Title: Willingness and hesitancy towards the governmental free human papillomavirus
vaccination among parents of eligible adolescent girls in Shenzhen, Southern China
Version: 0 Date: 12 Feb 2024
Reviewer's report:
The authors administered a survey to parents who had a female child entering grade 7 at one of 32
schools in Shenzhen, China. The objectives of the survey were to identify factors influencing the
willingness of parents to accept the government funded free domestic HPV vaccine. The survey
was given to parents prior to a government program to provide free HPV vaccine to all girls in
grade 7. In addition to describing factors associated with willingness to vaccinate, the survey
sought practical insights that could be used to improve the government HPV vaccine program.
The paper describes several factors that may have influenced a parent’s willingness to vaccinate
with the domestic HPV vaccine. As one would expect, parents that were identified as having
vaccine hesitant beliefs, via the validated Vaccine Hesitancy Scale, were less likely to be
willing to accept the domestic HPV vaccine. While most respondents were willing to have their
children receive the domestic HPV vaccine, surprisingly several factors were associated with
less willingness to vaccinate, including parents of children who attend public school, those with
more secure medical insurance, and those parents that themselves had received an HPV vaccine.
The paper cited a possible preference for imported vaccines as a contributor to these families
being less willing to receive the domestic vaccine. The paper achieves the objectives outlined
by the authors; however, there are several items that need to be added to the paper to better
describe the methods. I recommend that the following items be addressed before the paper is
accepted for publication.
Major Comments
Methods Section
• Can you comment on how the sample size was chosen for this survey. How was it determined
to select 32 schools? Were all eligible parents at each school surveyed, or only a subset?
• There should be more details about the logistic regression model in the methods section.
o  How were the final independent variables selected for inclusion in the model?
o The coding of the independent variables should be discussed in the methods
section to help with interpretation of the final model. For example, it is not clear
how the medical insurance variable was coded as there are multiple types of
insurance, including different insurance types for parents and children. How was
vaccine hesitancy coded (assuming hesitant >= 3 and non-hesitant < 3)?
o A discussion of whether collinearity and goodness of fit were considered, and
whether other models were assessed, would help readers understand how the final
model was chosen.
• Was the cut-off of 3 for the vaccine hesitancy selected a priori? The paper should state when
this cutoff was chosen.
Results Section
• Table 3. should include all the independent variables with their corresponding coefficients,
odds ratios, and p-values.
• Include the number of non-responders, refusals, and whether any partial responses were
excluded from the final analysis.
Minor Comments
Introduction
• Clarify what is meant by “moral obligations” at line 64. It is not clear what that means or is
referring to.
Methods
• Comment on why the “about’ modifier is used for the number of surveys at line 133. Is this
due to having the schools help with administering the surveys or how the survey was advertised
to parents?
• It would be helpful to see the wording of the question(s) regarding willingness to vaccinate.
• More of an explanation of the various insurance types and how these relate to socioeconomic
status would help readers understand better how insurance may have influenced parents’
willingness to vaccinate and beliefs about HPV vaccine.
• Comment on what language(s) were used for the survey questions.
Results
• The n and percent are missing for public schools in table 1.
• The X2 is missing for a direct relative having had cervical cancer in table 2.
• Typo in question f in figure 1. Vaccines is missing the letter a.
Discussion
• Do the authors have any thoughts about why the respondents reported having less vaccine
hesitancy than some of the previous studies that have used the VHS? Is this simply because two
questions were removed from the scale, did removing the neutral response option impact the
average scoring, or do parents in China have less vaccine hesitancy than other countries?
• The paper partially attributes the high willingness to vaccinate to the school-based government
funded HPV programs. Did the school-based programs entail administering the vaccines at
schools, or simply promoting HPV vaccines at schools? Did school vaccine requirements factor
into the program at all?
The authors achieve their objective of describing factors that influenced the willingness of
families in Shenzhen China to vaccinate their daughters with the government funded HPV
vaccine; however, there are areas that need to be clarified and some information that must be
added before I can recommend this paper be published. My recommendation is that the paper
be revised to help clarify the methods and describe the findings.