A Scoping Review of Influences on HPV Vaccine Uptake in the Rural US^†

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

Major Issues

1. Title Revision Required

• The current title is ambiguous. It does not explicitly refer to the HPV vaccine and might be misinterpreted as a study about HPV infection itself.

• Recommendation: Revise the title to clearly indicate the study design (scoping review), the setting (rural U.S.), and the focus on HPV vaccine uptake rather than HPV infection.

2. Abstract – Conceptual Ambiguity and Reporting Gaps

• The abstract lacks a clearly stated research question and uses “vaccine hesitancy” and “vaccine uptake” interchangeably, which is conceptually inaccurate. Hesitancy refers to attitudes or intentions, while uptake refers to actual vaccination behaviour.

• There is confusion about whether the review’s purpose is to identify predictors and determinants (Line 20) or to evaluate multi-component interventions (Lines 26 and 30).

• The abstract omits critical methodological details, including database names, coverage dates, and inclusion criteria.

• Recommendation: Clearly define the scope and objective of the review in the abstract, specify whether it focuses on uptake or hesitancy, and include essential methodological details (databases searched and date ranges).

3. Introduction – Background and Justification Gaps

• HPV is introduced without definition or contextualisation. Spell out “human papillomavirus” at first mention and clearly distinguish between infection and vaccination.

• The rationale for the review would benefit from data comparing urban vs. rural HPV vaccine coverage in the U.S. This would support the argument for rural-focused interventions.

• Consider including a temporal analysis of pre- vs. post-COVID-19 pandemic findings, as the pandemic significantly disrupted immunisation programmes.

• The previously cited reviews (e.g. reference 44) are mentioned as insufficient, but their specific limitations are not clearly articulated.

• Recommendation: Enhance the introduction with relevant epidemiological context and strengthen the justification by clarifying the gaps in prior reviews.

4. Methods – Methodological Transparency and Reporting

• The review lacks a clear and explicit research question, and the primary and secondary objectives are not stated.

• The manuscript should adhere more closely to the JBI Manual for Evidence Synthesis for scoping reviews. This guideline should be cited and used to structure the Methods section.

  • JBI Manual for Evidence Synthesis – Scoping Reviews

• The review protocol was not prospectively registered or published, which is a missed opportunity for transparency. If a protocol was not used, this should be acknowledged and justified.

• The search strategy was not included in a supplementary file as promised. Additionally, coverage dates for the database search are absent and should be reported clearly.

• Line 151: The simultaneous use of Distiller and Covidence for screening is not justified. The authors should explain the rationale for using two platforms and address potential concerns regarding consistency or duplication.

• Recommendation: Revise the Methods to include the protocol status, search date range, detailed search strategies (uploaded as supplementary), and alignment with JBI guidelines.

5. Results – Descriptive, Not Analytical

• While the volume of studies reviewed is commendable, the findings are largely descriptive, lacking analytical synthesis across levels (e.g. individual, organisational, community).

• Tables 4 and 5 are overly dense and could be formatted more clearly with thematic subheadings.

• A thematic visual summary (e.g. logic model or influence map) is missing but would aid interpretation.

• The authors note a lack of policy-level interventions but miss an opportunity to hypothesise or discuss what these could entail.

• Recommendation: Enhance the results with a synthesised thematic summary (visual or narrative), reformat key tables for readability, and expand discussion on potential or emerging policy-level strategies.

6. Absence of Quality Appraisal and Justification

• Although quality appraisal is not mandatory in scoping reviews, the authors should explicitly acknowledge its omission and provide a rationale.

• Recommendation: Include a brief justification in the Methods and a statement in the limitations regarding this decision.

Minor Issues

1. Terminology Consistency

• Key concepts such as “vaccine uptake,” “hesitancy,” “completion,” and “initiation” are used inconsistently.

• Recommendation: Define all outcome variables clearly at the beginning and maintain consistent usage throughout.

2. Language and Grammar

• Minor grammar and phrasing issues are scattered throughout the manuscript (e.g. redundancy, inconsistent tenses).

• Recommendation: A thorough language edit is advised to improve readability and flow.

3. Redundant Intervention Descriptions

• Several intervention features (e.g. reminder-recall, provider training) are repeated across sections.

• Recommendation: Consolidate similar interventions under thematic headings and avoid duplication.

4. Missing Appendices and Supplementary Files

• • No appendices were uploaded, despite references to supplementary materials containing the search strategy and full list of studies.

  • Recommendation: Upload all relevant supplementary materials, including:

    • Full search strategy

    • List of included and excluded studies

    • STROBE or PRISMA-ScR checklist

Author Response

Please find our response attached.

Author Response File: Author Response.docx

Reviewer 2 Report

Comments and Suggestions for Authors

Overall Assessment
This article is a comprehensive scoping review on the factors influencing
HPV vaccine uptake in rural areas of the United States. The study
systematically reviewed relevant literature over the past 13 years,
employing a multi-level analytical framework to explore the impact of
various factors on HPV vaccine uptake, ranging from individual to policy
levels. The findings provide deep insights into the lower vaccination rates
in rural areas and offer valuable references for future public health
practices and policy-making.However, this study needs to make
improvements in terms of logical structure, methodological clarity and
presentation.
Major Comments
Introduction
1.The first paragraph (lines 40–43) presents some logical inconsistencies.
While the manuscript notes that the definition of “ rural ” varies across
studies, it does not clearly specify the definition adopted in this review,
leaving ambiguity around the inclusion criteria.
2.Moreover, the literature review appears fragmented and lacks coherence.

A more structured presentation of prior studies is needed to highlight
existing gaps and justify the necessity of this review.

Results
1.In the section on multi-level interventions, only four studies are
mentioned, and the conclusion that these interventions are effective may
lack sufficient empirical support, considering the small sample size and
limited description of the intervention content and outcomes.
2.In addition, while the paper aims to explore factors influencing HPV
vaccine uptake in rural U.S. populations, these factors are not clearly
presented in the results section. They are only partially addressed in the
discussion. A structured summary in the results section would enhance
clarity and comprehensiveness.
Discussion
Although 101 studies were included, each subtopic is supported by
relatively few studies. It would strengthen the discussion to include a
detailed limitations section, addressing sample sizes, geographic scope,
and heterogeneity in study designs.
Conclusion
The manuscript currently lacks a standalone conclusion section. A
dedicated conclusion is important to summarize the key findings,
highlight their practical and policy implications, and suggest directions
for future research. Including such a section would greatly enhance the clarity and completeness of the paper.
Finally, there are several noticeable formatting issues throughout the
manuscript, including inconsistencies in the body text and figures/tables.
These formatting problems hinder readability and should be carefully
revised to ensure a clear and professional presentation.

Recommendation: Major Revisions

 

Author Response

Please find our response attached.

Author Response File: Author Response.docx

Reviewer 3 Report

Comments and Suggestions for Authors

The authors reviewed empirical studies published between 2010-2023 in English about the multilevel  influences on HPV vaccine hesitancy in US rural communities. The title looks like that the author intended to target the associated factors of HPV vaccine hesitancy in US rural communities, while the review focused on  precise intervention approaches to increase HPV vaccine uptake. There is a need to adjust the title in order to better reflect the real contents of the review.

Why the authors targeted US rural communities? how did "US rural community" was defined? Are there huge discrepancies of HPV vaccination hesitance between US rural and urban communities? If there are discrepancies, I think that exist among populations in different races, education background, faiths, etc. Why not included studies before 2010，which lost 4 years since the first HPV vaccine was marketed in the US in 2006. All these should be more clearly discussed and defined, in order for the readers to understand the added value of this scoping review.

There is no access of the search strategies used in multiple database. Based on the main text,  the key search terms included HPV, virus, vaccination, measures, rural. I cannot understand why "measures" was part of the search terms?  How did the authors targeted studies focused on the US rural communities? The authors only included empirical studies, are there any existing systematic reviews about the multilevel interventions on HPV vaccination hesitance in US which included both the rural and the urban communities? Did the authors checked the excluded reviews about this? And if yes, there is a need to further check if the reference list of those reviews included studies that were missed? Figure 1 should disclose more detailed information about how the initially identified studies were excluded step by step. 

The presentation and format of Tables do not follow the common principle adopted by most academic journals, and some critical information about the included studies were presented in the supplementary files, which should be moved to the main text. 

Author Response

Please find our response attached.

Author Response File: Author Response.docx

Reviewer 4 Report

Comments and Suggestions for Authors

To enhance the manuscript's impact and clarity, the authors should consider expanding the theoretical analysis to provide more mechanistic insights into why certain interventions succeed or fail in rural contexts. The geographic analysis could be strengthened by discussing how regional cultural, economic, and healthcare system differences might influence intervention effectiveness.

The intervention recommendations should be more specific and actionable, perhaps organized by implementation level (clinic, community, policy) with concrete examples of successful strategies. The authors could also benefit from discussing implementation science frameworks that might guide future intervention development and evaluation.

For improved readability, consider restructuring some complex sentences, reducing passive voice usage, and ensuring each paragraph has a clear central theme. The extensive data presentation could be made more accessible through strategic use of summary statements and clearer transitions between different types of findings.

Author Response

Please find our response attached.

Author Response File: Author Response.docx

Reviewer 5 Report

Comments and Suggestions for Authors

• Line 24: Specify the start and end year of the considered period.
• Line 46: The reference No. 1 cited here to back up the claim that the HPV vaccination rates are increasing in the USA leads to the part of webpage about HPV vaccine effectiveness. There is no data on the trends in HPV vaccine uptake in the USA here - thus, an appropriate reference must be provided.
• Lines 47-48: Cite a reference for the stated percentage of 58.5%. 
• Lines 98-107: Provide a clear and coherent definition of multi-level targets in multi-level strategies, given that this is an important focus and is presented as an advantage of your study. 
• Methods: Only Appendix B was available for download, so it was not possible to assess the appropriateness of reporting the search strings used in each searched database, alongside with the number of this. 
• Lines 120-121: Does this about MeSH terms refer to Pubmed only?
• Line 120: The word "School" is redundant here. 
• Lines 131-132: How come this updated search used SIMILAR and not the same search terms?
• Lines 137-138: Does this mean that the additional search yielded no studies for inclusion, given that you already had 101 studies prior to the new search.
• Search strategy: This paragraph lacks a clear and explicit description of the time frame considered by the search. Also, when the searches were conducted needs to be stated. 
• Eligibility criteria should state the study design that was considered for inclusion. 
• Methods: Was this review registered (i.e. its protocol)?
• Line 169: State which descriptive statistics methods.
• Methods: How did you check and ensure that two or more studies did not report outcomes on the same population?
• Line 175: Revise - you reviewed a lot more studies, and these were considered for eligibility. 
• Figure 1: Were references of systematic reviews checked?
• Table 1: Since you stated that HPV uptake was the considered outcome of this review, how did you assess it from qualitative studies? Did these report HPV uptake estimates?
• Table 1: Second and third columns can be combined into one - Number (Percent). 
• Table 1: Are adults 18 and over or 18 up to 26 as mentioned in the text?
• Results: Avoid extensively repeating in the text what is presented on the tables, rather provide a coherent logical summary of the most relevant observations. 
• Lines 292-293: Looking at the years of when these studies were published - it would be important to cautiously interpret the length of observed period that allowed a comprehensive assessment of the impact of the COVID-19 pandemic. 
• Tables 5 and 6: This table is hard to read and does not seem informative in its current form. 
• Lines 395-407: There are claims that need to be backed up by citing references. 
• Discussion: This section lacks a critical comparison with other conducted reviews (to the extent possible due to different scope), more detailed explanations for findings, a paragraph on limitations, and clear conclusions. 

Author Response

Please find our response attached.

Author Response File: Author Response.docx

Round 2

Reviewer 1 Report

Comments and Suggestions for Authors

Thank you for your meticulous revision. The manuscript’s presentation has improved significantly.

Author Response

Thank you very much for your positive review. 

Reviewer 3 Report

Comments and Suggestions for Authors

The revisions are satified.

Author Response

Thank you very much for your positive review. 

Reviewer 5 Report

Comments and Suggestions for Authors

I would like to thank the Authors for revising their text. It was not fully straightforward to appreciate all changes, because the response letter did not indicate where and on which lines cn the changes be seen, and the text did not use track changes and not all changes were marked in blue as mentioned. The revised paper represents an improvement compared to the orginal submission. 

• Line 26: The time frame considered is still vague. Revise to be precise. The revised Methods section now states this well. 
• Lines 45-46: I did not question the appropriateness of reference per se - what I stated was, and it still remains an issue left unaddressed by the authors, the statement "While HPV
  vaccination rates are increasing in the US (1)" - is simply nowhere to be seen when you access and read Ref. No. 1.
• Line 51: Check the cited references - 12 appears twice.
• Line 174: This name of section should go after data analysis subsection.
• Regarding the response to my question on whether references of systematic reviews were checked - what I asked was whether the so-called snowballing method of search was used. The papers on those references lists are not necessarily outside of the 7 searche databases but are sometimes missed by the search strategy no matter how rigorous it was.
• Regarding your response to my question how (and whether) HPV vaccine uptake was reported in qualitative studies - responding that you considered primary studies is not clear, as "primary" study is not the opposite or antonym of "qualitative" study.
• Lines 394-395: Reference to the mentioned recommendations is needed. 
• Thank for supplying the Appendix. When looking at search strings, there are phrases for considering papers between 2023 and 2025 - clarify how this relates to the considered period of 2010-2023. And that for a search done at the beginning of 2024.
• For the earliest conducted searches - there is no date for consideration. Technically, this could have included studies from when vaccine was introduced not only from 2010.

Author Response

Please see the attached. 

Author Response File: Author Response.docx

Round 3

Reviewer 5 Report

Comments and Suggestions for Authors

Since in the two rounds of responses the meaning of my initial question about qualitative studies got lost and somehow mixed up - I went back and checked what Authors reported as qualitative studies. For example, and this is simply after checking a few while the Authors should check all, the study cited as Ref. No. 75 is listed in Table 1 as qualitative study - and it is not a qualitative study. The Authors should double check and revise the results for correctness.

Similarly - Appendix lists Ref. No. 38 as a qualitative study, but Table 1 does not even include it. Further on, text of the paper on line 182 does not include e.g. Ref. No. 37 which is cited in Table 1. All of these inconsistencies need to be corrected, the text and resuslts aligned and everything checked for correctness. Further, check how Ref. No. 78 is described in Appendix and how in Table 1 of manuscript. 

As for the question of search dates in the search strings - I appreciate your response, although it is unnecessarily vague both in the response and in the text - it is usual and simple to state that the considered period is from which date to which date, while the search itself was conducted on this date. This could have been made much more clear than in the respone - especially since you still have a search said to be done in 2024 while the search string itself states mid-2023, as does the text.

Author Response

Thank you again for your very helpful suggestions. The paper is much improved by these revisions.

Since in the two rounds of responses the meaning of my initial question about qualitative studies got lost and somehow mixed up - I went back and checked what Authors reported as qualitative studies. For example, and this is simply after checking a few while the Authors should check all, the study cited as Ref. No. 75 is listed in Table 1 as qualitative study - and it is not a qualitative study. The Authors should double check and revise the results for correctness.

Response: In response to the reviewer’s important comment, we have reviewed the qualitative studies, including reference 75, that is more accurately listed as a cross-sectional study on Table 1 and throughout the paper. We have made some additional revisions that were due to a transposition of some of the reference numbers in this revision. Two members of the team have verified the accuracy of the citations for all of these papers.

Similarly - Appendix lists Ref. No. 38 as a qualitative study, but Table 1 does not even include it. Further on, text of the paper on line 182 does not include e.g. Ref. No. 37 which is cited in Table 1. All of these inconsistencies need to be corrected, the text and resuslts aligned and everything checked for correctness. Further, check how Ref. No. 78 is described in Appendix and how in Table 1 of manuscript. 

Response: Thanks to the reviewer’s additional suggestions about the citations, we have reviewed all of the citations, references, and appendixes in the paper. Regarding reference 38, it is included in Table 1, as the qualitative method is described by the authors as:  “…a thematic analysis of transcripts.” Reference 37 is included in the 101 reviewed studies cited on line 182. Reference 37 is not found on Table 1 as several studies by this author group included the same population, method, and time frame. The findings from these studies are included separately on Table 5, where relevant, however. Reference 78 remains on Table 1 as “a descriptive qualitative design.” Again, we appreciate your third review of the paper and your additional comments. Two members of the team have verified the accuracy of the citations for all of the papers, and the consonance of citations throughout.

As for the question of search dates in the search strings - I appreciate your response, although it is unnecessarily vague both in the response and in the text - it is usual and simple to state that the considered period is from which date to which date, while the search itself was conducted on this date. This could have been made much more clear than in the respone - especially since you still have a search said to be done in 2024 while the search string itself states mid-2023, as does the text.

Response: We appreciate the reviewer’s interest in additional clarity of the search strategy. We have further revised the description of the search in Appendix A given the reviewer’s request. We provide the dates of the review several times in the paper, including in the revised abstract, as well as the actual searches and their specific terms in Appendix A. The informaticist did, in fact, run a search in January, 2024, to capture any articles that were published in late 2023. According to our expert informaticist, it is conventional practice to list all of the searches that were conducted by date. Thus, we have retained this date in the description of the search for accuracy and completeness.

 

Author Response File: Author Response.docx