Title: Insufficient Knowledge of Human Papilloma Virus among Reproductive-Aged Women
from Arak, Iran
Version: 6 Date: 29 Aug 2024
Reviewer's report:
PEER REVIEWER ASSESSMENTS:
OBJECTIVE - Full research articles: is there a clear objective that addresses a testable research
question(s) (brief or other article types: is there a clear objective)?
Yes - there is a clear objective
DESIGN - Is the current approach (including controls and analysis protocols) appropriate for
the objective?
Yes - the approach is appropriate
EXECUTION - Are the experiments and analyses performed with technical rigor to allow
confidence in the results?
No - there are major issues
STATISTICS - Is the use of statistics in the manuscript appropriate?
No - there are issues with the statistics in the study
INTERPRETATION - Is the current interpretation/discussion of the results reasonable and not
overstated?
No - there are major issues
OVERALL MANUSCRIPT POTENTIAL - Is the current version of this work technically
sound? If not, can revisions be made to make the work technically sound?
Maybe - with major revisions
PEER REVIEWER COMMENTS:
GENERAL COMMENTS: In their present manuscript, authors reported through a cross
sectional study levels of knowledge of women of reproductive age towards HPV and its
vaccination in the locality of Arak, Iran. Although being mainly descriptive, the question is
of interest at a global level in the light of WHO 2030 cervical cancer elimination targets and
at a local level to raise awareness of health authorities to support preventive programs. While
authors have addressed some previously raised concerns, there are remaining issues that should
be considered to improve the content of their manuscript.
REQUESTED REVISIONS:
Major comments:
Introduction
1) When citing Global Cancer observatory, authors should use the latest version with 2022
updated data. In addition, based on these same metrics, cervical cancer does not ranked second
or even in the six more frequent malignancies in terms of incidence and mortality (see. https://
gco.iarc.who.int/today/en/dataviz/pie?mode=cancer&types=0&sexes=2&populations=364 ).
Authors might update their facts on the epidemiology of cervical cancer in Iran. In fact, reference
29 do not seem to address the epidemiology of cervical cancer in Iran. After reviewing Ref
28, there seem to be no particular section addressing the epidemiology of cervical cancer. In
addition, the method section of ref 28 article is quite lapidary, limiting the reliability of its
content. I am aware, that such data are extremely hard to estimate and that even IARC estimates
are probably largely biased (underestimate) as they rely on national data or those from nearby
countries if not available. However, authors should revise their statements and references in
accordance to the current state of knowledge.
Method
Sampling of study participants still deserve further information. How the 14 health service
centers of Arak city were selected out of the total health centers of the region? Are they
representative of the various sanitary level or only primary health facilities? How the 10 women
were selected from the list of daily clients each day? Consecutively, randomly if done at random
which process was applied?
“completed by a public health expert”. The term “public health expert” is not really informative.
If interviewers were recruited within the health facilities, authors should rather state the
professions (e.g. nurses, social workers…).
“At the next step, the 30-40 correct replies were considered as “sufficient”, 20-30 right answers
were evaluated as average, and below 20 correct responses were marked as “insufficient” over
HPV section.” I find this approach relatively arbitrary. There are no formal elements supporting
these stated cutoffs and no previous work using them accordingly. Therefore, comparing your
level of knowledge with the rest of the literature will be quite challenging. Alternatively, I
would emphasize responses to key questions that are obviously crucial basic knowledge needed
prior to any preventive intervention towards cervical cancer such as “Most people infected with
genital HPV infection do not have any symptoms or signs and recover with no introversion.”,
“HPV infection is preventable “ or “HPV infection can cause cervical cancer » and so on. Many
questions addressed genital warts that are quite specific and obviously not all question should
weight equal in such a score.
Statistical approach
Based on my previous recommendation, I would have considered the score as a continuous
variable and estimate associate factors through a linear model. That leads me to a subsequent
comment on factors associated with the knowledge score. The present approach relies solely
on univariate analyses. Using a multivariate model would address potential confusing effects of
covariates. If not done, authors should at least state that limitation.
Results
Any refusals from the total number of women initially asked to be part of the present study?
Presenting vaccination uptake and intention regardless of age and existing children is also
a missed opportunity. Vaccination intention for women have clear different consequences
according to age. As of today the greatest impact of HPV vaccination is expected in early ages
and recommended in Adolescents. A crucial information would be to know if women with
children would recommend vaccine for others (e.g. their own children). Authors should expand
on this in the text.
Table 2 is confusing, what OR refers to? Please explain
Discussion
As the present surveyed population is constituted with women of reproductive age, the absence
of information towards cervical cancer screening knowledge and practices is a real missed
opportunity as the first step towards prevention in this population would be screening not
immunization that is mainly targeting adolescents/girls 9-13 years old. Authors should comment
on this in their discussion/limitation section.
Authors have largely expanded their limitation section, maybe too much. Some are relevant and
appropriate and some are not. Consider removing the following: “Furthermore, the study did
not include comparison groups to assess differences in HPV knowledge and awareness among
different demographic groups or regions.” There was no need to include a “comparison group”
to address the present objective. Authors have already stated that they findings do not claim to
be representative of women of child bearing age outside the targeted locality.
“and the report does not provide detailed information on the methodology used for data
collection and analysis, which may affect the reproducibility and validity of the study findings.”
This is confusing, the present report needs to include the all necessary information to interpret
the present results. And this will be the case once comments are addressed no? consider deleting
this part
Aside the fact that there is currently no national program supporting any population-based
approach for HPV vaccination, there is limited information on where and how (which types,
costs) the HPV vaccine is available in the country. These would be valuable information to
readers.
Minor comments:
Introduction:
“There have been some studies about HPV in Iran where the vaccination rate is very low” this
statement should be supported by references reporting the “low rate” of HPV vaccination.