Reviewer ’s report  
 
Title: Factors associated with HPV vaccination uptake in Uganda: A multi -level analysis  
 
Version: 0 Date: 25 Mar 2020  
 
Reviewer: Nkiru Nwamaka Ezeama  
 
Reviewer's report:  
 
BMC WOMEN'S HEALTH  
REVIEW OF RESEARCH ARTICLE, MA NUSCRIPT NUMBER: BMWH -D-20-00112  
REVIEWER: Dr. Nkiru Nwamaka Ezeama  
 
TITLE: Factors associated with HPV vaccination in Uganda: A multi -level analysis  
 
1.  General comment  
The study is topical and relevant to women's public health. The research question of whether 
individual -level and community -level factors independently influence HPV vaccine uptake 
among girls aged 10 -14 years in Uganda is scientifically sound.   
 
2.  Abstract  
The aim of the study should be moved from the Methods section to the Background.  (Page 1, 
Line 13 - 15) 
 
3. Background, Methods  
As stated by the authors, the WHO and Uganda Ministry of Health policy of vaccination for 
primary prevention of cervical cancer includes girls aged 9 - 13 years. The researchers included 
girls aged 10 - 14 ye ars in their study. Why did the study not select girls aged 9 years? (Page 3, 
Line 59; Page 5, Line 105)  
 
4. Methods: Individual -level determinants  
Please provide examples of the types of media that were assessed for amount of media exposure.  
(Page 6, Line 126)  
 
5. Methods: Statistical analyses  
5a) Do the authors mean three -step multivariate multilevel logistic regression? 'Three -step' 
would be a better terminology than 'three -level'. (Page 8, Line 151)  
 
5b) The way the calculation of intra -cluster correlation coefficients (ICC) as well as likelihood 
ratio test (LR) and Akaike Information Criterion (AIC) were mentioned give the impression that 
these analysis were carried out independently of the logistic regression analysis and may be 
confusing to the reader. I suggest they each be placed in sequence at the particular step of logistic 
regression they occurred. In other words, Step one, the null model would have involved 
calculating the ICC. Step two, the individual -level determinants model would have involved 
calculating the LR and AIC. Step three, the final model involved interpreting the odds ratios and 
95% confidence intervals. (Page 8, Lines 161 - 165) 
 
6. Results  
6a) Include % for the following proportions: 24.9, 66.6, 59.5, 69.6, 66.6, 22.6,  and 34.6. (Page 9, 
Lines 181, 183, 184, 185; Page 10, Lines 195, 196)  
 
6b) In Table 1, the exact p -values for the following variables: 'currently attending school', 
'ethnicity', should be written or else presented as p &lt; 0.0001 rather than "0.000". (Pa ge 11)  
 
6c) Also in Table 1, what do the totals at the end of the table refer to? There is a disconnection 
with the rest of the table. (Page 11)  
6d) Also in Table 1, column 4, there is inconsistency in decimal placing: proportions for sex of 
household head , female (23), other relationship (20) (Page 11).  
 
6e) The abbreviation MMLRA should be first placed in brackets after the phrase it refers to 
before being used here to avoid confusing the reader.  (Page 12, Line 207)  
 
6f) Three age categories, 11, 13 and 1 4 years were presented; 12 was omitted. Odds ratios for 
three age categories and 95% CI for four categories are presented. The second OR was omitted. 
Please correct accordingly. (Page 13, Lines 248 - 249).  
 
6g) Please Include 95% before CI when reporting t he 95% confidence interval e.g. OR=1.30; 
95% CI 1.06 -1.61. Do this for every instance it occurs. (Pages 13 - 14, Lines 247 - 257).  
 
6h) In Table 2, the second column, null model is redundant; the column should be removed. 
Fixed effect (OR, 95% CI) should s traddle the other two columns. The word "including" should 
replace "with" i.e. "Model including individual -level determinants" and "Model including 
individual and community level determinants" respectively.  (Page 14)  
 
6i) Ref was used in Table 2 but RC was  placed in the footnotes. Please correct this.  (Page 15, 
Line 262.)  
 
7.  Discussion  
7a) The authors refer to study findings of low uptake of HPV vaccine among Ugandan girls aged 
9 - 14 years. This contradicts the inclusion criterion of 10 -14 years earlier  stated. (Page 16, Line 
267.)  
 
7b) The proportion of HPV uptake of 22% is presented in the discussion section for the first 
time; it wasn't mentioned in the results, neither in the text nor in Table 1. Overall HPV vaccine 
uptake should be included in Table 1. (Page 16, Line 268.)  
 
7c) P rovide background information on "long time lag of eligibility for reimbursement" and 
sensitization posters providing information about eligibility for HPV vaccine. These will enable 
the reader put into context procrastination as a probable reason for age variation in HPV vaccine 
uptake. (Page 17, Lines 298 - 303.)  
 
7d) The authors should expand more on the role of ethnicity in HPV vaccine uptake by 
explaining further what they mean by positive attitude. (Page 17, Lines 309 - 311) 
 
7e) It is interesting tha t despite the vaccination being free of charge, girls from the middle wealth 
quintile were more likely to be vaccinated. The authors should provide more information on the 
likely reasons for this association seeing that this association had also been repor ted by the 
studies they cited. (Page 18, Lines 312 - 317).  
 
8.  Grammatical check  
8a) Correct "call" to "calls i.e. "Additionally, goal three of the Sustainable Development Goals 
(SDGs) calls upon member states to reduce premature mortality from…" (Page 2,  Lines 39 - 40)' 
 
8b) Include the constant "per 100,000" for the global estimate of mortality rate i.e. 6.8 per 
100,000 (Page 3, Line 54).  
 
8c) Write WHO in full with abbreviation in brackets as this is the first time it's being mentioned  
Page 3, Line 59.  
  
 
8d) Correct "recognizes" to "recognize" i.e. "WHO and Uganda's Ministry of Health recognize 
primary prevention…" (Page 3, Line 60)  
 
8e) Insert 'the' i.e. "… paved the way…"  
      Insert 'a' i.e. "… a countrywide rollout"  
      Insert 'a' i.e. "… data of  a hierarchical nature" (Page 4, Lines 69 &amp;  81). 
  
8f) Correct "achieve" to "achieving" i.e. "…committed itself to achieving 80% HPV vaccine 
coverage…" (Page 4, Line 71).  
 
8g) It should be "crucial to" not "crucial for"  (Page 4, Line 86).  
 
8h) Househol d is one word. Remove gap  (Table 1 (page 11); Page 6, Lines 126 - 128).  
 
8i) Correct repetition of "status"  (Pages 6 -7, Lines 132 - 133).  
 
8j) Principal Component Analysis (PCA) not "principle". (Page 7, Lines 136 &amp;  137).  
 
8k) …community -level determinant not "determinants"  (Page 7, Line 138).  
 
8l) model not Model  
    "had" not has i.e. "This model had no determinant variable…:  (Page 8, Line 155)  
  
 
8m) These should be one sentence. Remove the full stop and insert a comma i. e. "We included 
all the individual -level determinants into model 2, while the final model encompassed 
individual -level and community -level determinants." (Page 8, Lines 158 &amp;  159).  
 
8n) "Pleasurable"? Do you mean "plausible" or "probable"? (Page 17, Li ne 305).  
 
Are t he methods appropriate and well described?  
If not, please specify what is required in your comments to the authors.  
 
No 
 
Does the work include the necessary controls?  
If not, please specify which controls are required in your comments to the authors.  
 
Yes 
 
Are the conclusions drawn adequately supported by the data shown?  
If not, please explain in your comments to the authors.  
 
Yes 
 
Are you able to assess any statistics in the manus cript or would you recommend an 
additional statistical review?  
If an additional statistical review is recommended, please speci fy what aspects require further 
assessment in your comments  to the editors.  
 
I am able to assess the statistics  
 
Quality of written English  
Please indicate the quality of language in the manuscript:  
 
Needs some language corrections before being published  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Declaration of competing interests  
Please complete a declaratio n of competing interests, considering the following questions:  
 
1. Have you in the past five years received reimbursements, f ees, funding, or salary from an 
organisation that may in any way gain or lose financial ly from the publication of this 
manuscript, e ither now or in the future?  
 
2. Do you hold any stocks or shares in an organisation t hat may in any way gain or lose 
financially from the publication of this manuscript, either now or in the future?  
 
3. Do you hold or are you currently applying for any paten ts relating to the content of the 
manuscript?  
 
4. Have you received reimbursements, fees, funding, or salary from an organiza tion that 
holds or has applied for patents relating to the content of the manuscript?  
 
5. Do you have any other financial competing interests?  
 
6. Do you have any non -financial competing interests in relation to this paper?  
 
If you can answer no to all of the above, write 'I declare that I have  no competing interests' 
below. If your reply is yes to any, please give de tails below.  
 
I declare that I have no competing interests.  
 
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