Review Reports

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

Dear Authors,
Thank you for submitting your manuscript. While the topic is important, the work requires significant revisions to address shortcomings. The manuscript frequently substitutes evidence with unsupported assertions such as addressing "Cultural and social norms may also present a barrier" which cites outdated sources. Similarly, claims about dentists’ potential role lack empirical evidence and needs citations. Moreover, the ongoing study section is vague and no methodology is provided. The claim that cultural and social norms present a barrier relies on an old US study not related to UK cultural contexts (stating some community as more religious communities without references). Some references such as reference number 15 is not a peer-reviewed source and should be replaced. 

Best Regards,

Author Response

Peer Reviewer 1

Dear reviewer,

We would like to express our sincere thanks and appreciation for your comments and feedback. We have revised the manuscript accordingly and provided a response to each of your comments below.

Feedback from peer reviewer 1

Reviewer Comment: The manuscript frequently substitutes evidence with unsupported assertions such as addressing "Cultural and social norms may also present a barrier" which cites outdated sources.

Author response: We thank the reviewer for this comment. We have gone through the manuscript and included more citations and those published within the last 5-10 years where possible which directly support the claims made throughout the manuscript.

Reviewer Comment: Similarly, claims about dentists’ potential role lack empirical evidence and needs citations.

Author response: We have added additional citations to strengthen the empirical evidence provided in this section – including the work of Lipsky et al. (2025) and Brunton et al. (2025). Please see lines 280-286.

Reviewer Comment: Moreover, the ongoing study section is vague, and no methodology is provided.

Author response: We apologise for this. We have added more detail with respect to the study proposed including methodological design. Please see lines 301-310.

Reviewer Comment: The claim that cultural and social norms present a barrier relies on an old US study not related to UK cultural contexts (stating some community as more religious communities without references).

Author response: We have modified this accordingly and made direct reference to a recently published study which highlights concerns about HPV vaccination among vaccine-hesitant parents in England (London). Please see lines 142-151.

Reviewer Comment: Some references such as reference number 15 is not a peer-reviewed source and should be replaced. 

Author response: Reference 15 refers to information published by The Eve Appeal, the UK’s leading gynaecological cancer charity. While this is not a peer-reviewed journal article, it represents an authoritative and trusted source of information widely used in clinical practice, public health communication, and policy guidance. Given the lack of equivalent peer-reviewed data in this specific area, we consider it an appropriate and relevant source to include. We respectfully wish to retain this but understand the reviewer’s initial concern.

Reviewer 2 Report

Comments and Suggestions for Authors

General Comments

This manuscript provides a timely and well-argued commentary on the gender disparities in HPV vaccination uptake in England. It examines historical, social, and systemic barriers that prevent equal access for boys and makes evidence-informed recommendations for a more inclusive and equitable vaccination approach. The paper is relevant, well-organized, and highly readable, with a strong grounding in UK-specific policy and data.

 

However, as a commentary-style article, it would benefit from greater conceptual clarity in a few sections, stronger critical engagement with existing literature, and refinements to language and structure. The inclusion of the authors' ongoing research is a strength, but its methodology and intended contribution need clearer articulation.

 

Strengths

Highly relevant public health issue, well contextualized within the UK’s HPV policy landscape.

 

Integration of recent data (2023–2025) makes the commentary current and policy-relevant.

 

Clear, multi-level recommendations addressing policy, delivery systems, healthcare professionals, and research gaps.

 

Strong referencing and citation of peer-reviewed and government sources.

 

Highlights gender equity and social determinants of health clearly, with implications for underserved groups.

 

Major Issues to Address

Limited Critical Depth in Some Sections

 

While the manuscript acknowledges barriers to vaccination, some of the discussion remains descriptive rather than analytical.

 

For example, cultural norms and parental beliefs are presented, but not linked clearly to potential intervention strategies beyond generalized messaging.

 

Suggestion: Incorporate health behavior theories (e.g., Health Belief Model, Theory of Planned Behavior) to ground proposed solutions.

 

Clarify the Contribution of Ongoing Research

 

The brief mention of ongoing research (Section 6) is too vague to be meaningful:

 

What methodology is being used?

 

What is the sample population and recruitment approach?

 

How does it intend to fill the stated evidence gap?

 

Suggestion: Add 2–3 sentences with more detail or omit if not yet ready to report.

 

Conflation of Commentary and Research Paper Format

 

The article uses a commentary voice, but includes formal subsections, reference formatting, and structured abstract like a research paper.

 

Suggestion: Consider whether this is intended as a "Perspective" or "Commentary" for the journal – adjust formatting and expectations accordingly.

 

Unequal Emphasis on Stakeholders

 

The role of schools and school staff is well developed. However, the perspectives of adolescents themselves are not sufficiently included.

 

Suggestion: Include more evidence or examples of adolescent-led campaigns, peer education, or youth feedback on HPV programs.

 

Minor Issues

Language and Grammar:

 

Line 14: "persistent gender and regional disparities" → Suggest: "persistent disparities by gender and region"

 

Line 25: "key public health strategy" → Consider specifying primary prevention strategy.

 

Line 137: "encourage their son(s) to be sexually active..." – Consider rephrasing for tone sensitivity, e.g., "concerns that the vaccine may signal sexual readiness".

 

Figure/Table Suggestion:

 

Although the manuscript is text-heavy, a summary table of barriers vs. proposed solutions would improve accessibility.

 

Reference Duplication:

 

Some recent references (e.g., #5 and #6) are cited frequently and might be used more selectively with synthesized insights.

Comments on the Quality of English Language

Abstract

• Original: “To realise the potential of HPV vaccination as a key public health strategy, uptake must be high and equitable.”

  • Issue: Slightly awkward; “realise the potential” is vague.

  • Suggested: “Maximising the public health impact of HPV vaccination requires high and equitable uptake.”

• Original: “Despite policy changes towards gender-neutral vaccination in England, persistent gender and regional disparities remain.”

  • Suggested: “Despite a shift toward gender-neutral vaccination policy in England, disparities by gender and region persist.”

Introduction

• Original: “This initiative aimed to reduce cervical cancer burden by immunising girls against HPV.”

  • Suggested: “...aimed to reduce the burden of cervical cancer through HPV immunisation of girls.”

• Original: “...leaving boys vulnerable to HPV-associated conditions including genital warts, anal, oral and penile cancers.”

  • Suggested: Add commas for clarity: “...including genital warts, anal, oral, and penile cancers.”

Barriers to Uptake

• Original: “...boys are less likely to be targeted by public health messaging...”

  • Consider rephrasing for precision: “...boys are less frequently targeted by HPV-related public health campaigns...”

• Original: “...because of false beliefs that the vaccine is only for girls.”

  • Slightly informal. Suggested: “...due to misconceptions that the vaccine is intended exclusively for girls.”

• Original: “Parents might also feel uncomfortable...”

  • Tone: This could be made more professional. Suggested: “Some parents may express discomfort...”

Social Norms and Misconceptions

• Original: “...fear that encouraging their son(s) to get vaccinated implies endorsing sexual activity.”

  • Suggested: “...due to concerns that HPV vaccination may be perceived as condoning early sexual activity.”

• Original: “...particularly in households with strong religious or cultural values.”

  • Suggested: “...especially among families guided by strong religious or cultural beliefs.”

Systemic and Structural Issues

• Original: “There are also gaps in training and confidence among healthcare professionals...”

  • Suggested: “Training and confidence gaps among healthcare professionals further limit engagement with boys and their families.”

Recommendations

• Original: “Addressing misconceptions requires clear and consistent messaging that vaccination protects against cancer, regardless of gender.”

  • Suggested: “Addressing misconceptions requires clear, consistent messaging that emphasizes HPV vaccination as cancer prevention for all genders.”

Ongoing Research Section

• Original: “Our ongoing research seeks to identify knowledge, attitudes, and behavioural drivers...”

  • Slightly vague. Consider specifying methods or populations: “We are conducting qualitative research to explore knowledge, attitudes, and behavioral drivers of HPV vaccine uptake among parents of adolescent boys.”

Author Response

Peer Reviewer 2

Dear reviewer, firstly, we would just like to extend a huge thank you for your thorough review and feedback. As first author, I would also like to thank you for highlighting the strengths of the manuscript. Some of the co-authors who contributed to this commentary are undergraduate and postgraduate students, and therefore, highlighting the strengths and providing constructive criticism really helps to improve their confidence in navigating the publication process and their contributions to the manuscript. I am appreciative of this – and extend my sincere thanks once again. Please see below for our replies.

Reviewer Comment: While the manuscript acknowledges barriers to vaccination, some of the discussion remains descriptive rather than analytical. For example, cultural norms and parental beliefs are presented, but not linked clearly to potential intervention strategies beyond generalized messaging. Suggestion: Incorporate health behaviour theories (e.g., Health Belief Model, Theory of Planned Behaviour) to ground proposed solutions.

Author response:

We agree with the reviewer and have made several changes to address the above. Firstly, we have added a paragraph which explicitly maps the barriers discussed to the Health Belief Model (HBM) and the Theory of Planned Behavior (TPB), thereby providing an analytical lens for understanding why HPV vaccination for boys is often deprioritised. Please see lines 153 – 164.

We then re-visit both models later, where we have included a new sub-section entitled “Embed behavioural theory in intervention design”. This section translates the identified barriers into theory-informed recommendations, showing how constructs from the HBM (e.g., perceived susceptibility, benefits, barriers, cues to action, self-efficacy) and TPB (e.g., attitudes, subjective norms, perceived behavioural control) can be targeted through specific interventions. These additions ensure that our discussion moves beyond description to provide clear, theory-grounded implications for policy and practice. Please see lines 378 – 394.

Reviewer Comment: Clarify the Contribution of Ongoing Research

The brief mention of ongoing research (Section 6) is too vague to be meaningful:

What methodology is being used?

What is the sample population and recruitment approach?

How does it intend to fill the stated evidence gap?

Suggestion: Add 2–3 sentences with more detail or omit if not yet ready to report.

Author response: We thank the reviewer for these comments and agree that additional detail was required. We have expanded the description of our ongoing study to specify the methodology (cross-sectional questionnaire design), the target population (parents of boys aged 9–12 in England), and the recruitment approach (via schools and online platforms). We also outline the key psychosocial and demographic predictors being assessed (including constructs from the Extended Health Belief Model, HPV knowledge, and vaccine hesitancy) and note that logistic regression will be used to identify the strongest predictors of parental intention to vaccinate. This additional detail clarifies how the study will address the evidence gap and inform targeted interventions and NHS England policy strategies. Please see lines 301-310.

Reviewer Comment: Conflation of Commentary and Research Paper Format. The article uses a commentary voice, but includes formal subsections, reference formatting, and structured abstract like a research paper. Suggestion: Consider whether this is intended as a "Perspective" or "Commentary" for the journal – adjust formatting and expectations accordingly.

Author response: We thank the reviewer for raising this issue. To the best of our knowledge, MDPI does not provide a rigid, one-size-fits-all formatting style exclusively for commentaries, and we have used the journal’s standard template (as instructed) for consistency. While we have adopted subheadings and a structured abstract to improve clarity and readability, our piece remains a commentary by tone, purpose, and intent: it advances a perspective (rather than reporting original results). That said, to align with your concerns, we have modestly revised the structure to emphasise interpretative discussion over a research-report feel (e.g., shortened abstract, fewer formal subsections).

Reviewer Comment: Unequal Emphasis on Stakeholders. The role of schools and school staff is well developed. However, the perspectives of adolescents themselves are not sufficiently included. Suggestion: Include more evidence or examples of adolescent-led campaigns, peer education, or youth feedback on HPV programs.

Author response:

We agree that adolescents are critical stakeholders in HPV vaccination, and we have added a section to incorporate their perspectives more fully. Specifically, we now include a paragraph noting the limited evidence base on adolescents’ views, highlighting that most studies focus either on parents or on older age groups. We also cite emerging evidence from a study in Turkey (Erbay et al., 2024) which demonstrated that peer education significantly improved HPV knowledge among secondary school students (equivalent to UK Years 10–12). While research in this area remains scarce, we emphasise that peer-led approaches may be particularly valuable for boys, who are generally less aware of HPV risks and less likely to view the vaccine as relevant. Please see lines 204-215.

We have also revised the Recommendations section by adding a bullet-point under “Improve school-based vaccine delivery systems” that explicitly recommends piloting peer education models within schools. We have framed this to complement staff-led delivery and consent processes, while leveraging adolescents’ influence on one another. Please see lines 339-340.

Reviewer Comment: Minor Issues

Language and Grammar:

Line 14: "persistent gender and regional disparities" → Suggest: "persistent disparities by gender and region"

Line 25: "key public health strategy" → Consider specifying primary prevention strategy.

Line 137: "encourage their son(s) to be sexually active..." – Consider rephrasing for tone sensitivity, e.g., "concerns that the vaccine may signal sexual readiness".

Author response: We thank the reviewer for these suggestions and have revised the phrasing accordingly.

Reviewer Comment: Figure/Table Suggestion:

Although the manuscript is text-heavy, a summary table of barriers vs. proposed solutions would improve accessibility.

Author response: We thank the reviewer for this excellent suggestion. In response, we have added a summary table (please see Table 1) that maps key barriers identified in the manuscript to our proposed solutions, with links to the HBM/TPB where appropriate.

Reviewer Comment: Reference Duplication:

Some recent references (e.g., #5 and #6) are cited frequently and might be used more selectively with synthesized insights.

Author response: We are slightly confused by this comment – recent references 5 and 6 are only mentioned once in the manuscript and thus are not cited frequently. As such, we have respectfully not modified this. The only references we have cited twice each are references 2, 7, 15 and 36, however we feel that this is justified and not excessive.

Comment: Abstract

Comments on the Quality of English Language

• Original: “To realise the potential of HPV vaccination as a key public health strategy, uptake must be high and equitable.”
• Issue: Slightly awkward; “realise the potential” is vague.
• Suggested: “Maximising the public health impact of HPV vaccination requires high and equitable uptake.”
• Original: “Despite policy changes towards gender-neutral vaccination in England, persistent gender and regional disparities remain.”
• Suggested: “Despite a shift toward gender-neutral vaccination policy in England, disparities by gender and region persist.”

Author response:

We thank the reviewer for these helpful suggestions. We have revised the abstract to adopt clearer, more precise phrasing, including the two suggested changes. In addition, we refined other sentences to avoid vague wording. We believe these revisions have improved the clarity and readability of the abstract. Please see lines 26-42.

Introduction

• Original: “This initiative aimed to reduce cervical cancer burden by immunising girls against HPV.”
• Suggested: “...aimed to reduce the burden of cervical cancer through HPV immunisation of girls.”
• Original: “...leaving boys vulnerable to HPV-associated conditions including genital warts, anal, oral and penile cancers.”
• Suggested: Add commas for clarity: “...including genital warts, anal, oral, and penile cancers.”

Barriers to Uptake

• Original: “...boys are less likely to be targeted by public health messaging...”
• Consider rephrasing for precision: “...boys are less frequently targeted by HPV-related public health campaigns...”
• Original: “...because of false beliefs that the vaccine is only for girls.”
• Slightly informal. Suggested: “...due to misconceptions that the vaccine is intended exclusively for girls.”
• Original: “Parents might also feel uncomfortable...”
• Tone: This could be made more professional. Suggested: “Some parents may express discomfort...”

Social Norms and Misconceptions

• Original: “...fear that encouraging their son(s) to get vaccinated implies endorsing sexual activity.”
• Suggested: “...due to concerns that HPV vaccination may be perceived as condoning early sexual activity.”
• Original: “...particularly in households with strong religious or cultural values.”
• Suggested: “...especially among families guided by strong religious or cultural beliefs.”

Systemic and Structural Issues

• Original: “There are also gaps in training and confidence among healthcare professionals...”
• Suggested: “Training and confidence gaps among healthcare professionals further limit engagement with boys and their families.”

Recommendations

• Original: “Addressing misconceptions requires clear and consistent messaging that vaccination protects against cancer, regardless of gender.”
• Suggested: “Addressing misconceptions requires clear, consistent messaging that emphasizes HPV vaccination as cancer prevention for all genders.”

Ongoing Research Section

• Original: “Our ongoing research seeks to identify knowledge, attitudes, and behavioural drivers...”
• Slightly vague. Consider specifying methods or populations: “We are conducting qualitative research to explore knowledge, attitudes, and behavioural drivers of HPV vaccine uptake among parents of adolescent boys.”

Author Response:

In revising the manuscript, we have substantially restructured and rephrased several sections in response to other reviewer comments (e.g., to integrate behavioural theory and improve critical depth). As a result, many of the specific sentences flagged  are no longer present in their original form. Nonetheless, we carefully reviewed each of your points and have ensured that equivalent passages in the revised manuscript reflect the nature of your suggestions. Thank you for taking the time to provide such detail.

Reviewer 3 Report

Comments and Suggestions for Authors

The authors reviewed the gender and regional disparities in HPV vaccine uptake and provided possible enablers to promote vaccination among boys. The manuscript is well-written. I would recommend acceptance if the following questions are addressed:

1. Can you elaborate on vaccine accessibility across genders? For instance, are insurance coverage and free vaccination programs equally available to both genders?

2. The manuscript recommends multiple vaccination enablers. Could you propose a suggested scheme of action - which should be prioritized and what steps should follow?

 

 

Author Response

Peer Reviewer 3

Dear reviewer,

We would like to express our sincere thanks and appreciation for your comments and feedback. We have revised the manuscript accordingly and provided a response to each of your comments below.

Reviewer Comment: Can you elaborate on vaccine accessibility across genders? For instance, are insurance coverage and free vaccination programs equally available to both genders?

Author Response: We thank the reviewer for raising this important point. We note that concerns about insurance coverage and unequal access to free vaccination programmes are particularly relevant in contexts such as the United States, where healthcare access can differ substantially across genders and insurance plans. However, in the United Kingdom, HPV vaccination is delivered universally through the NHS at no cost to patients, with both girls and boys offered vaccination in schools from age 12–13 (since 2019), and with catch-up vaccination available up to age 25. As such, gender disparities in the UK context have historically related less to insurance or financial accessibility, and more to the timing of policy implementation (girls were prioritised before boys) and to social/behavioural determinants of uptake.

Reviewer Comment:

Author Response: In response, we have now added a short section clarifying the sequencing of our recommendations. Specifically, we propose that immediate priorities should centre on gender-inclusive public health campaigns and strengthening school-based delivery systems, as these create the foundation for equitable uptake. In the short-to-medium term, these efforts can be reinforced through enhanced training for school staff and healthcare professionals, stronger GP and primary care involvement, and the roll-out of digital health tools such as NHS App functionalities. Finally, longer-term, more innovative strategies – including peer education initiatives, pharmacy-led outreach in low-uptake communities, and behavioural science–informed intervention research – should be piloted and scaled once national campaigns have normalised HPV vaccination across genders and school-based delivery systems are reliably achieving high baseline coverage. This has now been added to the revised manuscript (please see lines 395-408).

Reviewer 4 Report

Comments and Suggestions for Authors

In general, more attention needs to be given to whether the descriptions/recommendations are specifically aimed at increasing boys' uptake or if they are more general.

1. Abstract, Line 35, does the issue of teachers lacking training and confidence in disseminating HPV-related information pertain to gender-specific information, or is it more about general HPV awareness? Line 32 to 35, it is unclear whether this is talking specifically about vaccine uptake among boys.
2. Page 51, add reference
3. Line 60-61, Any changes in uptake among boys before and after the adoption of gender-neutral HPV vaccination? The fact that vaccine uptake remains below target does not mean progress has not been made.
4. Line 63-69, what years of data were used in describing the vaccination coverage from year 8 to year 10?
5. It is unclear how regional disparities were addressed in this manuscript. The authors highlighted the use of digital health technologies to identify geographic and demographic gaps in vaccine coverage at the end. However, digital health technologies may also be subject to regional disparities. How might other recommendations, such as campaigns, school-based programs, and the involvement of GPs and primary care, address these regional inequalities?
6. Line 98 to line104. Provide more details regarding these cost effectiveness studies What take-up rates were used in the calculations, by girls and by boys? Do they include any expected changes in these rates over long term?
7. Line 106, uptake has declined in recent years. Can you break down the decline by sex, is the decline more in girls or boys?
8. Line 116, who were the YouGov survey respondents? Are they representative of any population?
9. Section 3, why boys are missing out, all the studies referenced in this section lack a time frame. Line 115, a recent survey, what was the year for the survey? Please add time for the studies you referenced whenever possible.
10. Line 186, this challenges, such as absenteeism on vaccination days and administrative challenges etc. apply to both girls and boys. Please add more takeaways regarding how school-based delivery could improve HPV vaccination update of boys.

Author Response

 

Peer reviewer 4

Dear reviewer,

We would like to express our sincere thanks and appreciation for your comments and feedback. We have revised the manuscript accordingly and provided a response to each of your comments below.

Reviewer Comment: Abstract, Line 35, does the issue of teachers lacking training and confidence in disseminating HPV-related information pertain to gender-specific information, or is it more about general HPV awareness? Line 32 to 35, it is unclear whether this is talking specifically about vaccine uptake among boys.

Author Response: Thank you for raising these important points. We have now revised the abstract accordingly. Please see lines 26-42.

Reviewer Comment: Page 51, add reference

Author Response: A reference has been added. Thank you.

Reviewer Comment: Line 60-61, Any changes in uptake among boys before and after the adoption of gender-neutral HPV vaccination? The fact that vaccine uptake remains below target does not mean progress has not been made.

Author response: Upon reflection, we have made several changes to this section. Prior to the adoption of GNV for HPV, uptake data among boys were not systematically collected, as vaccination was not routinely offered to this group. The only exceptions would have been limited provision to men who have sex with men in GUM clinics, which does not provide a comparable or generalisable baseline for assessing changes in uptake. For this reason, we do not believe it is appropriate to refer to progress pre-GNV. Please see lines 57-76.

 

Reviewer Comment: Line 63-69, what years of data were used in describing the vaccination coverage from year 8 to year 10?

Author Response: This has been modified accordingly. Please see lines 78-87.

Reviewer Comment: It is unclear how regional disparities were addressed in this manuscript. The authors highlighted the use of digital health technologies to identify geographic and demographic gaps in vaccine coverage at the end. However, digital health technologies may also be subject to regional disparities. How might other recommendations, such as campaigns, school-based programs, and the involvement of GPs and primary care, address these regional inequalities?

Author response: We have revised the manuscript to clarify that the disparities in England are not in access per se (since HPV vaccination is universally offered free of charge in schools), but rather in uptake and delivery consistency, with some regions demonstrating persistently lower coverage (e.g., Lambeth – London). We now note that while digital health technologies can help identify gaps, they should be combined with non-digital strategies. Specifically, we highlight that campaigns can be tailored to local contexts, school-based programmes can prioritise catch-up provision in areas with lower baseline coverage, and GP and pharmacy outreach may be particularly valuable in regions where follow-up systems or workforce capacity are inconsistent. These additions have been incorporated into the revised manuscript (lines 370–376).

Reviewer Comment: Line 98 to line104. Provide more details regarding these cost effectiveness studies What take-up rates were used in the calculations, by girls and by boys? Do they include any expected changes in these rates over long term?

Author response: We would like to clarify that our intention in referring to cost-effectiveness was not to re-examine their assumptions in detail, but to provide historical context for the eventual introduction of GNV for HPV. As boys were not previously included in the vaccination programme, modelling necessarily drew upon historical uptake from girls, applying a range of estimated uptake scenarios for boys. Results varied depending on assumptions, with some finding girls-only vaccination to be more cost effective, while others supported the inclusion of boys. Since our commentary is not advancing the argument about introducing GNV but rather exploring the challenges to equitable HPV uptake following its implementation, we feel it would be disproportionate to expand further on these technical details.

Reviewer Comment: Line 106, uptake has declined in recent years. Can you break down the decline by sex, is the decline more in girls or boys?

Author response: As we initially noted uptake data are available by sex, and recent UKHSA reports indicate that declines have occurred among both girls and boys, though there have been increases in Year 8. Interpretation is quite difficult, however, because data are reported by school year of eligibility rather than cohort, which makes direct comparisons less straightforward. To avoid confusion, we have revised the manuscript to more clearly present our discussion of uptake trends and to ensure the sex-specific data are presented together in one section. Please see lines 78-87.

Reviewer Comment: Line 116, who were the YouGov survey respondents? Are they representative of any population?

Author response: We thank the reviewer for this. We have now clarified both the year of the survey and the sample characteristics. Specifically, we now state that the survey was conducted in 2025 among UK adults and highlight that, while the findings provide a useful indication of public awareness, the respondents were not specifically parents of eligible boys. We have therefore added a note that these results should be interpreted with this limitation in mind. To our knowledge, no further methodological details have been made publicly available by YouGov or The Eve Appeal. These clarifications have been incorporated into the revised manuscript (please see lines 113–118).

Reviewer Comment: Section 3, why boys are missing out, all the studies referenced in this section lack a time frame. Line 115, a recent survey, what was the year for the survey? Please add time for the studies you referenced whenever possible.

Author response: We have revised this section to include the relevant time frames for all cited studies and surveys. Specifically, we now note that Sherman and Nailer’s study was published in 2020, the YouGov survey was conducted in 2021, and Fisher et al.’s qualitative research was published in 2024. We have also ensured that publication years are added for other supporting evidence where appropriate, while keeping within the journal’s reference style. Please note that the reason for this was due to the referencing style required by MDPI (numbers in text).  Please see lines 104-118.

Reviewer Comment: Line 186, this challenges, such as absenteeism on vaccination days and administrative challenges etc. apply to both girls and boys. Please add more takeaways regarding how school-based delivery could improve HPV vaccination update of boys.

Author response: We thank the reviewer for this suggestion. We have revised the manuscript to make explicit how school-based delivery could be strengthened to improve uptake among boys. We now highlight the importance of improving follow-up systems and catch-up opportunities, providing clearer parental communication about boys’ risk of HPV-related cancers and available catch-up routes, and introducing robust reminder systems targeted at families of boys. We also suggest embedding peer-led initiatives that feature male role models and messages normalising HPV vaccination as routine for boys. These additions have been incorporated into the revised manuscript (please see lines 228-236).

Round 2

Reviewer 2 Report

Comments and Suggestions for Authors

The authors have addressed all the raised issues, hence the recommendation of acceptance.

Reviewer 3 Report

Comments and Suggestions for Authors

Thanks for your response - I have no further comments.