (one FGD) . The manuscript acknowledges this as a limitation (lines 383–389), stating that recruitment of decliners was challenging given intensive vaccination efforts.

However, the analysis and discussion treat the findings as broadly representative of factors influencing both acceptance and declination. With such a small and potentially unrepresentative sample of decliners, there is a risk that:

• Factors specific to decliners may be under-identified.

• The single decliner FGD (urban) may not capture rural decliner perspectives.

• Thematic saturation for decliner perspectives was almost certainly not achieved.

Required action:

• Reframe the manuscript to more clearly emphasize that the findings primarily reflect acceptor perspectives, with decliner insights offered as exploratory.

• In the Discussion, add a sentence stating: *“Given the small number of decliners (n=6), our findings on barriers and reasons for refusal should be considered preliminary and require further investigation in larger samples of vaccine-declining caregivers.”*

• Consider renaming the study to reflect the acceptor focus (e.g., “Factors influencing HPV vaccine uptake and non-uptake…” but with emphasis on acceptors).

3. Missing Information on Recruitment and Sampling

The Methods section (lines 115-120) describes recruitment via community mobilizers and WhatsApp groups. However, several details are missing:

• How were community mobilizers selected? Were they health workers, community leaders, or lay volunteers?

• What was the response rate? How many caregivers were approached? How many declined to participate? This is important for assessing potential selection bias (e.g., acceptors may have been more willing to participate).

• How was saturation determined? The manuscript mentions “Data saturation was monitored during coding” (line 142) but does not specify how many FGDs were conducted before saturation was reached, or whether any additional FGDs were planned but not conducted.

Required action:

• Add a paragraph in Methods describing the recruitment process in more detail, including the roles of community mobilizers, the number of caregivers approached, and the number who declined.

• Specify how saturation was assessed (e.g., “Saturation was considered reached when three consecutive FGDs yielded no new codes.”).

4. Overstatement of Findings on “Historical Medical Mistrust”

The manuscript makes strong claims about historical medical exploitation (e.g., lines 319–326: “The legacy of unethical medical experimentation has created lasting mistrust… from German-backed sterilization tests… to the Pfizer meningitis drug trial”). While these historical events are documented, the manuscript presents them as directly causative of current HPV vaccine hesitancy without empirical evidence from the participants themselves.

The participant quotes (lines 203-215) mention “rumours that the whites are trying to use it to reduce our population” and COVID-19 vaccine experiences, but no participant explicitly mentioned the Pfizer trial or colonial-era medical experiments. The connection is inferential, not directly reported.

Required action:

• Temper the language to reflect that these historical events may contribute to a broader context of mistrust, rather than stating they directly cause current hesitancy.

• Change “explain why population control narratives resonate so powerfully as they echo real experiences” to “may help explain why population control narratives resonate, as they echo documented historical experiences of medical exploitation.”

• Ensure that the manuscript does not attribute to participants beliefs or knowledge they did not explicitly express.

Minor Revisions

Abstract

• Line 28: “Despite removing cost barriers, misinformation about fertility impacts and population control resulted in variable uptake across states” – change “resulted in” to “contributed to” (causality cannot be established from this study alone).

• Line 36: “Four themes emerged from analysis” – add “(Table 2)” for clarity.

• Line 42: “free vaccine provision alone is insufficient” – good. Add “but not sufficient” after “free provision.”

Introduction

• Line 50-52: “Cervical cancer is the fourth leading cause of death amongst women globally, with more than 342,000 deaths in 2020” – provide reference (Sung et al., 2021 – already in references, line 418). Good.

• Line 60-62: “the Federal Government of Nigeria… partnered with… Gavi, IFFIm, and WHO” – add the year (2023) earlier in the sentence for clarity.

• Line 72-75: “Understanding what influenced caregivers… is crucial to understand this low response rate” – change second “understand” to “addressing.”

Methods

• Line 84-86: “This study was underpinned by the constructionist paradigm” – good. Add a sentence on how this paradigm influenced data collection and analysis (e.g., “We therefore focused on how shared social meanings, rather than individual psychological traits, shaped vaccination decisions.”)

• Line 89-91: “Focus group discussions (FGDs) were considered most appropriate” – justify why FGDs rather than individual interviews. Mention that FGDs allow for interaction and identification of shared community norms.

• Line 95-97: Ethical approval – provide approval numbers for both committees (UoN and UITH). Currently missing.

• Line 108–110: “The study population comprised 41 caregivers” – add the total number of eligible children represented (if known).

• Line 115-121: Recruitment – as noted above, add more detail on response rate and mobilizer roles.

• Line 124-126: “We held four FGDs with accepting caregivers… and one FGD with declining caregivers” – specify that the decliner FGD was urban only. Add: “We were unable to recruit decliners from rural areas.”

• Line 135-136: “Participants received 2,500 (equivalent to £5) as compensation” – specify the currency (2,500 Nigerian Naira). Add that this amount was ethically approved and did not constitute undue inducement.

Results

• Table 1 (page 18–19): The table is clear. Add a footnote: “Percentages may not sum to 100 due to rounding.” Also, “Age of child” – add total n? It sums to 41? Check: 4+8+3+3+11+13 = 42. Correct to 41.

• Theme 1 (page 20-22): Well presented. Add a quote from a Fulani-Hausa participant if available (acknowledged that none were directly included – see limitation).

• Subtheme 1.2 (line 187-191): The quote about inadequately trained personnel (R03, F, Urban, Decliner) is important. Add a brief interpretive comment linking this to trust in health system competence.

• Subtheme 1.4 (line 203-215): The claim about COVID-19 experiences is supported by a quote (line 209–210). However, the quote does not explicitly mention COVID-19 – it says “she did not take the vaccine [during COVID-19?]” – clarify. The participant says “during COVID… because of the rumour” – acceptable but ensure the quote is fully presented.

• Subtheme 3.1 (line 232-239): “inadequate pre-vaccination counselling about potential side effects deterred others” – add a quote that explicitly mentions lack of counselling. The existing quote (R04, M, Urban, Decliner) says “they did not explain the implications, the side effect” – acceptable.

• Subtheme 4.1 (line 250-262): School-based delivery gaps – excellent point. Add a recommendation from participants about how to improve this (e.g., advance notice, letters sent home with students).

Discussion

• Line 294-297: “Radio emerged as the primary mass media source” – good. Add that radio reach in rural areas is often higher than internet/social media, which is relevant for intervention design.

• Line 306-313: Trust as pivotal – excellent. Add a brief link to the 3C model of vaccine hesitancy (confidence, complacency, convenience) – trust aligns with “confidence.”

• Line 319–326: Historical medical mistrust – as noted above, temper causal language.

• Line 336-338: “Western settings such as the United Kingdom grant children under 16 a degree of autonomy… through Gillick Competence” – this is an interesting comparison but somewhat tangential. Consider shortening or moving to a footnote.

• Line 367-373: “Strengths and Limitations” – add one more limitation: social desirability bias. In FGDs, participants may have been reluctant to express vaccine refusal views in front of acceptors. This may explain the difficulty recruiting decliners and the small number of decliners who participated.

• Line 385-389: “The small number of decliners means their perspectives… may not represent the full spectrum” – good. Add: “Future research should specifically oversample decliners using targeted recruitment strategies (e.g., through community leaders in areas with known lower coverage).”

Implications (lines 390-410)

• Line 393-396: “The National Orientation Agency… could develop strategies to counter misinformation” – specific and actionable. Add that these strategies should be pre-tested with target communities to avoid unintended reinforcement of misinformation.

• Line 398-400: “high quality research involving co-production with marginalised Fulani-Hausa communities” – excellent. Add that this research should use qualitative methods conducted in Hausa or Fulfude by native speakers.

• Line 402-406: “house-to-house approach… successfully implemented during oral polio vaccination campaigns” – good. Add that this approach is resource-intensive; discuss feasibility and cost implications.

Conclusion

• Line 408-414: “This study provides insights into HPV vaccination experiences in Nigeria” – good. Add a sentence on the need for quantitative studies to assess the prevalence of the barriers identified here (e.g., what proportion of caregivers endorse fertility concerns?).

Language and Presentation

Grammar and Style

• Line 56: “Before 2023, the high cost of HPV vaccines in Nigeria created significant access barriers” – change “created” to “posed.”

• Line 77: “Ilorin East local government area (LGA)” – capitalize “Local Government Area” for consistency.

• Line 143-144: “Familiarization of the data was done through repeated reading” – change “was done” to “began with” for active voice.

• Line 150-151: “quotes were selected to support themes and sub-themes” – add “illustrative” before “quotes.”

• Line 203-215: The quote in Subtheme 1.4 ends with “(R03, F, Urban, Decliner)” – but R03 earlier was male (line 182). Check consistency. R03 appears multiple times with different genders. Correct.

Tables and Figures

• Table 1 (page 18-19): As noted, verify age of child frequencies (sum to 42, not 41). Also, “Marital status” – add “Total” row.

• Table 2 (page 19-20): Well organized. Add page numbers for where each theme is discussed.

• Appendix A (FGD guide): The file is referenced but not visible in the PDF. Ensure it is included in the final submission.

References

• Reference 1 (Sung et al.) – correct.

• Reference 2 (WHO Regional Office for Africa) – URL provided. Add access date.

• Reference 8 (Agha & Nsofor, 2025) – PLOS One. Verify year (2025 is future relative to submission? Acceptable if published online ahead of print).

• Reference 21 (Gauna et al.) – missing journal name? It is “Human Vaccines & Immunotherapeutics.” Add.

• Reference 31 (Richards et al.) – correct.

• Inconsistent formatting: Some references have DOIs, others do not. Add DOIs where available. Some have issue numbers, others do not. Standardize.

Ethics Statement

• The ethics statement on page 4 is clear. However, the approval numbers are missing. Add: “University of Nottingham Faculty of Medicine and Health Sciences Research Ethics Committee (approval number: [XXX]) and University of Ilorin Teaching Hospital Research Ethics Committee (approval number: [XXX]).”

Data Availability – Additional Note

The manuscript states (page 8) that “data are available upon request from the corresponding author.” As noted above, this is insufficient for PLOS ONE. In addition to the revisions suggested, please ensure that the Data Availability Statement in the manuscript matches the information provided in the submission system. Currently, the submission system states “No – some restrictions will apply” (page 6) while the manuscript text says data are available upon request. These must be consistent.

Decision Rationale

This qualitative study provides valuable, context-specific insights into HPV vaccine decision-making among caregivers in Kwara State, Nigeria. The findings on multi-level trust, historical medical mistrust, personal cancer experiences, and implementation gaps are policy-relevant and contribute to the growing literature on vaccine acceptance in Africa. The manuscript is well-written and methodologically sound in most respects.

However, the manuscript cannot be accepted in its current form due to:

1. Non-compliance with PLOS ONE data availability policy (data available “upon request” without clear conditions; no anonymized transcripts provided).

2. Limited representation of vaccine decliners (n=6, one FGD) leading to potential bias in findings on barriers to uptake.

3. Missing methodological details (recruitment response rate, saturation criteria, ethics approval numbers).

4. Overstatement of historical mistrust claims without direct participant quotations.

These issues are fixable with moderate revisions. The authors do not need to collect new data, but they must clarify the data availability conditions, temper the historical mistrust interpretation, and provide missing methodological details.

Recommendation: Minor Revision – I look forward to seeing the revised manuscript.

Sincerely,

Morufu Olalekan Raimi, PhD

Academic Editor (Environmental Epidemiology)

PLOS One

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Reviewers' comments:

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Reviewer #1: This is a highly relevant and insightful qualitative study. Understanding the barriers and facilitators to HPV vaccine uptake in Nigeria, especially following the recent 2023 campaign, is crucial for improving global cervical cancer prevention.

I appreciate your rigorous use of reflexive thematic analysis and the deliberate inclusion of both vaccine acceptors and decliners in your focus groups. Your findings regarding the multi-layered nature of trust, the impact of historical medical mistrust, and the specific geographic and language barriers facing certain communities provide highly actionable insights for future public health campaigns.

I have no changes to request. Congratulations on a well-executed and valuable paper.

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Reviewer #1: Yes:  Ganesh Praneeth Roy Avula

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Understanding factors influencing HPV vaccine uptake among caregivers in Kwara state, Nigeria: A qualitative study

PONE-D-26-17339R1

Dear Author,

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 ID: PONE-D-26-17339_R1

Title: Understanding factors influencing HPV vaccine uptake among caregivers in Kwara state, Nigeria: A qualitative study

Authors: Laura Asher, Abdulmujeeb O. Muhammad-Olodo

Editor: Dr. Morufu Olalekan Raimi, PhD (Academic Editor, PLOS ONE – Vaccine Acceptance & Global Health)

Date of Decision: 29 May 2026

Decision: Accept

Summary of Evaluation

The authors have submitted a thoroughly revised manuscript that addresses all major and minor concerns raised during the original review. The revisions are comprehensive, methodologically appropriate, and responsive to each point of critique. No new data collection or analytical reworking is required. The manuscript now meets PLOS ONE’s standards for publication in terms of scientific rigor, ethical transparency, and reporting quality.

Detailed Assessment of Revisions Against Prior Concerns

1. Data Availability (Previously Major Concern)

Resolved.

The revised Data Availability Statement is specific, actionable, and compliant with PLOS ONE policy. It now identifies the institutional ethics committee (University of Nottingham) as the gatekeeper, specifies the conditions for access (methodologically sound proposal + data access agreement), and explains the residual re-identification risk. The submission system entry has been aligned with the manuscript text.

2. Limited Representation of Vaccine Decliners (Previously Major Concern)

Resolved.

The authors have appropriately reframed the study’s findings as primarily reflecting acceptor perspectives, with decliner insights explicitly labelled exploratory. The Strengths and Limitations section now contains clear preliminary statements, acknowledges lack of saturation and rural decliner representation, and proposes targeted oversampling strategies. The title remains accurate and is not misleading given the revised framing.

3. Missing Recruitment & Sampling Details (Previously Major Concern)

Resolved.

The Methods section now includes: selection criteria for lay community mobilizers, approximate number approached (~60), response rate (~68%), and explicit saturation criteria (three consecutive FGDs with no new codes). All missing methodological information has been supplied.

4. Overstatement of Historical Medical Mistrust (Previously Major Concern)

Resolved.

The Discussion has been rewritten to temper causal language. The text now correctly frames historical events as providing a contextual backdrop that may help explain why population-control narratives resonate, rather than claiming direct causation. No participant is attributed with knowledge they did not express. Abstract and introductory Discussion sentences have also been appropriately hedged.

5. Minor Revisions (Abstract, Introduction, Methods, Results, Discussion, Implications, Conclusion, Language, Tables, References, Ethics Statement)

Resolved.

Every minor revision requested has been addressed systematically, including:

• Abstract

• Constructionist paradigm justification and FGD rationale

• Ethics approval numbers added

• Currency specification and compensation ethical justification

• Table 1 corrections (age of child sum, total rows, footnote)

• Interpretive comment linking vaccinator competence to system trust

• Fully presented COVID-19 quote

• Participant recommendation on school advance notices

• Radio reach in rural areas

• 3C model linkage

• Shortened Gillick Competence reference

• Social desirability bias added as limitation

• Counter-misinformation pre-testing, native-language research, and house-to-house cost feasibility added

• Quantitative study need in Conclusion

• Language corrections (posed, Local Government Area, began with, illustrative quotes)

• Participant identifier convention clarified

• Table 2 page numbers added

• Supporting Information (FGD guide) confirmed included

• Reference formatting standardised

• Ethics statement with approval numbers

Remaining Minor Copyediting Recommendations (Not Required for Acceptance)

The following are optional suggestions that do not affect scientific integrity or publication readiness. The journal’s production team may address these during typesetting:

1. Line 141: “£2,500 Nigerian Naira” – correct to “₦2,500” (the pound sign appears to be a typographical error; the text correctly uses “₦” elsewhere).

2. Line 177 (Table 2): Page numbers in parentheses – ensure they match the final pagination after typesetting (production will handle this).

3. Reference 21: Journal name is correct (“Human Vaccines & Immunotherapeutics”) – no further action needed.

4. Consistency in abbreviation: “UITh” vs “UITH” – the manuscript uses “UITH” in the ethics statement (line 91) – standardise to “UITH” throughout.

These do not require author revision at this stage.

Final Editorial Comment

This is a well-executed qualitative study that makes a meaningful contribution to understanding HPV vaccine decision-making in a real-world campaign context in Nigeria. The authors have demonstrated exemplary responsiveness to peer review, and the manuscript is now clear, balanced, and transparent about its methodological limitations. The findings have clear policy implications for Nigeria’s National Programme on Immunisation and similar LMIC settings.

Accept as is. Production will handle minor copyediting.

Sincerely,

Dr. Morufu Olalekan Raimi, PhD

Academic Editor (Environmental Epidemiology)

PLOS ONE

Reviewers' comments: