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

Mohammad Delwer Hossain Hawlader; Fahima Nasrin Eva; Md Abdullah Saeed Khan; Tariful Islam; Umme Kulsum Monisha; Irin Chowdhury; Rifat Ara; Nur-E-Safa Meem; Mohammad Ali Hossain; Arpita Goutam; Tahmina Zerin; Nishat Alam; Rima Nath; Shamma Sifat; Sayla Sultana; Mosammat Sadeka Sultana; Sumit Kumar Saha; Naifa Enam Sarker; Mohammad Hayatun Nabi; Mohammad Lutfor Rahman

doi:10.1371/journal.pone.0310779

. 2024 Nov 8;19(11):e0310779. doi: 10.1371/journal.pone.0310779

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

Mohammad Delwer Hossain Hawlader ¹, Fahima Nasrin Eva ^1,^2,^*, Md Abdullah Saeed Khan ^2,³, Tariful Islam ^1,², Umme Kulsum Monisha ^2,⁴, Irin Chowdhury ^1,², Rifat Ara ^2,⁵, Nur-E-Safa Meem ^1,², Mohammad Ali Hossain ^2,⁶, Arpita Goutam ^1,², Tahmina Zerin ^1,², Nishat Alam ^1,², Rima Nath ^1,², Shamma Sifat ^1,², Sayla Sultana ^1,², Mosammat Sadeka Sultana ^1,², Sumit Kumar Saha ^1,², Naifa Enam Sarker ^1,², Mohammad Hayatun Nabi ¹, Mohammad Lutfor Rahman ⁷

Editor: Rashidul Alam Mahumud⁸

¹Department of Public Health, North South University, Dhaka, Bangladesh

²Public Health Promotion and Development Society (PPDS), Dhaka, Bangladesh

³National Institute of Preventive and Social Medicine (NIPSOM), Dhaka, Bangladesh

⁴Mandy Dental College & Hospital, Dhaka, Bangladesh

⁵Institute for Global Health, University College London, London, United Kingdom

⁶Ibn Sina Medical College Hospital, Kallyanpur, Dhaka, Bangladesh

⁷Institute of Statistical Research and Training (ISRT), University of Dhaka, Dhaka, Bangladesh

⁸The University of Sydney, AUSTRALIA

Competing Interests: The authors have declared that no competing interests exist.

^✉

* E-mail: fahima.eva@northsouth.edu

Roles

Mohammad Delwer Hossain Hawlader: Conceptualization, Investigation, Project administration, Resources, Supervision, Validation, Writing – review & editing

Fahima Nasrin Eva: Conceptualization, Investigation, Methodology, Project administration, Resources, Validation, Writing – original draft

Md Abdullah Saeed Khan: Data curation, Formal analysis, Methodology, Project administration, Software, Writing – review & editing

Tariful Islam: Data curation, Investigation, Resources, Software, Validation

Umme Kulsum Monisha: Investigation, Resources, Validation, Writing – original draft

Irin Chowdhury: Investigation, Methodology, Resources, Validation, Writing – original draft

Rifat Ara: Methodology, Validation, Visualization, Writing – original draft

Nur-E-Safa Meem: Data curation, Investigation, Resources, Software, Validation

Mohammad Ali Hossain: Investigation, Resources, Validation, Writing – original draft

Arpita Goutam: Investigation, Methodology, Resources, Validation, Writing – original draft

Tahmina Zerin: Investigation, Resources, Validation

Nishat Alam: Investigation, Resources, Validation

Rima Nath: Investigation, Resources, Validation

Shamma Sifat: Investigation, Resources, Validation

Sayla Sultana: Investigation, Resources, Validation

Mosammat Sadeka Sultana: Investigation, Resources, Validation

Sumit Kumar Saha: Investigation, Resources, Validation

Naifa Enam Sarker: Investigation, Resources, Validation

Mohammad Hayatun Nabi: Supervision, Visualization, Writing – review & editing

Mohammad Lutfor Rahman: Methodology, Supervision, Visualization, Writing – review & editing

Rashidul Alam Mahumud: Editor

PMCID: PMC11548773 PMID: 39514578

Abstract

Background

To align with the 2030 vision of the World Health Organization (WHO) to ensure 90% of girls receive the HPV vaccine before turning 15, Bangladesh has recently started the (HPV) vaccine campaign nationwide. Therefore, our study aimed to assess the level of its acceptance among parents of eligible daughters in Bangladesh.

Methods

This nationwide cross-sectional study was conducted among the self-identified parents of daughters in the age group of 9–15 years between June 28 and August 2, 2023. A total of 2,151 parents were conveniently selected from all eight divisions of Bangladesh. Data was collected through face-to-face interviews using a semi-structured questionnaire. The Health Belief Model was used to appraise respondents’ beliefs concerning HPV and its vaccination. Adjusted odds ratios (AOR) with a corresponding 95% confidence interval (CI), and a p-value of <0.05 was considered statistically significant. R Studio (Version 2023.09.0+463) was used as an interface for data analysis, while R (the programming language) was used for statistical computations.

Results

The mean age of the study participants was 38.18 (±5.86) years. The overall acceptance rate of the HPV vaccine was 86.61% (95%CI: 85.09–88.02). The vaccine acceptance level was positively associated with all the domains of the HBM (p<0.001), except in the perceived barrier domain (p = 0.489). After adjustment for other factors, it was found that higher age was associated with a decreased acceptance (AOR: 0.92; 95% CI: 0.89–0.95). The urban residents exhibited 42% lower odds of vaccine acceptance than rural (AOR: 0.58; 95% CI: 0.36–0.92). Similarly, participants of the middle-income group had 44% lower odds than the lower-income group (AOR: 0.56; 95% CI: 0.32–0.97).

Conclusion

Our study found a reasonably good level of acceptance of the HPV vaccine among the parents of eligible daughters. Multiple factors such as younger age, urban residence, belonging to the middle income group, history of regular routine health check-ups, knowledge of cervical cancer, positive perception about benefits of the vaccine, and positive cues to actions were associated with HPV vaccine acceptance.

Introduction

The global surge in HPV (Human Papillomavirus) infections is a critical concern today. HPV contributes to around 500,000 annual cancer cases, including cervical, vulvar, anal, penile, and oropharyngeal cancer [1]. Ninety-nine percent of cervical cancer cases in females result from sexually transmitted HPV [2]. Cervical cancer is the fourth most common cancer among women, with a global age-standardized incidence rate of 13.3/100,000 women and a mortality rate of 7.3/100,000 women [3]. In Bangladesh, cervical carcinoma is the second leading malignancy in women, causing 12,000 new cases and over 6,000 deaths annually [4]. HPV, specifically high-risk strains HPV-16 and 18, accounts for over 70% of cervical cancer cases worldwide [5].

The vaccination against HPV emerges as a pivotal strategy for significantly reducing cervical cancer incidence, offering both bivalent and quadrivalent options. While bivalent vaccines primarily protect against high-risk HPV varieties (HPV 16, 18), quadrivalent vaccines target both low and high-risk HPV strains (HPV 6, 11, 16, and 18) [6]. Moreover, screening methods like the Pap smear, visual examination with acetic acid, and self-sampling for HPV DNA testing are effective in cervical cancer prevention [7]. However, eliminating sexual risk factors and vaccination are the primary prevention methods [8]. The WHO recommends vaccinating girls aged 9–14 as the primary target group, with females ≥15 as the secondary group [9].

Though vaccination is an effective way to reduce cervical cancer, there exists a distinction in vaccination coverage based on the development status of the country [10]. In high-income countries, the coverage is almost 80% [11]. Although data on low-and-middle-income countries and low-income countries are scarce, one study reported that in low-and-middle-income countries, the vaccination coverage is about 64% [7].

With a vision for 2030, WHO aims to ensure that 90% of girls receive the HPV vaccine before turning 15 [12]. The success of this ambitious goal depends largely on the broad acceptance of the vaccine, a factor closely tied to knowledge and awareness about cancer prevention measures among both the target population and their parents [6, 13]. For the HPV vaccine, the acceptance of parents is essential as the recipient groups are minors dependent on their parents for decision-making. However, vaccine acceptance among parents is not universal. They often refuse to vaccinate their children on philosophical or religious grounds or out of concern for adverse outcomes [14]. For instance, two studies conducted in Ethiopia found that 81.3% and 94.3% of the parents and guardians of eligible daughters were willing to vaccinate their children, respectively [5, 15]. In China, a meta-analysis reported a pooled acceptance of 55.29% among parents of primary and junior high school students only [16]. The study also noted that parental awareness is a significant determinant of HPV vaccine acceptance. The Government of Bangladesh, with support from UNICEF, the Vaccine Alliance (Gavi), and WHO, initiated a groundbreaking Human Papillomavirus (HPV) vaccination campaign on October 2, 2023 [17]. However, there is a lack of comprehensive, nationwide cross-sectional studies regarding the acceptance of the HPV vaccine among the parents of adolescent girls in Bangladesh. Therefore, our nationwide study aimed to assess the level of acceptance of HPV vaccines among parents of adolescent girls in Bangladesh before the national rollout, with the ultimate goal of ensuring the program’s success.

Methodology

Study design and participants

We conducted a nationwide cross-sectional study among the self-identified parents of daughters in the age group of 9–15 years in Bangladesh. Parents with foreign nationality and/or those who were diagnosed and were taking medication for mental health illness were excluded. To ensure representative sampling, we determined division-specific sample sizes using the 2022 Population & Housing Census [18], resulting in a total adjusted sample size of 2,160 participants, while considering an 80% vaccine acceptance among parents based on the existing literature [9, 19–21] and 10% non-response. We collected samples conveniently from all eight divisions (Dhaka, Mymensingh, Chattogram, Sylhet, Rajshahi, Khulna, Rangpur, and Barisal) of Bangladesh and covered 42 out of 64 districts between June 28 and August 2, 2023. The division-wise distribution of samples is listed in the supplementary table (S1 Table). The overall response rate, considering those who actively participated in the survey, is approximately 90%. Of the 2160 eligible participants who agreed to participate, 2151 completed the entire questionnaire (completion rate: 99.58%); incomplete questionnaires were excluded from the analysis.

Study procedure

A team of 20 competent and trained public health graduates and students collected data from the respondents through face-to-face interviews. They were instructed to speak with as many parents as they could, regardless of their backgrounds, since a convenience sampling technique was used. To avoid linguistic hurdles, the team allocated and trained interviewers according to their locality. Participants were approached in public settings such as hospitals, schools, pharmacies, food markets, roadways, offices, and houses. Along with interacting with the general public, relatives, friends, neighbours, and colleagues of the respondents were invited for the interview. To make the questionnaire easier for the study participants to understand, we translated the difficult terms into a straightforward, native version. While answering the questionnaire, our interviewers provided explanations to participants to assist them understand certain items. Participation was entirely voluntary, and written informed consent was obtained prior to enrolment in the study.

Questionnaire

We used a semi-structured questionnaire to conduct face-to-face interviews. The questionnaire consisted of sections on 1) socio-demographic information, vaccination history of daughters, and health behaviour (21 items); 2) knowledge and information sources related to HPV and the HPV vaccine (11 items); 3) HBM constructs surrounding HPV and HPV vaccine (24 items); 4) acceptance of HPV vaccine (2 items). After a comprehensive literature review, an English draft questionnaire covering the HBM model was developed based on previous studies [22–24]. The questions were developed to cover the domains of the HBM model, which was proposed by a group of social psychologists at the US Public Health Service [25]. We modified and adjusted the framing and wording of questions to reflect Bangladesh’s socio-cultural and healthcare context. Following that, a Bangla translation of the questionnaire was made. Translated versions were validated by repeated revisions and agreement among the researchers. Forward-background translation by certified translators and review by relevant experts were outside the scope of the investigation due to the time-sensitive nature of the study. However, in two steps, the questionnaire’s face validity was ensured. First, we shared the tool with the study supervisor and other researchers in order to obtain expert feedback on its clarity, relevance, and significance. Second, before commencing the actual data collection, a pre-test involving 28 parents of daughters aged between 9–15 years old was undertaken. To enhance participant comprehension and bolster both face- and construct validity, certain questions were revised or clarified in the questionnaire. For the pilot study, we chose participants from a wide range of socioeconomic backgrounds. In order to maintain consistency with recent literature, participant amendments were taken into account and incorporated into the survey. Following a thorough discussion, the authors finalized the questionnaire (58 items) and distributed it for the purpose of the study. Per participant, the questionnaire took about 10 to 12 minutes to complete. The complete English version of the questionnaire is available in the supplementary materials (S1 File).

Variables and measurement

Socio-demographic information, previous vaccination history of daughters, religious belief, and health profile

The survey categorized participants as either mothers (i.e., females) or fathers (i.e., males). Comprehensive personal information encompassing address, age, marital status, religion, residence, education, occupation, average monthly family income, family size, number of children, and daughters’ ages were collected. Binary questions assessed the healthcare worker status and daughters’ educational enrollment. Childhood vaccinations were classified as received or not. Responses indicating "yes all" or "yes some" for other recommended vaccines were grouped as "yes," whereas "no" or "not sure" responses were categorized as "others." Academic institution type (government, private, madrasa) and location (rural, semi-urban, urban) were assessed as nominal variables. Health check-up frequency was measured on an ordinal scale: "never," "<1 year," "1–2 years," "2–5 years," and ">5 years".

Knowledge and source of information about HPV and HPV vaccine

Knowledge was defined as the state of being aware of the term of interest in this study. Respondents’ knowledge and source of information about HPV, HPV vaccine, cervical cancer, and cervical cancer-related vaccines were assessed through eight questions. First, they were asked if they had heard about HPV to investigate their awareness of HPV. If respondents answered affirmatively in the awareness-related question, their sources of information were sought. Knowledge about the HPV vaccine, cervical cancer, and cervical cancer-related vaccines was sought in a similar fashion.

HBM constructs surrounding HPV and HPV vaccine

The Health Belief Model was employed to appraise respondents’ beliefs concerning HPV and its vaccination. This evaluation encompassed five aspects: perceived susceptibility (5 items), severity (5 items), benefits (5 items), barriers (5 items), and cues to action (4 items) related to HPV and its vaccine. Respondents’ perceptions of susceptibility, severity, benefits, and barriers were rated on a five-point Likert scale, ranging from "Strongly Disagree" (1 point) to "Strongly Agree" (5 points). Meanwhile, cues to action were measured using a binary ’Yes’/’No’ scale, with ’Yes’ scored as 1 and ’No’ as 0.

HPV vaccine acceptance

HPV vaccine acceptance was evaluated using two questions on vaccinating daughters and response to a government-provided free vaccination, employing a 3-point scale (‘Yes’, ‘No and ‘Not Sure’).

Statistical analysis

All data were checked for completeness, outliers, and assumption violations prior to analysis. Descriptive statistics were used to characterize the socio-demographic information of the study participants. The responses to the questions about acceptance of the HPV vaccine- ’No’ and ’Not sure’ were merged to produce one response- ’No’ for statistical analysis. In HBM domains, answers to each individual question were first added for perceived vulnerability, perceived severity, perceived benefit, and perceived barrier domains. This gave a total score between 5 to 25. Then, a score of ≥20 was considered a ‘positive’, and <20 was considered a ‘negative’ response for each domain. For the cues to action domain, a positive answer in one of the four questions was considered positive for the overall domain. Knowledge and beliefs about HPV and its vaccines and their association with the acceptance of the vaccine were analyzed using the Chi-square test, Fisher’s exact test, and Welch’s Two Sample t-test where appropriate. Multivariable binary logistic regression analysis was performed to identify the determinants of HPV vaccine acceptance among parents’ sociodemographic factors, health check-up frequency, and knowledge and belief regarding the HPV and HPV vaccine and cervical cancer. Vaccine acceptance was dichotomized by grouping “no” and “not sure” into one category. Thereby, the emphasis was on the acceptance of the vaccine rather than uncertainty or denial. The model performance was measured using Nagelkerke’s pseudo-R-squared (0.368), Receiver Operating Characteristics Curve (Area under the curve: 0.8471), and Hosmer-Lemeshow goodness of fit test (χ² = 2145, df = 8, p <0.001). Although the model was not a good fit, we kept the model because of its overall significance over a null model (p<0.001) and because we were interested in identifying significant determinants of vaccine acceptance rather than the predictive accuracy of the overall model. Variables that were significant in bivariate analyses were included in the multivariable logistic model. Adjusted odds ratios (AOR) were expressed with a corresponding 95% confidence interval (CI). A p-value of <0.05 was considered significant for statistical tests. R Studio (Version 2023.09.0+463) was used as an interface for data analysis, while R (the programming language) was used for statistical computations.

Ethical statement

All the procedures were carried out in accordance with the ethical guidelines of North South University’s Institutional Review Board (IRB)/Ethical Review Committee (ERC) (Approval no: 2023/OR-NSU/IRB/0507). Wherever applicable, the ethical standards outlined in the 1964 Helsinki Declaration and its subsequent amendments, or comparable ethical standards, were followed [26]. During the face-to-face interviews, we obtained written informed consent from all the participants involved in the study. Before providing their written consent, all the participants were informed that their participation was entirely voluntary and that they could withdraw participation at any time. Additionally, they were also informed that all data would be presented on a group level and that only the researchers would have access to it.

Results

Table 1 represents the characteristics of the respondents. The mean age of the study participants was 38.18 (±5.86) years. Of all, 81.40% were female, and 93.86% lived with their spouse. On average, participants had 11.37 (±4.51) years of education. Most of the participants were housewives (63.41%), while only 8.51% were healthcare workers, 51.60% of the respondents lived in an urban area, and 27.98% of households had a monthly income of 35,001–50,000 Bangladeshi Taka (BDT). Joint families (57.12%) were more common than nuclear families (42.88%). About 31.19% of respondents had done regular health check-ups. A significant portion of the population was aware of cervical cancer (80.15%). However, only 22.55% of respondents heard about Human Papillomavirus. Approximately 48.72% of participants knew about the cervical cancer vaccination, while only 22.32% knew about the HPV vaccine. About 21.57% of participants reported feeling vulnerable due to HPV infection, 19.39% felt the severity of the HPV infection and its health risk, 38.45% thought that the vaccination was beneficial, only 0.79% thought that there were barriers that would prohibit them from giving their daughters the HPV vaccine, and 41.79% of respondents had the urge to take action against cervical cancer. The overall acceptance rate of the HPV vaccine among the participants was 86.61% (Fig 1).

Table 1. Characteristics of the respondents (n = 2,151).

Characteristic	n (%)
Age (years)	38.18 ±5.86
Sex
Female	1,751 (81.40)
Male	400 (18.60)
Marital Status
Living with spouse	2,019 (93.86)
Living without spouse	76 (3.53)
Others	56 (2.60)
Religion
Islam	1,784 (82.94)
Hindu	337 (15.67)
Buddhist	4 (0.19)
Christian	26 (1.21)
Residence
Rural	783 (36.40)
Semi-urban	258 (11.99)
Urban	1,110 (51.60)
Years of Education	11.37 ±4.51
Occupation
Job	511 (23.76)
Business	186 (8.65)
Housewife	1,364 (63.41)
Others	90 (4.18)
Health Care Worker	183 (8.51)
Monthly household income (BDT)
< = 20000	547 (25.47)
20001–35000	569 (26.49)
35001–50000	601 (27.98)
>50000	431 (20.07)
Number of family members	5.00 (4.00–6.00)
Family Type
Nuclear	922 (42.88)
Joint	1,228 (57.12)
Routine Health Checkup
Regular	671 (31.19)
Irregular	890 (41.38)
Never	590 (27.43)
Heard about the Human Papillomavirus	485 (22.55)
Heard about the HPV Vaccine	480 (22.32)
Heard about Cervical Cancer	1,724 (80.15)
Heard about Cervical Cancer Vaccination	1,048 (48.72)
Perceived Vulnerability
Negative	1,687 (78.43)
Positive	464 (21.57)
Perceived Severity
Negative	1,734 (80.61)
Positive	417 (19.39)
Perceived Benefit
Negative	1,324 (61.55)
Positive	827 (38.45)
Perceived Barrier
Negative	2,134 (99.21)
Positive	17 (0.79)
Cues to Action
Negative	1,252 (58.21)
Positive	899 (41.79)

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Continuous data was expressed as Mean ±SD and Median (IQR)

Table 2 outlines participants’ responses to health belief model-related questions. Regarding the Perceived Vulnerability domain, a significant portion of respondents agreed that HPV can cause sexually transmitted diseases (39.19%), can lead to condyloma/genital warts (66.20%), poses a risk for young women (37.94% agreed), represents a serious health concern (48.35%), and expressed concern about their child contracting HPV (47.28%). On the Perceived Severity domain, 24.17% of participants agreed that individuals with HPV might not exhibit symptoms, while the majority of the participants remained neutral (68.85%). Concerning the seriousness of conditions, a significant majority agreed (55.00%) that HPV-associated cervical cancer is a serious health concern. Furthermore, a notable portion of participants (49.37%) agreed regarding the possibility of HPV-associated cervical cancer occurring in middle age. Regarding the Perceived Benefits domain, the majority of the participants (64.71%) agreed that they trust vaccinations, citing ongoing research as a reason for their trust. Regarding cervical cancer prevention, a considerable proportion agreed (54.21%) that the HPV vaccine would effectively prevent cervical cancer in their daughters. Regarding HPV transmission, 59.65% agreed vaccinated girls are less likely to contract HPV than unvaccinated girls. Moreover, 50.26% of the participants agreed that HPV vaccination increases awareness of sexually transmitted diseases. On the Perceived Barrier domain, a substantial portion of participants strongly disagreed with several barriers. Specifically, many disagreed (67.46%) with the notion that vaccination should be avoided because of potential pain. In terms of concerns related to adverse effects, a significant number disagreed (54.81%) with this barrier, suggesting that they do not view adverse effects as a significant obstacle. Similarly, participants largely disagreed (60.25%) with the statement that the vaccine’s requirement of two injections was a barrier. Regarding the perception that the HPV vaccine is new and requires waiting, participants varied in their responses, with a higher proportion agreeing (36.91%) and a notable proportion disagreeing (24.97%). Finally, regarding the cost barrier, a good number of participants (32.78%) agreed that they would vaccinate their daughters despite the cost.

Table 2. Distribution of responses to health belief model-related questions (n = 2,151).

Characteristic					n (%)
	Strongly Disagree	Disagree	Neutral	Agree	Strongly Agree
Perceived Vulnerability
HPV can cause sexually transmitted diseases.	1 (0.05)	29 (1.35)	1,175 (54.63)	843 (39.19)	103 (4.79)
HPV can cause condyloma/genital warts.	1 (0.05)	41 (1.91)	1,424 (66.20)	613 (28.50)	72 (3.35)
There is a risk for young women to contract HPV.	4 (0.19)	44 (2.05)	1,204 (55.97)	816 (37.94)	83 (3.86)
HPV infection is a serious health concern.	4 (0.19)	18 (0.84)	870 (40.45)	1,040 (48.35)	219 (10.18)
I worry that my child might get HPV.	7 (0.33)	121 (5.63)	860 (39.98)	1,017 (47.28)	146 (6.79)
Perceived Severity
People with HPV might not have symptoms.	4 (0.19)	90 (4.18)	1,481 (68.85)	520 (24.17)	56 (2.60)
HPV-associated warts could be uncomfortable or itchy.	1 (0.05)	42 (1.95)	1,306 (60.72)	739 (34.36)	63 (2.93)
HPV-associated wart is a serious condition.	1 (0.05)	21 (0.98)	1,245 (57.88)	785 (36.49)	99 (4.60)
HPV-associated cervical cancer is a serious condition.	1 (0.05)	9 (0.42)	643 (29.89)	1,183 (55.00)	315 (14.64)
HPV-associated cervical cancer can occur in middle age.	2 (0.09)	23 (1.07)	932 (43.33)	1,062 (49.37)	132 (6.14)
Perceived Benefit
I trust vaccinations as it is getting better all the time because of research.	3 (0.14)	13 (0.60)	480 (22.32)	1,392 (64.71)	263 (12.23)
The HPV vaccine is effective in preventing condyloma/genital warts in my daughter.	0 (0.00)	45 (2.09)	1,170 (54.39)	845 (39.28)	91 (4.23)
HPV vaccine will be effective in preventing cervical cancer in my daughter.	1 (0.05)	22 (1.02)	833 (38.73)	1,166 (54.21)	129 (6.00)
Vaccinated girls are less likely to get HPV than unvaccinated girls.	0 (0.00)	7 (0.33)	647 (30.08)	1,283 (59.65)	214 (9.95)
HPV vaccination increases awareness of sexually transmitted diseases.	0 (0.00)	31 (1.44)	864 (40.17)	1,081 (50.26)	175 (8.14)
Perceived Barrier
I shall not vaccinate my daughter as it is painful.	226 (10.51)	1,451 (67.46)	392 (18.22)	79 (3.67)	3 (0.14)
I shall not vaccinate my daughter as the HPV vaccine can cause an adverse effect.	140 (6.51)	1,179 (54.81)	600 (27.89)	219 (10.18)	13 (0.60)
I shall not vaccinate my daughter as the HPV vaccine needs two injections.	183 (8.51)	1,296 (60.25)	579 (26.92)	89 (4.14)	4 (0.19)
The HPV vaccine is so new that I want to wait a while before deciding if my daughter should get it.	62 (2.88)	537 (24.97)	672 (31.24)	794 (36.91)	86 (4.00)
I shall vaccinate my daughter even if it is not free despite knowing that the HPV vaccine costs around 2500 BDT.	69 (3.21)	555 (25.80)	722 (33.57)	705 (32.78)	100 (4.65)

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In response to cues to the action domain, individuals demonstrated diverse cancer-related backgrounds. While a minority disclosed their own experiences with cancer (1.53%) or cervical cancer (1.49%), a notable majority acknowledged a cancer history (35.33%) or cervical cancer history (17.29%) within their circle of friends or family (Fig 2).

The association between participants’ characteristics and HPV vaccine acceptance for their daughters is illustrated in Table 3. The average age of the parents willing to vaccinate their girls was significantly lower than those who did not accept the vaccine (p<0.001). Vaccine acceptance was significantly higher among mothers (i.e., female) (87.95%) than fathers (i.e., male) (p<0.001). The respondents living with their spouses were notably more interested in vaccinating their daughters than those living without their spouses. (p = 0.027). Semi-urban and rural dwellers were substantially more receptive to vaccinations than others. (p = 0.018). A notable positive association between education level and the acceptance of vaccines was found (p<0.001). Job holders and healthcare workers showed a higher inclination to get their daughters vaccinated compared to their other groups (p<0.001). The majority of the parents who expressed acceptance of the vaccine had relatively lower monthly family income (p = 0.003) and belonged to the nuclear family (p<0.001). Individuals with a history of regular (93.89%) routine health checkups were more willing to vaccinate their children than others (p<0.001). Moreover, a considerable peak in vaccine acceptance level was observed among parents who heard about HPV (97.53%), HPV vaccine (97.71%), cervical cancer (93.33%), and cervical cancer vaccination (95.42%) compared to those who were unaware of that information (p<0.001). The vaccine acceptance level was positively associated with all the domains of the HBM except in the perceived barrier domain, where no association was found (p = 0.489). Participants perceiving lesser vulnerability (97.63%) and lesser severity (97.60%) about the HPV, as well as greater benefits regarding the HPV vaccine (97.10%) and having apparent cues to actions (91.99%), demonstrated greater willingness to vaccinate their daughters.

Table 3. Association of characteristics of the respondents with HPV vaccine acceptance.

	Accepts Vaccine
Characteristic	No, (n = 288)	Yes, (n = 1,863)	p-value
Age (years)	40.70 ±6.20	37.79 ±5.71	<0.001 ²
Sex			<0.001 ³
Female	211 (12.05)	1,540 (87.95)
Male	77 (19.25)	323 (80.75)
Marital Status			0.027 ³
Living with spouse	263 (13.03)	1,756 (86.97)
Living without spouse	18 (23.68)	58 (76.32)
Others	7 (12.50)	49 (87.50)
Religion			0.244⁴
Islam	236 (13.23)	1,548 (86.77)
Hindu	45 (13.35)	292 (86.65)
Buddhist	0 (0.00)	4 (100.00)
Christian	7 (26.92)	19 (73.08)
Residence			0.018 ³
Rural	89 (11.37)	694 (88.63)
Semi-urban	28 (10.85)	230 (89.15)
Urban	171 (15.41)	939 (84.59)
Years of Education	10.09 ±4.06	11.57 ±4.54	<0.001 ²
Occupation			<0.001 ³
Job	28 (5.48)	483 (94.52)
Business	55 (29.57)	131 (70.43)
Housewife	191 (14.00)	1,173 (86.00)
Others	14 (15.56)	76 (84.44)
Health Care Worker	0 (0.00)	183 (100.00)	<0.001 ³
Monthly household income (BDT)			0.003 ³
< = 20000	63 (11.52)	484 (88.48)
20001–35000	63 (11.07)	506 (88.93)
35001–50000	106 (17.64)	495 (82.36)
>50000	55 (12.76)	376 (87.24)
Family Type			<0.001 ³
Nuclear	89 (9.65)	833 (90.35)
Joint	199 (16.21)	1,029 (83.79)
Routine Health Checkup			<0.001 ³
Regular	41 (6.11)	630 (93.89)
Irregular	160 (17.98)	730 (82.02)
Never	87 (14.75)	503 (85.25)
Heard about Human Papilloma Virus	12 (2.47)	473 (97.53)	<0.001 ³
Heard about HPV Vaccine	11 (2.29)	469 (97.71)	<0.001 ³
Heard about Cervical Cancer	115 (6.67)	1,609 (93.33)	<0.001 ³
Heard about Cervical Cancer Vaccination	48 (4.58)	1,000 (95.42)	<0.001 ³
Perceived Vulnerability			<0.001 ³
Negative	277 (16.42)	1,410 (83.58)
Positive	11 (2.37)	453 (97.63)
Perceived Severity			<0.001 ³
Negative	278 (16.03)	1,456 (83.97)
Positive	10 (2.40)	407 (97.60)
Perceived Benefit			<0.001 ³
Negative	264 (19.94)	1,060 (80.06)
Positive	24 (2.90)	803 (97.10)
Perceived Barrier			0.489⁴
Negative	285 (13.36)	1,849 (86.64)
Positive	3 (17.65)	14 (82.35)
Cues to Action			<0.001 ³
Negative	216 (17.25)	1,036 (82.75)
Positive	72 (8.01)	827 (91.99)

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¹Mean ±SD; n (%); Median (IQR)

²Welch Two Sample t-test

³Pearson’s Chi-squared test

⁴Fisher’s exact test

⁵Wilcoxon rank sum test

Significant p-values are shown in bold

To identify the factors influencing the acceptability of the HPV vaccine among parents of young daughters, both univariate and multivariate logistic regression analysis was carried out. (Table 4). After adjustment for other factors, it was found that a higher age was associated with a noticeable decrease in the parents’ acceptance of vaccines for their daughters. (AOR: 0.92; 95% CI: 0.89–0.95). The urban residents exhibited 42% lower odds of vaccine acceptance than those in rural areas (AOR: 0.58; 95% CI: 0.36–0.92). Similarly, participants of the middle-income group had 44% lower odds of vaccination than the lower-income group. (AOR: 0.56; 95% CI: 0.32–0.97). Moreover, those with no history of regular health checkups had 45% lesser odds of vaccine acceptance than those with a history of regular health checkups. (AOR: 0.55; 95% CI: 0.35–0.85) Contrastingly, individuals with knowledge of cervical cancer had 4.10 times higher odds than those without such knowledge. (AOR: 4.10, 95%CI: 2.89–5.85). Concerning the perceived benefits, vaccine acceptance was 3.77-fold higher odds with positive attitudes towards the benefits of the HPV vaccine (AOR: 3.77, 95%CI: 2.32–6.35). Individuals experiencing cues to actions had 1.95 times higher odds of vaccinating their girls (AOR: 1.95, 95%CI: 1.37–2.80).

Table 4. Determinants of HPV vaccine acceptance.

	Univariate Models			Multivariate Model
Characteristic	OR	95% CI	p-value	OR	95% CI	p-value
Age (years)	0.92	0.90 to 0.94	<0.001	0.92	0.89 to 0.95	<0.001
Sex
Female	—	—		—	—
Male	0.57	0.43 to 0.77	<0.001	1.05	0.53 to 2.04	0.882
Marital Status
Living with spouse	—	—		—	—
Living without spouse	0.48	0.29 to 0.85	0.009	0.72	0.37 to 1.46	0.349
Others	1.05	0.50 to 2.56	0.908	0.93	0.38 to 2.56	0.886
Residence
Rural	—	—		—	—
Semi-urban	1.05	0.68 to 1.68	0.821	0.72	0.42 to 1.27	0.248
Urban	0.70	0.53 to 0.92	0.012	0.58	0.36 to 0.92	0.021
Years of Education	1.07	1.05 to 1.10	<0.001	1.02	0.97 to 1.08	0.375
Occupation
Job	—	—		—	—
Business	0.14	0.08 to 0.22	<0.001	0.59	0.31 to 1.10	0.098
Housewife	0.36	0.23 to 0.53	<0.001	0.62	0.33 to 1.11	0.118
Others	0.31	0.16 to 0.64	<0.001	0.63	0.27 to 1.53	0.300
Monthly household income (BDT)
< = 20000	—	—		—	—
20001–35000	1.05	0.72 to 1.52	0.814	0.85	0.54 to 1.35	0.504
35001–50000	0.61	0.43 to 0.85	0.004	0.56	0.32 to 0.97	0.039
>50000	0.89	0.61 to 1.31	0.553	0.57	0.30 to 1.08	0.084
Family Type
Nuclear	—	—		—	—
Joint	0.55	0.42 to 0.72	<0.001	0.79	0.56 to 1.11	0.171
Routine Health Checkup
Regular	—	—		—	—
Irregular	0.30	0.20 to 0.42	<0.001	0.70	0.46 to 1.07	0.105
Never	0.38	0.25 to 0.55	<0.001	0.55	0.35 to 0.85	0.007
Heard about Human Papilloma Virus
No	—	—		—	—
Yes	7.83	4.55 to 14.9	<0.001	1.16	0.42 to 3.49	0.783
Heard about HPV Vaccine
No	—	—		—	—
Yes	8.47	4.83 to 16.6	<0.001	1.45	0.49 to 4.43	0.515
Heard about Cervical Cancer
No	—	—		—	—
Yes	9.53	7.28 to 12.5	<0.001	4.10	2.89 to 5.85	<0.001
Heard about Cervical Cancer Vaccination
No	—	—		—	—
Yes	5.79	4.23 to 8.09	<0.001	1.32	0.86 to 2.05	0.211
Perceived Vulnerability
Negative	—	—		—	—
Positive	8.09	4.61 to 15.8	<0.001	1.77	0.89 to 3.87	0.125
Perceived Severity
Negative	—	—		—	—
Positive	7.77	4.32 to 15.8	<0.001	1.29	0.62 to 2.93	0.523
Perceived Benefit
Negative	—	—		—	—
Positive	8.33	5.55 to 13.1	<0.001	3.77	2.32 to 6.35	<0.001
Perceived Barrier
Negative	—	—		—	—
Positive	0.72	0.23 to 3.13	0.606	0.32	0.07 to 1.87	0.166
Cues to Action
Negative	—	—		—	—
Positive	2.39	1.82 to 3.19	<0.001	1.95	1.37 to 2.80	<0.001

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OR = Odds Ratio, CI = Confidence Interval; Dashes (-) represent reference values. Significant p-values are shown in bold.

Discussion

The acceptance of the Human Papillomavirus (HPV) vaccine has emerged as a critical determinant in the global effort to combat cervical cancer, a leading cause of morbidity and mortality among women [27]. In the context of Bangladesh, where cervical cancer is the second most common cancer among females and poses a significant health burden [28], understanding the factors that influence parental acceptance of the HPV vaccine is of paramount importance. This nationwide study employs the Health Belief Model as a framework to explore and elucidate the multifaceted factors that shape HPV vaccine acceptance among Bangladeshi parents.

Our study observed an impressively high acceptance rate of the HPV vaccine among parents, with an overall acceptance rate of 86.61%. This finding demonstrates a substantial willingness among Bangladeshi parents to embrace HPV vaccination as a crucial preventive measure against cervical cancer. It’s important to note the variability in global acceptance of the HPV vaccine, as approval rates in different studies range from 44% to 79% [29–34]. Notably, two studies conducted in Japan and Hong Kong found that less than a third of mothers expressed the intention to vaccinate their daughters [35, 36]. 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 [13, 19], our study stands out with its significantly higher acceptance rate. However, compared to other countries, recent nationwide vaccination for COVID-19 might have been a mover for higher acceptance of the vaccine in general, explaining the findings in our study.

The sociodemographic analysis reveals pivotal factors influencing HPV vaccine acceptance among Bangladeshi parents. Notably, younger parents show a greater propensity for vaccine acceptance, aligning with previous studies conducted in comparable contexts in Iran and Ethiopia [37, 38]. This inclination is likely attributed to their greater exposure to health-related information and receptiveness to novel healthcare interventions. The acceptance rate is notably influenced by sex, as females exhibit a higher acceptance rate than males, which mirrors consistent trends detected in research conducted in various geographic areas [39, 40]. This variation can be attributed to the traditional caregiving roles of females in healthcare decision-making. However, it’s worth noting that the percentage of males who participated in our study was 18.60%, indicating a relatively small sample size.

A significant observation in our study was that both urban residents and individuals in the middle-income group had lower vaccine acceptance rates compared to their counterparts in rural areas and lower-income groups, respectively. This aligned with research by Liu et al. [41], which revealed that individuals who were well-educated, had higher incomes, and lived in urban areas exhibited greater vaccine hesitancy. Similarly, Wagner et al. [42] and Lin et al. [43] reported similar results, indicating lower vaccine hesitancy and fewer safety concerns in low and middle-income regions compared to high-income areas of China. The higher acceptance in rural communities of Bangladesh with relatively low economic capacity could be explained by the fact that healthcare workers employed by the Ministry of Health, including health assistants and community healthcare providers, play a proactive role in increasing vaccine uptake in rural areas, while the urban health care services managed by the city corporation lacks such community-centric health delivery system.

The study revealed a strong correlation between regular health checkups and an enhanced inclination to receive vaccinations, affirming prior research by Wheldon et al. that consistently underscored the enduring importance of readily accessible healthcare in influencing vaccination behavior [44]. Furthermore, a systematic review and meta-analysis conducted by Newman et al. identified a positive association between routine child preventive check-ups and parents’ willingness to accept the HPV vaccine [45]. Individuals who undergo regular health check-ups are more likely to be self-conscious about their health compared to those who do not have regular health check-ups, explaining the higher HPV vaccine acceptance among the former.

Furthermore, in the analysis, it became evident that having knowledge about cervical cancer and HPV significantly motivated vaccine acceptance. This aligned with previous research by Zouheir et al. (2016) [46], which highlighted the impact of these factors as influential. A similar trend was noted in a study by Zhou et al. (2019) [47], where parental awareness was a positive factor influencing the intention for HPV vaccination among adolescents. This emphasizes the vital need for specific awareness initiatives targeting these sociodemographic aspects to enhance the uptake of the HPV vaccine.

The application of the Health Belief Model (HBM) to understand vaccine acceptance in this context yielded several important insights. Participants generally recognized that young women were susceptible to HPV and were worried about their children getting infected with the virus, showing a sense of vulnerability to it. Nevertheless, there was a degree of uncertainty regarding the seriousness of HPV, especially concerning the presence of symptoms. This finding corresponds with earlier research by Vermandere et al. and Yarici et al. [48, 49], which highlighted differing levels of comprehension regarding the health risks linked to HPV infection due to limited knowledge and awareness. Nevertheless, the majority of our participants had trust in vaccinations and believed the HPV vaccine would effectively prevent cervical cancer in their daughters. This perception of benefit emerged as an independent determinant of HPV vaccine acceptance in the multivariable model. Suo et al. [50] also observed that the perceived safety of the HPV vaccine improved its acceptance among parents of adolescent girls. Participants mostly disagreed with potential barriers to HPV vaccination, such as concerns about pain, side effects, and the number of shots required. Similar findings were reported in studies by Guvenc et al. and Marlow et al. [51, 52], indicating that these barriers typically do not pose significant obstacles to vaccine acceptance. Individuals often prioritize the perceived benefits and risks associated with HPV vaccination over the potential barriers. We found that even perceived severity was superseded by the perception of benefit in vaccine acceptance. Additionally, our multivariable analysis revealed that cues to action was another independent determinant of vaccine acceptance. Individuals who had history of any cervical cancer or other cancer, and individual who saw any family member or friend affected by those cancers were significantly most likely to accept the vaccine, because they had first-hand experience of the consequences of cancers.

The Global Vaccine Action Plan aims to save lives by ensuring equitable vaccine access worldwide [53]. In Bangladesh, the battle against cervical cancer is paramount. However, the findings of this nationwide study revealed that HPV vaccine acceptance is shaped by factors like age, maternal engagement, and healthcare access. To address this, tailored awareness campaigns, educational initiatives, and enhanced healthcare services are imperative. Overcoming barriers and implementing effective cues can significantly enhance vaccine acceptance, a crucial step in the fight against cervical cancer.

Strengths and limitations

The strengths of this study are grounded in its nationwide coverage, offering a comprehensive understanding of HPV vaccine acceptance across diverse regions of Bangladesh. Furthermore, the structured application of the Health Belief Model as a framework allows for a systematic and theory-driven analysis of the factors influencing vaccine acceptance. Additionally, the study underwent a rigorous piloting process, which contributed to the refinement of survey instruments, ensuring the clarity and consistency of data collection. Moreover, the study also considered a wide range of sociodemographic variables, adding depth to the analysis and contributing to a more nuanced understanding of the determinants of vaccine acceptance. These collective strengths bolster the robustness, representativeness, and methodological rigor of the study’s findings, providing valuable insights into the landscape of HPV vaccine acceptance in Bangladesh.

The limitations of the study include its cross-sectional design, providing a brief glimpse into HPV vaccine acceptance without the ability to establish causation or observe changes over time. The use of convenience sampling may introduce biases affecting the study’s overall representation. Another limitation is that the representation of fathers was low in our study, potentially missing their intentions regarding HPV vaccine acceptance for their daughters. The lack of longitudinal data hinders the exploration of acceptance trends. Additionally, the study predominantly offers quantitative insights, with limited qualitative depth, to probe into the reasons behind the socio-demographic determinants of HPV vaccine acceptance. Furthermore, the study did not thoroughly investigate external influences on acceptance, such as policy shifts or external awareness campaigns, which could have influenced attitudes and behaviours. These aspects should be taken into account when interpreting the study’s outcomes.

Conclusion

Our nationwide study found a reasonably good level of acceptance of the HPV vaccine among the parents of eligible daughters. The vaccine acceptance level was positively associated with almost all the domains of the HBM. Multiple factors such as younger age, urban residence, monthly income in the lowest quartile, history of regular routine health check-ups, knowledge of cervical cancer, positive perception about vaccine benefits, and positive cues to actions were associated with HPV vaccine acceptance. However, as the awareness level is still very low, the government should take steps to initiate awareness campaigns at all levels.

Recommendation

Implement tailored awareness campaigns for specific demographic groups, including younger parents, mothers, urban residents, and middle-income individuals.
Implement policies and interventions to improve healthcare availability, particularly in urban areas and among the middle-income population, ensuring that parents have easy access to vaccination services.
Strengthen educational initiatives to increase awareness about cervical cancer and the benefits of HPV vaccination.
Conduct longitudinal studies to track trends in HPV vaccine acceptance over time and assess the long-term effectiveness of interventions aimed at increasing vaccine uptake.

Supporting information

S1 Table. The division-wise distribution of samples.

(DOCX)

pone.0310779.s001.docx^{(18.2KB, docx)}

S1 File. Completed questionnaire used for data collection.

(DOCX)

pone.0310779.s002.docx^{(50.9KB, docx)}

S1 Dataset. Dataset used to generate figures, tables, and statistics.

(CSV)

pone.0310779.s003.csv^{(1.4MB, csv)}

Acknowledgments

The authors would like to extend their profound gratitude to all the participants in this study, who voluntarily and spontaneously contributed to our research.

Data Availability

All relevant data are within the manuscript and its Supporting Information files.

Funding Statement

The author(s) received no specific funding for this work.

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PLoS One. doi: 10.1371/journal.pone.0310779.r001

Decision Letter 0

Kehinde Kazeem Kanmodi

9 Jan 2024

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,

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Reviewer #4: Yes

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

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Reviewer #3: Yes

Reviewer #4: I Don't Know

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Reviewer #1: Yes

Reviewer #2: Yes

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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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Attachment

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

pone.0310779.s004.pdf^{(1.1MB, pdf)}

PLoS One. 2024 Nov 8;19(11):e0310779. doi: 10.1371/journal.pone.0310779.r002

Author response to Decision Letter 0

1 Apr 2024

Response to Reviewer#1’s Comment:

Comment: 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.

Response: Thank you for your valuable feedback. Our study has received IRB approval (Approval no: 2023/OR-NSU/IRB/0507) from North South University’s Ethical Review Committee. Additionally, we have followed the ethical standards outlined in the 1964 Helsinki Declaration and its subsequent amendments wherever applicable and the STROBE guidelines to craft the manuscript (Kindly refer to the lines 193-201 in the revised manuscript). We believe this oversight adequately addresses ethical considerations.

Moreover, we have incorporated the recommendations in bullet points in the revised manuscript in the recommendation section (Please refer to lines 408-415) to highlight the implications of our study.

Response to Reviewer#2’s Comment:

Comment: 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.

Response: Thank you for your comment. The questionnaire underwent a rigorous validation process and was reviewed by study supervisors and expert researchers, ensuring its appropriateness and relevance to the study objectives. Content validity was addressed through pre-testing, construct definition, item analysis, modification, pilot study and continuous review, as detailed in the questionnaire part (Please refer to lines 117-141 in the revised manuscript) under the methodology section. We believe these steps robustly address the content validity concerns of the questionnaire.

In response to the reviewer's query regarding the disparity between the total adjusted sample size (2160) and the total sample size used after exclusion (2151), we would like to clarify that the difference arises from the exclusion of participants who had incomplete data. These exclusions were necessary to ensure the integrity and validity of the study results.

In response to the concern about the representativeness of the sample size in our nationwide study, we want to highlight that we meticulously covered all eight divisions of Bangladesh and collected samples from 42 out of 64 districts. This extensive geographical coverage enhances the representativeness of our sample, ensuring a comprehensive reflection of diverse demographic and regional characteristics across the country. We have provided detailed information about the sampling strategy and coverage in the methodology section (Please refer to lines 91-116 in the revised manuscript) of the manuscript.

To address the reviewer's comment regarding the referencing of pretest and pilot protocols, we appreciate the suggestion. However, the detailed protocols for the pretest and pilot study were not published separately as part of the manuscript. Hence, direct referencing to specific pilot protocols is not feasible. To enhance clarity, we have included relevant information about the pretest and pilot study within the questionnaire section (Lines 133-138) of the methodology, providing a comprehensive understanding of the rationale and implementation. We trust this clarification meets the reviewer's expectations.

Comment: 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.

Response: Thank you for your valuable feedback. We have carefully reviewed and revised the manuscript for grammatical errors, including the mentioned lines. The line is now read as follows (Lines 318-320: The acceptance rate is notably influenced by sex, as females exhibit a higher acceptance rate than males….). We believe this adjustment improves the clarity and readability of the manuscript.

Response to Reviewer#3’s Comment:

Comment: 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:

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

Response: Thank you for bringing this to our attention. We have now appropriately referenced the statement in Lines 65-66. The relevant citations have been added to ensure accuracy and credibility. Please refer to the updated manuscript for the correct referencing (Lines 67-68).

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

Response: Thank you for pointing this out. We agree that the statement 'mental illnesses were excluded' can be clarified for better understanding. In the revised manuscript, we have provided a more detailed explanation of the criteria and process used for the exclusion of mental illnesses. Please refer to lines 93-94 in the revised manuscript, which is now read as follows-

“…..those who were diagnosed and were taking medication for mental health illness were excluded.”

Comment: 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.

Response: Thank you very much for the suggestion. The reference you mentioned (reference no 13, now 18) opens the preliminary report of the Population and Housing Census 2022. Please note that the number ‘84’ in the sentence that you copied is the line number. It does not refer to anything else. Note also that our target was to ensure proportionate representation of the eight administrative divisions of Bangladesh. Based on your suggestion, we have included a supplementary table (S1 Table) where the population of each division with their proportion is listed alongside a number of samples taken from each division with their proportion. We extracted this data from the preliminary reports of the population and housing census available for free from the Bangladesh Bureau of Statistics. Our sample gives a complete representation of the divisions we intended to cover.

(Bangladesh Bureau of Statistics (BBS), 2022. Population & Housing Census 2022, Preliminary report. Ministry of Planning, Government of the People’s Republic of Bangladesh, 11. Available from: https://bbs.portal.gov.bd/sites/default/files/files/bbs.portal.gov.bd/page/b343a8b4_956b_45ca_872f_4cf9b2f1a6e0/2023-09-27-09-50-a3672cdf61961a45347ab8660a3109b6.pdf)

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

Response: Thank you for your observation. Referencing issues on lines 85-86 have been addressed in the revised manuscript. Please refer to line 97 in the revised manuscript to find the updated reference.

Comment: 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.

Response: We appreciate your feedback. The methodology section of the revised manuscript now includes details on the overall response rate upon invitation, total responses before exclusions, and the exclusion criteria. Please refer to lines 101-104 in the revised manuscript, which are now read as follows-

“The overall response rate, considering those who actively participated in the survey, was approximately 90%. Of the 2160 eligible participants who agreed to participate, 2151 completed the entire questionnaire (completion rate: 99.58%); incomplete questionnaires were excluded from the analysis.”

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

Response: Thank you for your feedback. The English version of the study questionnaire is attached in the supplemental material section (Please refer to S1 File).

Comment: 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?

Response: Thank you for bringing this to our attention. The statement in lines 117-120 has been revised for better clarity. In the revised manuscript, the lines are (Line 133-135) now read as follows-

“Second, before commencing the actual data collection, a pre-test involving 28 parents of daughters aged between 9–15 years old was undertaken. To enhance participant comprehension and bolster both face- and construct validity, certain questions were revised or clarified in the questionnaire.”

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

Response: Thank you for your suggestion. Although, based on your suggestion, we have included the questionnaire in the supplementary table, we believe the explanatory description provided on pages 4 to 6 is not redundant. If you note carefully, you may notice that we provided explanation on how some of the responses were grouped for analyses. Also, how we operationalized knowledge in the context of this research was explained.

Comment: 9. How was knowledge scored?

Response: Thank you for the question. We explained it in the “knowledge and source of information about HPV and HPV vaccine” subsection of the method section. However, we noticed that the explanation was inadequate. Therefore, this section was modified to make it clear. The section now reads as follows-

“Knowledge was defined as the state of being aware of the term of interest in this study. Respondents' knowledge and source of information about HPV, HPV vaccine, cervical cancer, and cervical cancer-related vaccines were assessed through eight questions. First, they were asked if they had heard about HPV to investigate their awareness of HPV. If respondents answered affirmatively in the awareness-related question, their sources of information were sought. Knowledge about the HPV vaccine, cervical cancer, and cervical cancer-related vaccines was sought in a similar fashion. (lines 156 – 162).”

Hence, the knowledge-related questions had mostly binary answers and didn’t require scoring.

Comment: 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)

Response: Thank you for your suggestions. As explained earlier, knowledge meant ‘the state of being aware (or heard) about the term.’ If one was aware, we asked them about the sources of knowledge. Hence, this section of the questionnaire was built through brainstorming and discussion among the investigators. The literature review mainly helped us formulate the HBM-related question. We have now placed the references in the exact place to make it clear in the manuscript. Please check line 123.

Comment: 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”

Response: “BDT” is the short form used globally to mean the monetary exchange note “Bangladeshi Taka”. Hence, we didn’t spell it out earlier. However, we have now spelt it in its first instance in the manuscript. Please check lines 207, 208.

Comment: 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.

Response: The academic institution type was the institute type of the daughters of the respondents. The question was not about the respondents (i.e., mother or father). We believe, the institute type of the respondents would have been valuable in the context of the vaccine acceptance by the respondent (not the adolescent girl). This is why this information was dropped.

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

Response: Thank you for your query. We examined the possibility of including division in the model. However, as you know, the underlying calculation of logistic regression involves combinations of categories of the different variables in the multivariable regression leading to the bifurcation of samples into incrementally smaller groups. Hence, when we add division, it produces unrealistic intervals in the multivariable regression. Therefore, we decided to exclude it from the final model and discuss divisional differences in follow-up papers.

Comment: 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.

Response: We choose years of education instead of level of education to incorporate the differences in institutional education among our participants. In our country, not everyone follows the same trajectory of education after secondary level. For example, some people directly go for a diploma in technical education rather than going for graduating from a university. Again, some choose the ‘Madrasa’ board, which again has two divisions (Aliya and Qaumi) instead of the national curriculum. Hence, we preferred to capture years of education instead of level of education.

Comment: 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 appro

Attachment

Submitted filename: Response to Reviewers.docx

pone.0310779.s005.docx^{(49KB, docx)}

PLoS One. doi: 10.1371/journal.pone.0310779.r003

Decision Letter 1

Miquel Vall-llosera Camps

18 Jun 2024

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,

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Senior Staff Editor

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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)

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

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?

Reviewer #2: Yes

Reviewer #3: No

Reviewer #5: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

Reviewer #2: Yes

Reviewer #3: Yes

Reviewer #5: No

**********

6. Review Comments to the Author

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.

**********

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.

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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

**********

PLoS One. 2024 Nov 8;19(11):e0310779. doi: 10.1371/journal.pone.0310779.r004

Author response to Decision Letter 1

8 Jul 2024

REBUTTAL LETTER

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

Authors Response: Thank you for your thorough review of our manuscript.

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.

Authors Response: Thank you for your insightful observation. We have revised the wording in the abstract conclusion for clarity. The updated text now reads:

Line 46-49: “Multiple factors such as younger age, urban residence, belonging to the middle income group, history of regular routine health check-ups, knowledge of cervical cancer, positive perception about benefits of the vaccine, and positive cues to actions were associated with HPV vaccine acceptance.”

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

Authors Response: Thank you for your comment.

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

Authors Response: The model performance was measured using Nagelkerke’s pseudo-R-squared (0.368), Receiver Operating Characteristics Curve (Area under the curve: 0.8471), and Hosmer-Lemeshow goodness of fit test (χ2 = 2145, df = 8, p <0.001). Although the model was not a good fit, we kept the model because of its overall significance over a null model (p<0.001) and because we were interested in identifying significant determinants of vaccine acceptance rather than the predictive accuracy of the overall model.

We added this part in the methodology section. Please check lines 191 to 196.

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.

Authors Response: Thank you for your feedback regarding the Results section. We understand your concern about the level of detail. However, we believe that the current description provides necessary context and clarity for the reader. The detailed narrative is essential to fully convey the complexity of our findings and their implications. We have ensured that key points are highlighted and have referred to relevant figures and tables to support and illustrate the results. We hope this approach strikes an appropriate balance between detail and readability.

Authors Response: Thank you for the nice suggestion. We added this as a limitation in line numbers 404 – 405.

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.

Authors Response: Thank you for your observation. We have addressed this comment in the revised manuscript. Please refer to lines 179-181 for the updated content.

Authors Response: Thank you for your comment. We have revised the wording for clarity and accuracy. The updated line (Line 199-201) now reads:

"R Studio (Version 2023.09.0+463) was used as an interface for data analysis, while R (the programming language) was used for statistical computations."

Authors Response: Thank you again for the detailed comment. We added clarification in the statistical analysis subsection of the methods section. Please check lines 189– 191.

Authors Response: Thank you for your valuable suggestion. We have now incorporated a recommendations section for future research based on our study's findings. Please refer to lines 420-429 in the revised manuscript for these updates.

Attachment

Submitted filename: Response to reviewers.docx

pone.0310779.s006.docx^{(19.1KB, docx)}

PLoS One. doi: 10.1371/journal.pone.0310779.r005

Decision Letter 2

Rashidul Alam Mahumud

5 Sep 2024

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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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

Reviewer #2: All comments have been addressed

Reviewer #3: All comments have been addressed

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

Reviewer #2: Yes

Reviewer #3: Yes

**********

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?

Reviewer #2: Yes

Reviewer #3: No

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

Reviewer #2: Yes

Reviewer #3: Yes

**********

6. Review Comments to the Author

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.

**********

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

**********

PLoS One. doi: 10.1371/journal.pone.0310779.r006

Acceptance letter

Rashidul Alam Mahumud

9 Sep 2024

PONE-D-23-37347R2

PLOS ONE

Dear Dr. Eva,

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now being handed over to our production team.

At this stage, our production department will prepare your paper for publication. This includes ensuring the following:

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Thank you for submitting your work to PLOS ONE and supporting open access.

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on behalf of

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Academic Editor

PLOS ONE

Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

S1 Table. The division-wise distribution of samples.

(DOCX)

pone.0310779.s001.docx^{(18.2KB, docx)}

S1 File. Completed questionnaire used for data collection.

(DOCX)

pone.0310779.s002.docx^{(50.9KB, docx)}

S1 Dataset. Dataset used to generate figures, tables, and statistics.

(CSV)

pone.0310779.s003.csv^{(1.4MB, csv)}

Attachment

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

pone.0310779.s004.pdf^{(1.1MB, pdf)}

Attachment

Submitted filename: Response to Reviewers.docx

pone.0310779.s005.docx^{(49KB, docx)}

Attachment

Submitted filename: Response to reviewers.docx

pone.0310779.s006.docx^{(19.1KB, docx)}

Data Availability Statement

All relevant data are within the manuscript and its Supporting Information files.

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PERMALINK

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

Mohammad Delwer Hossain Hawlader

Fahima Nasrin Eva

Md Abdullah Saeed Khan

Tariful Islam

Umme Kulsum Monisha

Irin Chowdhury

Rifat Ara

Nur-E-Safa Meem

Mohammad Ali Hossain

Arpita Goutam

Tahmina Zerin

Nishat Alam

Rima Nath

Shamma Sifat

Sayla Sultana

Mosammat Sadeka Sultana

Sumit Kumar Saha

Naifa Enam Sarker

Mohammad Hayatun Nabi

Mohammad Lutfor Rahman

Roles

Abstract

Background

Methods

Results

Conclusion

Introduction

Methodology

Study design and participants

Study procedure

Questionnaire

Variables and measurement

Socio-demographic information, previous vaccination history of daughters, religious belief, and health profile

Knowledge and source of information about HPV and HPV vaccine

HBM constructs surrounding HPV and HPV vaccine

HPV vaccine acceptance

Statistical analysis

Ethical statement

Results

Table 1. Characteristics of the respondents (n = 2,151).

Fig 1. Acceptance of the HPV vaccine.

Table 2. Distribution of responses to health belief model-related questions (n = 2,151).

Fig 2. Cues to the action question.

Table 3. Association of characteristics of the respondents with HPV vaccine acceptance.

Table 4. Determinants of HPV vaccine acceptance.

Discussion

Strengths and limitations

Conclusion

Recommendation

Supporting information

Acknowledgments

Data Availability

Funding Statement

References

Decision Letter 0

Kehinde Kazeem Kanmodi

Roles

Author response to Decision Letter 0

Decision Letter 1

Miquel Vall-llosera Camps

Roles

Author response to Decision Letter 1

Decision Letter 2

Rashidul Alam Mahumud

Roles

Acceptance letter

Rashidul Alam Mahumud

Roles

Associated Data

Supplementary Materials

Data Availability Statement

ACTIONS

PERMALINK

RESOURCES

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