Title: Insufficient Knowledge of Human Papilloma Virus among Reproductive-Aged Women
from Arak, Iran
Version: 4 Date: 24 May 2024
Reviewer's report:
Dear Authors:
It may not be feasible to incorporate the requested items at the current stage of the manuscript
due to the inherent nature of your study. Therefore, if the requested data and information are
not fully available, you may address and analyze these issues within the discussion section of
the article. You may also present them as limitations of the study or suggest them as areas for
future research.
Weaknesses:
1. Exclusion of Socioeconomic Status Information:
- Claim: The study lacks information on participants' socioeconomic status.
-   Support:   Socioeconomic status can significantly influence access to healthcare and
information, potentially confounding the results. Including this data would allow for a more
nuanced analysis of the barriers to HPV knowledge and vaccination.
2.   Limited Focus on Attitudes and Beliefs:
-   Claim:   The questionnaire should assess attitudes and beliefs towards HPV and the HPV
vaccine.
-   Support:   Understanding attitudes and beliefs is critical to designing effective educational
interventions. For instance, if there are prevalent misconceptions or fear surrounding the vaccine,
these need to be addressed to improve vaccination rates.
3.   Unexplored Reasons for Low Vaccination Rate:
-   Claim:   The study does not explore reasons behind the low vaccination rate.
-   Support:   Identifying barriers (e.g., cultural beliefs, accessibility issues, cost) is essential
for tailoring public health interventions. Without this information, recommendations will lack
specificity and may not be effective.
Validity of Arguments:
1.   Correlation between Knowledge and Education:
-   Claim Validity:   The finding that higher education levels are associated with better knowledge
about HPV and the vaccine is valid and consistent with previous research. Educational
attainment often correlates with better access to health information and resources.
-   Example:   The study could include examples or quotes from participants illustrating this
correlation, or reference broader literature supporting this finding.
2.   Need for Routine Vaccination Program:
-   Claim Validity:   The argument for the need for a routine vaccination program is compelling
given the low vaccination rates highlighted in the study.
-   Example:   Reference successful vaccination programs in other countries that have improved
HPV coverage and reduced cervical cancer rates.
3.   Low Knowledge about HPV and Vaccines:
-   Claim Validity:   The paper’s assertion about widespread lack of knowledge is supported by
the data (e.g., 86.5% and 79% of participants had insufficient knowledge about HPV and the
vaccine, respectively).
-   Example:   The paper could benefit from including specific misconceptions or knowledge
gaps identified during the survey.
Potential research gaps:
1. Comparative analysis: There is a lack of research comparing the knowledge levels of HPV
and cervical cancer among different demographic groups within Iran, such as urban vs. rural
populations or different age groups. Further studies could explore these differences to tailor
educational campaigns effectively.
2. Impact of educational interventions: While the study highlights the insufficient knowledge
of HPV among Iranian women, there is a gap in understanding the effectiveness of educational
interventions in improving awareness. Future research could focus on evaluating the impact of
specific educational programs on knowledge levels and vaccination uptake.
3. Cultural influences: The study does not delve into the cultural factors that may affect the
awareness and acceptance of HPV vaccination in Iran. Research focusing on cultural beliefs,
attitudes, and barriers towards HPV vaccination could provide valuable insights for designing
culturally sensitive public health campaigns.
4. Long term outcomes: The study primarily focuses on the current knowledge levels of HPV
among Iranian women. Future research gaps could include longitudinal studies to assess the long
term impact of knowledge improvement on vaccination rates and cervical cancer prevention in
the population.
5. Healthcare provider perspectives: The study mainly focuses on the knowledge levels of the
general population. Research could explore the perspectives of healthcare providers in Iran
regarding HPV vaccination, including their knowledge, attitudes, and practices in promoting
vaccination among their patients.
Additional Suggestions and Feedback:
-   Introduction section:
- Add a stronger introductory hook to captivate the reader’s attention.
-   Example  : "HPV is a leading cause of cervical cancer, yet awareness and vaccination rates
remain alarmingly low among women in many regions."
-    Method section:
1. Reliance on self-reported data: The data collection was based on a researcher-made
questionnaire completed by a public health expert. Self-reported data may be subject to bias and
may not accurately reflect participants' actual knowledge levels.
2. Lack of comparison groups: The study did not include comparison groups to assess differences
in HPV knowledge and awareness among different demographic groups or regions.
3. Limited generalizability: The study focused on a specific region in Iran and may not be
generalizable to other populations or countries.
4. Lack of detailed methodology: The report does not provide detailed information on the
methodology used for data collection and analysis, which may impact the reproducibility and
validity of the study findings.
-   Results Section:
- Provide context for the statistical data to help the reader understand its significance.
-   Example  : "86.5% scored as insufficient on the HPV knowledge section, highlighting a
critical gap in awareness that hinders preventive measures."
- influencing participants' knowledge and awareness levels regarding HPV and its vaccine. The
section primarily focuses on presenting the data without delving into potential reasons for the
observed trends or discussing implications for public health interventions. Additionally, the
section lacks comparison with existing literature or studies in the field, which could provide
valuable context for interpreting the results. Overall, the result section could benefit from a more
comprehensive and in-depth analysis of the findings.
-   Discussion Section:
- Expand on the implications of the results and suggest directions for future research.
-   Example  : "These findings underscore the urgent need for targeted education campaigns.
Future research should explore the most effective methods of information dissemination to
improve HPV awareness."
-  Detailed Limitations Discussion:
-   Claim:   The paper needs a more detailed discussion of the study’s limitations.
-   Support:   Discussing limitations such as regional scope, potential biases, and the cross-
sectional nature of the study would provide readers with a clearer understanding of the study's
context and constraints.
- Specific Recommendations:
-   Claim:   The paper should offer concrete recommendations for improving HPV awareness
and vaccination rates.
-   Support:   For example, the authors could suggest initiatives such as integrating HPV
education into school curriculums or setting up mobile vaccination clinics in rural areas to
improve accessibility.
- broader perspective on the knowledge levels of HPV among women. Additionally, they could
discuss the implications of their findings in terms of public health interventions and strategies
that could be implemented to increase awareness and knowledge about HPV and vaccination.
Furthermore, the authors could explore potential barriers to knowledge dissemination and uptake
of vaccination in Iran and suggest recommendations for future research and policy development
in this area. Finally, they could also discuss the limitations of their study in more detail and
propose ways to address these limitations in future research endeavors.
Language, Grammar, and Writing Style
The paper effectively investigates a critical public health issue by examining HPV knowledge
and vaccination rates among reproductive-aged women in Arak, Iran. However, some
improvements in language, grammar, and writing style can enhance its overall readability and
clarity.
Examples and Suggestions
1.   Paragraph Structure and Conciseness:
-   Original  : "The study population and the number of the questions are limited."
-   Revised  : "The study is limited by its small sample size and the few questions included in
the survey."
The revised version is more concise and combines related ideas to improve readability.
2.   Word Choice:
-   Original  : "Some of these infections have hopefully preventive vaccinations while others are
still under investigation."
-   Revised  : "Some of these infections have preventive vaccines available, while others are
still being researched."
Replacing "hopefully" with more definitive language eliminates subjectivity and makes the
statement clearer.
3.   Use of Passive Voice:
-   Original  : "The results of the study revealed that the majority of participants had insufficient
knowledge about HPV."
-   Revised  : "The study revealed that the majority of participants lacked sufficient knowledge
about HPV."
Using active voice makes the sentence more direct and engaging.
4.   Redundancy:
-   Original  : "The HPV vaccine knowledge score and HPV vaccine knowledge..."
-   Revised  : "The HPV vaccine knowledge score..."
Removing unnecessary repetition makes the text clearer and less wordy.
5.   Sentence Structure:
-   Original  : "In our study, there was no significant difference regarding the knowledge between
the urban and rural populations, similar to two studies which were performed in the US and
South Africa."
-   Revised  : "Our study found no significant difference in knowledge between urban and rural
populations, consistent with studies from the US and South Africa."
Breaking up the sentence for better flow and replacing "regarding" with "in" simplifies and
clarifies the statement.