PONE-D-23-37347Acceptance of Human Papillomavirus (HPV) vaccine among the parents of eligible daughters (9-15 years) in Bangladesh: a nationwide study using Health Belief ModelPLOS ONE

Dear Dr. Eva,

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.

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Kehinde Kazeem Kanmodi, BDS

Academic Editor

PLOS ONE

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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: Yes

Reviewer #2: Yes

Reviewer #3: Partly

Reviewer #4: Yes

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

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

Reviewer #4: I Don't Know

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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

Reviewer #2: Yes

Reviewer #3: No

Reviewer #4: No

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Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

Reviewer #4: Yes

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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: Few minor changes are required . Which being mentioned in the uploaded script. It may be considered for publication following the minor changes are made. The ethical permission part needs to be considered and Bangladesh bio-ethics society permission needs to be considered. Recommendations needs to be added in bullet points . It will provide the implication of this study.

Reviewer #2: Thank you Authors for coming up with this interesting manuscript. However, I have made the following review comments for better quality of the manuscript.

1. Under the methodology, authors should endeavor to shed more light on the content validity of the questionnaire.

Also, the total adjusted sample size was 2160 and the total sample size used after exclusion was 2151. Can authors expatiate on this disparity?. Again, this is a national survey, is the sample size representative?

The pretest and pilot protocols were not referenced. Authors should kindly reference this for better understanding of the rationale behind the pretest and pilot protocol employed.

2. Authors should evaluate the manuscript for grammatical errors overall. For example, Lines 295-296 do not read well. ....."Maternal gender emerges as significant determinant, with mothers demonstrating higher acceptance rate than fathers...." This should be corrected.

Overall, I will suggest a minor revision to this manuscript.

Reviewer #3: I thank the Editor for inviting me to review this important manuscript. The authors have done a very good job of performing this needful study. The study has several policy implications and strengths, including large sample size, unprecedentedness, and rigor. However, I still believe the manuscript needs substantial improvements in the ways it is prepared by the authors. My comments to them are:

1. Lines 65 and 66, without reference, the authors wrote: “In high-income countries, the coverage is almost 80%.”

2. Line 83, the authors wrote “mental illnesses were excluded.”

3. Lines 83-84, the authors wrote: “To ensure representative sampling, we determined division 84 specific sample sizes using the 2022 Population & Housing Census (13)”. Firstly, this statement about the study being “representative” is not objective. Second, the reference you provided opens to a page I assume to be in Bengal language. To make it easy for the authors and the reader to ascertain the study’s so-called representativeness, the authors should consider to extract the socio-demographics of Bangladeshi population from this page or any other reference and create a table showing the study’s socio-demographics on one hand and the Bangladeshi general population on the other [e.g. study’s female N 9%) vs national female N (%), study’s rural N (%) vs national rural dwellers N (%), e.t.c.]. In this way, it will be known objectively whether the study is entirely, partially, or completely not representative of the Bangladeshi population.

4. Lines 85-86: without providing the reference, the authors wrote “while considering an 80% vaccine acceptance among parents based on the existing literature”

5. Lines 88-89: the authors wrote “of Bangladesh between June 28 and August 2, 2023, resulting in a total sample size of 2,151 after exclusions”. Your reader may be interested in knowing the overall response rate when invitation was issued to potential participants, total responses before the exclusion, and the exclusion criteria.

6. Also, can the authors consider attaching an English version of their study questionnaire as supplement?

7. Lines 117-120, why is this statement (Second, a pre-test was conducted among 28 parents of 118 daughters aged between 9–15 years old prior to the start of the actual data collection. In order to make the questionnaire more understandable for the participants and to improve face- and construct validity, some questions were rewritten or clarified.) bolder than the rest of the manuscript?

8. Pages 4, 5, and 6 have some redundancy of information. Please, try to scale down this. You may which to just reference the study questionnaire you attach in the supplement.

9. How was knowledge scored?

10. Also try to disaggregate the references for each questionnaire used to assess the various domains of the study, e.g. knowledge(reference), HBM(reference)

11. On what basis did the authors classify monthly household income? One would expect the country’s minimum wage to be the reference for the income groups. Also, in no where in your manuscript did you spelt out your “BDT”

12. Line 136, The authors also mentioned “Academic institution type (government, private, madrasa)” as part of the study’s socio-demographic variables, which is important. However, they have not included this in the analysis without any explanation for dropping it.

13. In the regression model, why have the authors not considered exploring the eight divisions of the country as potential determinant?

14. There’s plethora of evidence supporting a parent’s/caregiver’s “level” of education with vaccination. However, I noticed the authors used “years of education” instead of “levels (primary, secondary, tertiary, university, e.t.c.”), which is more objective and informative. Why have the authors used their approach? I ask this because years of education does not necessarily mean level of education since one, for example, can decide to continue doing certificates after a primary or secondary education without progressing to a university degree.

15. Lines 287-290 in the discussion, the authors wrote: “When compared to prior research in similar contexts in India and China, where parental acceptance of the HPV vaccine was approximately 71% and 83%, respectively (11,29), our study stands out with its significantly higher acceptance rate. This indicates a promising upward trend in HPV vaccine acceptance within Bangladesh.” Why would you cite studies from India and China that reported an acceptance rate lower than that of your study and then say” This indicates a promising upward trend in HPV vaccine acceptance “within” Bangladesh. For you to say “upward trend within Bangladesh’, the reference studies have to be from Bangladesh as well.

16. In line 295, the authors wrote: “The maternal gender emerges…..”. What is the meaning of this phrase: and why are you now mentioning gender after you’ve explicitly mentioned in the Methods and Results that you evaluated “sex”. And why maternal? Or are you saying the women you evaluated are pregnant or what?

17. Lines 377 and 378 of the Conclusion, the authors wrote: “Our nationwide study found a very high level of acceptance of the HPV vaccine among the parents of eligible daughters”, referring to the study’s acceptance rate of 86%. If we assume that, all the 86% who accepted actually have their daughters vaccinated, will this proportion meet of with the WHO target of 2030 you cited in your introduction?

18. In the Conclusion, lines 379-381, the authors wrote: “Multiple factors such as age, residence, education, income, history of medical check-ups, knowledge of cervical cancer, having a positive attitude towards the benefits, and cues to actions were associated with HPV vaccine acceptance.” This statement is not supported by the study findings because some of the variables mentioned were not statistically significant at the multivariate level of analysis done by the authors. Consider to revise specific to your findings.

I look forward to reading the revised version of this manuscript

Reviewer #4: Comment to authors

Title: Acceptance of Human Papillomavirus (HPV) vaccine among the parents of eligible daughters (9-15 years) in Bangladesh: a nationwide study using Health Belief Model

Manuscript number: PONE-D-23-37347

Abstract

Background – how parent acceptance contribute to ensure 90% of girls receive the HPV vaccine before turning 15?

Method – make it summary of method section. For instance, how was sampling conducted? How data were collected?

Result – provide the finding with its upper and lower limit of the prevalence.

Conclusion – what is authors’ landmark to reach at high acceptance? “The vaccine acceptance was positively associated with almost all the domains of the HBM.” What authors want to convey? If it is to indicate direction of association; all their factors are preventive.

Line 45-46: “Multiple factors such as age, residence, education, income, history of medical check-ups, knowledge of cervical cancer, and cues to actions were associated with HPV vaccine acceptance” These are crude to be used in conclusion; be specific, which classification are associated with outcome? For instance is it younger age or older? Is it having higher degree or not attending formal education?

Introduction

How many of the increased coverage of HPV vaccine is attributable to HPV vaccine acceptance of parent across the globe or in low and middle income countries? What is really matter? What are role of knowledge and attitude of the parents? What factors were contribute to high or low acceptance of the vaccine when you summarize previous studies? How you intend to uncover their gaps?

Method

How authors maintained external validity of the finding? “We collected samples conveniently from all eight divisions” How conveniently sampled study was generalized to source?

Line 99-100; how you minimize interviewer bias?

Authors should explain how they measure HPV vaccine acceptance well. The measurement for all potential variables were not described? Authors should also provide appropriate citations for measurement of outcome and explanatory variables anywhere appropriate.

How variables were selected for multivariable analysis? How model fitness were check? Was there multi-collinearity?

Result

Line 186: No sentence or paragraph should begin with number.

Table 1 and 2: what is n? Is it representing sample or frequency? Check and correct. Indentation needed for classification of variables to make easy for readers.

Line 230-250: the explanation for crude analysis are not needed. There are a lot of confounding for these association, hence you need to explain after controlling for these confounding.

Can authors merge findings of table 3 and 4?

How many variables can be included in the model at once? In this study about 19 variables were run at once!

Table 4- what are dashes (-) represent? How about bolds?

Discussion

Line 274-280: the discussion usually begin with purpose of the study and summary of findings.

Why acceptance of the vaccine in Bangladesh were higher compared to other countries like china and Japan?

Authors should explain why those in urban and middle income are lower acceptance compared to rural and low income in contradiction to previous findings.

Line 311-318: why those who have no routine checkup have lower odds of acceptance? What really contributed to this association?

Line 326-348: what are the relationship between HBM and acceptance? In your table 4, only perceived benefit and cue to action are associated. Focus on you finding and explain why and its implications.

Conclusion

The same comments to conclusion in abstract.

Why Fig 1 is three dimensional? Is key is not acceptance rather willing to vaccine, do you think they are the same? Is accepting is willing to vaccinate?

Figure 2, what is x-y axis indicate? Label them. Figure title should fulfil its criteria.

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Reviewer #1: No

Reviewer #2: No

Reviewer #3: Yes: Sahabi Kabir Sulaiman

Reviewer #4: Yes: Kasiye Shiferaw

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Submitted filename: PONE-D-23-37347_reviewer.pdf

PONE-D-23-37347R1Acceptance of Human Papillomavirus (HPV) vaccine among the parents of eligible daughters (9-15 years) in Bangladesh: a nationwide study using Health Belief ModelPLOS ONE

Dear Dr. Eva,

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 01 2024 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,

Miquel Vall-llosera Camps

Senior Staff Editor

PLOS ONE

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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.

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #2: All comments have been addressed

Reviewer #3: All comments have been addressed

Reviewer #5: (No Response)

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2. 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 #2: Yes

Reviewer #3: Yes

Reviewer #5: Yes

**********

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

Reviewer #2: Yes

Reviewer #3: Yes

Reviewer #5: Yes

**********

4. 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 #2: Yes

Reviewer #3: No

Reviewer #5: Yes

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5. 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 #2: Yes

Reviewer #3: Yes

Reviewer #5: No

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6. 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 #2: Authors have satisfactorily responded to my review comments. I recommend that this manuscript be accepted for publication.

Reviewer #3: 1. In Abstract Conclusion, the authors wrote “monthly income in the lowest quartile”, which is contrary to what they found from multivariable analysis. This should be middle-income since the income variable has four categories.

2. The Introduction is well-written and well-justified.

3. In the analysis section, how did the authors evaluate the fitness of their model? Consider to cite the references where applicable.

4. I think the description of the Results section is too wordy. Doesn’t it suffice to bring out some of the most salient point and refer the rest to the appropriate figure or table.

5. A significant number of studies on caregiver acceptance/hesitancy of childhood vaccines has reported being male (a father) as a significant determinant. In view of this, can your low number of male participants also be a limitation?

Best

Reviewer #5: It's good to see that the author has addressed quite a number of comments; however, there are a few lapses that need to be addressed:

1. Line 178 - "Perceived barrier" was repeated. Kindly address.

2. Line 191- You mentioned that R studio was used for data analysis. Please note that R studio is an integrated development environment (IDE) for the R programming language. It would be more accurate to mention that R Studio was used as an interface for data analysis, while R (the programming language) was used for statistical computations.

3. Throughout the data analysis section, there was no justification provided for the merging of responses for the HPV vaccine acceptance analysis. Therefore, please state the rationale behind merging the "No" and "Not sure" responses for the HPV vaccine acceptance analysis. This clarification assists readers in understanding the methodology and ensures transparency in the research process.

4. Lastly, consider including recommendations for future research. Providing suggestions for future research based on the study's findings, such as exploring interventions to address specific barriers to vaccine acceptance or conducting longitudinal studies to track acceptance trends, could be valuable.

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7. 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 #2: No

Reviewer #3: Yes: Dr Sahabi Kabir Sulaiman

Reviewer #5: No

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[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.

Acceptance of Human Papillomavirus (HPV) vaccine among the parents of eligible daughters (9-15 years) in Bangladesh: a nationwide study using Health Belief Model

PONE-D-23-37347R2

Dear Dr. Eva,

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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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,

Rashidul Alam Mahumud, PhD, MCncrSc (Cancer Medicine), MPH, MSc,

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #2: All comments have been addressed

Reviewer #3: All comments have been addressed

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2. 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 #2: Yes

Reviewer #3: Yes

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

Reviewer #2: Yes

Reviewer #3: Yes

**********

4. 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 #2: Yes

Reviewer #3: No

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5. 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 #2: Yes

Reviewer #3: Yes

**********

6. 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 #2: (No Response)

Reviewer #3: My concerns have been addressed. The manuscripts has also significantly improved in this revision. I have no further comments.

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7. 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 #2: No

Reviewer #3: Yes: Sahabi Kabir Sulaiman

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