Strategies to Raise Awareness About Screening and Vaccination for the Human Papillomavirus Among Women in Limpopo Province, South Africa

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

1. The article “Strategies To Create Awareness Regarding Human Papilloma Virus Screening And Vaccination Among Women In Limpopo Province, South Africa by Mushasha et al., conducted a study to develop strategies to increase awareness of Human Papilloma Virus screening and vaccination among women in Limpopo Province, South Africa. Authors have found that providing education about recent guidelines of HPV screening is highly appreciated by majority of study participants.  Since HPV infections are the major contributors for the development of cervical cancer, strategies that create awareness among women about this virus, virus infections, screening approaches and benefits of undergoing screening and participating in vaccination programs is highly significant.

 

Comments

Section: 2.5 Data collection instrument - Correct “four responses” to “five responses”

Information pertaining to ethical approval is not provided.

            Validity of the questionnaire used for collecting the data is not mentioned

            Section: 3.2 Avoid starting the sentence with a numerical digit. 

Although the study thoroughly evaluated the key factors and strategies to be considered for providing effective education among the study participants, the strategies that are needed for un-educated and the ones with no knowledge in the usage of social media have not been mentioned.  Moreover, the study suffers from very minimal sample size.  The authors would have compared the results of this study with that of the published ones.

Keeping all these drawbacks, I recommend the acceptance of this manuscript only after thorough revision

 

Comments on the Quality of English Language

Quality of writing - Can be improved

Author Response

Comment 1: Section: 2.5 Data collection instrument - Correct “four responses” to “five responses”

Response 1: Thank you for the comment- Under section 2.5, four responses were replaced with five responses

Comment 2: Information pertaining to ethical approval is not provided.

Response 2: Information pertaining to ethical approval is now provided see section 2.6

Comment 3: Validity of the questionnaire used for collecting the data is not mentioned

Response  3: Information Pertaining validity and reliability of the questionnare is now provided see section 2.5

Comment 4: Section: 3.2 Avoid starting the sentence with a numerical digit. 

Response 4: Starting sentences with numerical digits is now corrected see section 3.2 and 3.3

Comment 5: Although the study thoroughly evaluated the key factors and strategies to be considered for providing effective education among the study participants, the strategies that are needed for un-educated and the ones with no knowledge in the usage of social media have not been mentioned.  Moreover, the study suffers from very minimal sample size.  The authors would have compared the results of this study with that of the published ones.

Response 5:

Thank you for your valuable comment. We would like to clarify that the sample size reported in this manuscript does not represent the main study. A larger primary study was conducted prior to this phase, which assessed participants’ knowledge and awareness regarding HPV screening and vaccination.

The findings from that main study informed the development of the strategies presented in this paper. Therefore, the current manuscript focuses specifically on the development and validation of these strategies. As such, a smaller, purposively selected group of participants was involved to evaluate and validate the developed strategies. 

We acknowledge the limitation of the smaller sample size in this phase and have clarified this in the revised manuscript see under section 2. Additionally, we have strengthened the discussion by linking our findings to relevant published studies.

 

 

 

Reviewer 2 Report

Comments and Suggestions for Authors

Dear Authors,

This paper addresses an interesting topic, however, I would recommend a few modifications before considering its publication. Below these are some suggestions for You:

1. Lines 12-15: This fragment should be deleted, as it is just a template instruction
2. Line 36: Not 80%, but almost 100% 
3. Line 59: You should first state that nearly 100% of cervical cancer cases are caused by HPV, regardless of the specific HPV types involved.
4. Line 64: Are you sure you mean "source of infection"? It seems more likely that you intended to say "source of information."
5. Lines 70-72: Regarding the section on Australia, it is worth noting the specific cervical cancer morbidity rates to provide better context.
6. Lines 72-73: The decline in HPV infection rates is a direct and expected consequence of vaccination, as the vaccine is specifically designed to prevent these infections.

Best regards and good luck

Author Response

Comment 1: Lines 12-15: This fragment should be deleted, as it is just a template instruction

Response 1: The template instruction is now deleted as advised see page 1

Comment 2: Line 36: Not 80%, but almost 100%

Response 2: Line 36 corrected- approximately 80% is deleted and replaced with "Almost 100%"

Comment 3: Line 59: You should first state that nearly 100% of cervical cancer cases are caused by HPV, regardless of the specific HPV types involved.

Response 3: Thank you for the suggestion, it is done as suggested see line 60 under introduction

Comment 4: Line 64: Are you sure you mean "source of infection"? It seems more likely that you intended to say "source of information."

Response 4: line 64 corrected to " source of information" not source of infection

Comment 5: Lines 70-72: Regarding the section on Australia, it is worth noting the specific cervical cancer morbidity rates to provide better context.

Response 5: Section on Australia has been revised to also include cervical cancer morbidity rates in order to provide better context, see line 73-81

Comment 6: Lines 72-73: The decline in HPV infection rates is a direct and expected consequence of vaccination, as the vaccine is specifically designed to prevent these infections.

Response 6: Thank you for the comment. I believe this  is just a comment to note not to address.

Reviewer 3 Report

Comments and Suggestions for Authors

Thank you for submitting this manuscript addressing strategies to improve awareness of HPV screening and vaccination among women in Limpopo Province. The topic is important and relevant to public health, particularly in low‑resource settings. However, several areas require clarification and strengthening before the manuscript can be considered for publication. My detailed comments are provided below with page and line references for ease of revision.

1. Clarify and strengthen the methodological description
- The description of the E‑Delphi method is incomplete. On Page 3, lines 91–94, the manuscript states that questionnaires were completed “in a group environment,” which contradicts the anonymity principle of Delphi studies.
- On Page 3, lines 129–136, the process of reaching consensus is described only briefly. Please specify:
- number of Delphi rounds
- how consensus was defined (e.g., ≥70% agreement)
- how feedback was provided between rounds
- how stability of responses was assessed
- These details are essential for methodological transparency.

2. Correct inconsistencies in the sampling description
- The manuscript refers to “non‑probability random sampling” (Page 3, lines 101–103), which is contradictory.
- Since the study included all 15 eligible nursing managers, this appears to be purposive sampling, not random sampling.
- Please revise the terminology and justify why the sample size is appropriate for a Delphi study.

3. Improve clarity and structure of the Results section
- The Results section is highly descriptive and repeats information already presented in Tables 1 and 2 (e.g., Page 5, lines 188–202; Page 6, lines 228–239).
- Consider summarizing key findings and reducing repetition.
- Highlight patterns or insights rather than restating percentages.

4. Ethical approval details are missing
- There is no explicit statement regarding ethics approval, IRB reference number, or informed consent procedures.
- Please add a dedicated Ethics section, as this is mandatory for studies involving human participants.

5. Improve the quality of English language and academic writing
- Several sentences are grammatically incorrect or awkwardly phrased (e.g., Pages 1-2, lines 35–53).
- Some paragraphs are overly long and lack clear transitions.
- A thorough language edit is recommended to improve clarity, flow, and academic tone.

6. Strengthen the Introduction with theoretical grounding
- The Introduction (Page 2, lines 57–88) provides background but lacks a conceptual or behavioral framework (e.g., Health Belief Model, Social Ecological Model).
- Incorporating such a framework would strengthen the rationale for the proposed strategies.

7. Improve the Highlights and Abstract sections
- The Highlights section (Page 1, lines 17–33) contains long sentences and should be more concise.
- The Abstract (Page 2, lines 44–48) should include:
- definition of consensus
- clearer description of outcomes

8. Lack of Study Limitations
- The study sample size was relatively small and lacked of external validation.

Comments on the Quality of English Language

The manuscript would benefit from substantial English language editing. Several sections contain grammatical errors, awkward phrasing, and inconsistent sentence structure that affect clarity and readability. The narrative is often repetitive, and some sentences are overly long or lack proper punctuation. A thorough professional language revision is recommended to improve flow, precision, and academic tone

Author Response

Comment 1:  Clarify and strengthen the methodological description
- The description of the E‑Delphi method is incomplete. On Page 3, lines 91–94, the manuscript states that questionnaires were completed “in a group environment,” which contradicts the anonymity principle of Delphi studies.
- On Page 3, lines 129–136, the process of reaching consensus is described only briefly. Please specify:
- number of Delphi rounds
- how consensus was defined (e.g., ≥70% agreement)
- how feedback was provided between rounds
- how stability of responses was assessed
- These details are essential for methodological transparency.

Response 1: The description of E-delphi method has been revised, see research design under material and methods. The process of reaching concensus in E-Delphi technique is now revised seen data collection procedure section.

Comment 2:  Correct inconsistencies in the sampling description
- The manuscript refers to “non‑probability random sampling” (Page 3, lines 101–103), which is contradictory.
- Since the study included all 15 eligible nursing managers, this appears to be purposive sampling, not random sampling.
- Please revise the terminology and justify why the sample size is appropriate for a Delphi study.

Response 2: The inconsistencies in the sampling section has been corrected, see under population and sampling size section.

Comment 3: Improve clarity and structure of the Results section
- The Results section is highly descriptive and repeats information already presented in Tables 1 and 2 (e.g., Page 5, lines 188–202; Page 6, lines 228–239).
- Consider summarizing key findings and reducing repetition.
- Highlight patterns or insights rather than restating percentages.

Response 3: The clarity and structure under results section has been revised as suggested, see results section

Comment 4: Ethical approval details are missing
- There is no explicit statement regarding ethics approval, IRB reference number, or informed consent procedures.
- Please add a dedicated Ethics section, as this is mandatory for studies involving human participants.

Response 4: Ethical approval details have been added, see under data collection procedure

Comment 5:  Improve the quality of English language and academic writing
- Several sentences are grammatically incorrect or awkwardly phrased (e.g., Pages 1-2, lines 35–53).
- Some paragraphs are overly long and lack clear transitions.
- A thorough language edit is recommended to improve clarity, flow, and academic tone.

Response 5: Language editing has been done. See the whole document

Comment 6: Strengthen the Introduction with theoretical grounding
- The Introduction (Page 2, lines 57–88) provides background but lacks a conceptual or behavioral framework (e.g., Health Belief Model, Social Ecological Model).
- Incorporating such a framework would strengthen the rationale for the proposed strategies.

Response 6: Paragraph added under the introduction section on Health belief model to strengthen the rationale for the proposed strategies.

 Comment 7: Improve the Highlights and Abstract sections
- The Highlights section (Page 1, lines 17–33) contains long sentences and should be more concise.
- The Abstract (Page 2, lines 44–48) should include:
- definition of consensus
- clearer description of outcomes

Response 7: Thank you for the comment on the highlights. However, I feel reducing the sentence further will lose meaning. The abstract section was revised see line 38-45. 

Comment 8: . Lack of Study Limitations
- The study sample size was relatively small and lacked of external validation.

Response 8: The relatively small sample size reflects the nature of the Delphi process used in this study, which relied on a purposively selected panel of experts rather than a large representative sample. Furthermore, the development of the strategies was informed by findings from the main study, which had a larger sample size and provided the empirical foundation. The Delphi phase was therefore used for expert validation and refinement of these strategies, which typically requires a smaller, specialised group rather than broad external validation. However, it is acknowledged that the small sample size may limit the external generalisability of the findings. see also section 2 under materials and methods.

Reviewer 4 Report

Comments and Suggestions for Authors

The manuscript reads more as a descriptive report of consensus opinions rather than a robust scientific investigation generating new knowledge. Major revisions are required across all sections.

1. Conceptual and scientific contribution is weak - the central claim is that the study “develops strategies” to improve HPV awareness. However, the strategies presented are generic, already well-established public health practices (e.g., education campaigns, media use, curriculum integration). There is no clear novelty, innovation, or theoretical contribution. The manuscript does not demonstrate how these strategies differ from existing WHO or national HPV frameworks.

Suggestions to authors: clearly define what is new about your contribution. Situate your strategies within existing frameworks (WHO, South African DoH, implementation science models).Explicitly state: What gap does this study fill that prior literature has not?

2. Misapplication and poor justification of the E-Delphi method - the use of the E-Delphi method is conceptually weak and poorly executed. The sample size (n = 15) is very small and homogeneous (only nursing managers). There is no justification for expert selection beyond convenience. The process violates core Delphi principles, including lack of true anonymity (group-based responses were shared openly) and no iterative refinement of ideas (participants did not generate strategies—only rated pre-defined ones). No clear definition of “consensus” threshold is provided.

Suggestions to authors: justify why Delphi is appropriate for this research question. Define consensus criteria (e.g., ≥70% agreement) explicitly. Clarify how strategies were initially generated, whether experts could modify or propose alternatives and consider reframing the study as a “structured expert opinion survey” rather than a Delphi study.

3. Methodological inconsistency and lack of transparency - there are serious internal contradictions: the study claims to be quantitative, yet also states it is part of a mixed-methods project without presenting qualitative data. It claims strategies are derived from “triangulation,” but no triangulated data are shown. Also, the questionnaire is not provided or described in sufficient detail.

Suggestions to authors: clearly define the study design - is this Delphi, survey, or mixed-methods? Provide full questionnaire (appendix), development process of items and remove claims of triangulation unless actual qualitative findings are presented.

4. Superficial data analysis - the analysis is extremely basic and insufficient for publication. Only frequencies and percentages are used, no measures of consensus (e.g., IQR, Kendall’s W), reliability testing or comparative analysis between rounds. The “results” simply restate percentages without interpretation.

Suggestions to authors: incorporate Delphi-specific statistical measures such as Kendall’s coefficient of concordance (W) and interquartile ranges (IR).  Provide analytical interpretation, not just descriptive repetition. Explain why consensus changed between rounds.

5. Results lack depth and critical insight - the results are mechanical and repetitive, each strategy is described in the same format (percentages of agreement). There is no prioritization, ranking, or weighting of strategies. There is no attempt to identify most impactful strategies, feasibility constraints or context-specific barriers.

Suggestions to authors: rank strategies based on importance, feasibility and expected impact. Provide comparative insights (e.g., which strategies gained strongest consensus and why).

6. Discussion is descriptive, not analytical - the discussion section merely restates general knowledge about HPV. It does not engage critically with study findings, local context (Limpopo Province) or implementation barriers. References are used to justify obvious statements, not to deepen analysis.

Suggestions to authors: Shift from description → interpretation: why did experts prefer certain strategies? what does this reveal about the health system?

Integrate implementation science frameworks (e.g., RE-AIM, CFIR).

7. Serious language and academic writing issues - the manuscript contains frequent grammatical, structural, and stylistic errors such as redundancy and repetition (e.g., “strongly supported… strongly agreed…” repeated excessively), inconsistent terminology (HPV, Human Papilloma Virus) or informal phrasing and awkward sentence construction.

Suggestions to authors: undertake professional academic editing, use precise, concise language and avoid repetition of numerical descriptions.

8. Ethical and reporting concerns - the claim of anonymity is questionable given group-based Delphi interaction. The use of AI (ChatGPT) is disclosed but not clearly bounded in scope. 

Suggestions to authors: Please clarify how anonymity was preserved in practice and the exact role of AI tools in manuscript preparation.

9. Keywords are too generic and not optimized.
10. Tables are overly dense and repetitive (Tables 2 & 3).
11. Inconsistent formatting (e.g., headings, capitalization).
12. Missing limitations section (critical omission).
13. The manuscript relies on a notably limited number of references to support broad and well-established claims. This lack of adequate citation undermines the academic rigor of the work and raises concerns regarding the depth of the literature review. The authors should substantially expand their engagement with relevant and recent studies, particularly in the areas of HPV awareness interventions and vaccination uptake.

The manuscript has potential due to its important topic and local relevance, but it currently lacks methodological rigor, analytical depth and conceptual originality. Substantial restructuring and strengthening are necessary before it can be considered for publication.

 

Author Response

The authors sincerely appreciate the reviewers’ insightful and constructive comments, which have contributed to strengthening the methodological clarity, analytical depth, and overall quality of the manuscript.

Comment 1: Suggestions to authors: Clearly define what is new about your contribution. Situate your strategies within existing frameworks (WHO, South African DoH, implementation science models). Explicitly state: What gap does this study fill that prior literature has not?

Response 1: A paragraph has been added at the end of the introduction and 2 paragraphs under the discussion section, in the beginning of section 4 (discussion), addressing the first comment.

Comment 2: Suggestions to authors: justify why Delphi is appropriate for this research question. Define consensus criteria (e.g., ≥70% agreement) explicitly. Clarify how strategies were initially generated, whether experts could modify or propose alternatives and consider reframing the study as a “structured expert opinion survey” rather than a Delphi study.

Response 2: See 2nd paragraph under study design, justifying how Delphi is appropriate for this study. Consensus was defined under the data collection procedure, see the second paragraph. see first paragraph under research design on how strategies were generated. it is explained at the end of 1st paragraph under data collection procedure whether experts were allowed to modify or give outputs. 

Comment 3: Suggestions to authors: clearly define the study design - is this Delphi, survey, or mixed-methods? Provide full questionnaire (appendix), development process of items and remove claims of triangulation unless actual qualitative findings are presented.

Response 3: A clear study definition has been provided, see under Research Design. Quetionnare used has beed attached at the end of the manuscript.

Comment 4: Suggestions to authors: incorporate Delphi-specific statistical measures such as Kendall’s coefficient of concordance (W) and interquartile ranges (IR).  Provide analytical interpretation, not just descriptive repetition. Explain why consensus changed between rounds.

Response 4: Thank you for this comment. We have clarified the analysis of consensus in the manuscript. Due to limited variability in responses (ceiling effect), Kendall’s W was not informative in this case. However, consensus was determined using established Delphi criteria, including high levels of agreement, low dispersion of responses, and consistent endorsement of all proposed strategies. This clarification has been added to the Results sections.

Comment 5: Suggestions to authors: rank strategies based on importance, feasibility and expected impact. Provide comparative insights (e.g., which strategies gained the strongest consensus and why).

Response 5: See 2 paragraphs added under table 3 addressing suggestion 5 from the reviewer

Comment 6: Suggestions to authors: Shift from description → interpretation: why did experts prefer certain strategies? what does this reveal about the health system? Integrate implementation science frameworks (e.g., RE-AIM, CFIR).

Response 6: Strong interpretation of the discussion section has been provided and also integrating it with HBM.

Comment 7: Suggestions to authors: undertake professional academic editing, use precise, concise language and avoid repetition of numerical descriptions.

Response 7: Proofreading has been done, see the whole document. And repetition of numbers under the results section has been minimised

Comment 8: Suggestions to authors: Please clarify how anonymity was preserved in practice and the exact role of AI tools in manuscript preparation.

Response 8: See second paragraph 2.6 (data collection procedure) addressing ethical and reporting concerns. See the revised AI disclosure statement before the reference list.

Comment 9: Keywords are too generic and not optimized.

Response 9 : Keywords has been improved

Comment 10: Tables are overly dense and repetitive (Tables 2 & 3).

Response 10: Repetative information in the text has been reduced since same numbers appear in the tables, see results section

Comment 11: Inconsistent formatting (e.g., headings, capitalization).

Response 11: I couldn't  locate this but most of the formating was done during proofreading

Comment 12: Missing limitations section (critical omission).

Response 12: Limitation section have been added before conclusion section

Comment 13: The manuscript relies on a notably limited number of references to support broad and well-established claims. This lack of adequate citation undermines the academic rigor of the work and raises concerns regarding the depth of the literature review. The authors should substantially expand their engagement with relevant and recent studies, particularly in the areas of HPV awareness interventions and vaccination uptake.

Responses 13: More sources or literature have been added, see the discussion section

 

Round 2

Reviewer 1 Report

Comments and Suggestions for Authors

Authors have thoroughly addressed the comments and provided additional information

Comments on the Quality of English Language

Quality of writing - Can be improved

Author Response

Thank you for the comment

Reviewer 3 Report

Comments and Suggestions for Authors

The manuscript now meets IJERPH standards for:
- Relevance to public health
- Methodological appropriateness
- Clarity of reporting
- Contribution to practice and policy
- Ethical compliance

Remaining Minor Issues：
These do not affect scientific validity but should be corrected before publication:
2.1. Language and Grammar
Several sentences remain lengthy or repetitive. A light professional language edit would improve clarity.
Examples:
- “This study forms part of a larger research project conducted in two distinct phases: qualitative and quantitative .. .”  (Page 5; Line 211)
- Some paragraphs contain minor spacing or punctuation inconsistencies.
2.2. Formatting
- Ensure consistent use of percentages (e.g., “73.3%” vs “73.3 %”).
2.3. Clarify One Statistical Point
- The manuscript states that HPV screening coverage was “2055.5%” in 2017/2018 (Page 2; Line 83). This appears to be a typographical or data extraction error and should be corrected or explained. 
2.4. Minor Structural Refinements
- The transition between Round 1 and Round 2 results could be more concise.
- The Conclusion could briefly restate the practical implications for policymakers and PHC managers.

Comments on the Quality of English Language

The overall English has improved compared with the previous version; however, several sections would still benefit from light editorial refinement. Minor issues remain with sentence structure, grammar, spacing, and occasional repetition. Some long sentences could be shortened for clarity, and a few typographical inconsistencies (e.g., percentages, formatting artifacts) should be corrected. A final language edit is recommended to enhance readability and ensure smooth academic flow.

Author Response

Comment 1:  Language and Grammar
Several sentences remain lengthy or repetitive. A light professional language edit would improve clarity.
Examples:
- “This study forms part of a larger research project conducted in two distinct phases: qualitative and quantitative .. .”  (Page 5; Line 211)
- Some paragraphs contain minor spacing or punctuation inconsistencies.

Response 1: The authors tried to work on the language and grammar. However, more language editing will be done once the manuscript is accepted. 

Comment 2:  Formatting
- Ensure consistent use of percentages (e.g., “73.3%” vs “73.3 %”).

Response 2: See comment above

Comment 3: Clarify One Statistical Point
- The manuscript states that HPV screening coverage was “2055.5%” in 2017/2018 (Page 2; Line 83). This appears to be a typographical or data extraction error and should be corrected or explained. 

Response 3: Typo error has been rectified, see introduction section

Comment 4: Minor Structural Refinements
- The transition between Round 1 and Round 2 results could be more concise.
- The Conclusion could briefly restate the practical implications for policymakers and PHC managers.

Response 4: Transitioning paragraphs from round 1 to 2 has been revised, see results section. The conclusion has been revised; see the conclusion section.

Reviewer 4 Report

Comments and Suggestions for Authors

The batch is too small to have substantial statistical significance.

Author Response

Thank you for the valuable comments/suggestion, which really helped to improve my manuscript.

Please note that the authors tried to work on the Language and grammar of the manuscript. However, more proofreading will be done once the manuscript is accepted, as per advise from the editor.

Comment 1: The batch is too small to have substantial statistical significance.

Response 1: Authors have acknowledge the smaller sample and justification has been provided see material and methods section and sampling section