Author's response to reviews

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1 Author's response to reviews Title:Greek health professionals' perceptions of the HPV vaccine, state policy recommendations and their own role with regards to communication of relevant health information. Authors: Christina Karamanidou Costas Dimopoulos Version:3Date:5 September 2015 Author's response to reviews: see over

2 University of Peloponnese, Dept. of Social and Educational Policy, Dr Christina Karamanidou Πανεπιστήμιο Πελοποννήσου, Τμήμα Κοινωνικής και Εκπαιδευτικής Πολιτικής, Δρ. Χριστίνα Καραμανίδου Victorino Silvestre Journal Editorial Office BioMed - BMC Public Health Korinthos, 04/09/2015 Dear Editor, Firstly, we would like to thank you and the reviewers of our paper Greek health professionals' perceptions of the HPV vaccine, state policy recommendations and their own role with regards to communication of relevant health information. We have read the reviewers comments very carefully and we felt that they were very useful and constructive. We are now in a position to re-submit a revised version of this manuscript. We hope you will find that the revisions have improved it and that it is now appropriate for publication in BMC Public Health. Please find our responses to the reviewers comments below.

3 Reviewers comments Reviewer's report 1 Version:2 Date:5 May 2015 Reviewer: Catriona Kennedy Authors responses The authors thank the reviewer for the useful comments. Reviewer's report: Thank you for the opportunity to review this paper which is about an important and relevant topic. Overall the paper is well presented and there are some links to the International position in relation to HPV. However I am not clear what this paper adds to the debates which are new and innovative? It would be important to position the Greek situation in a broader European context. It is not clear where the presentation of themes ends and the discussion starts but I am assuming this is at line 488? In relation to the methods the rationale for the approach to sampling and data analysis needs further explanation and justification. In Greece there is limited research to date with regards to the HPV vaccine. Specifically, there are a few epidemiological studies looking at prevalence of HPV infections (Tsiodras et al, 2011; Agorastos et al, 1995; Panotopoulou et al 2007; Stamataki et al, 2010), there is one study, considering medical aspects, concerning vaccination such as age of administration, whether the vaccine should be administered to both sexes etc (Mammas et al, 2011), a study looking at factors which could potentially influence women either to vaccinate themselves or their daughters (Sotiriadis et al, 2012) and some studies investigating vaccination coverage in female university students (Papagiannis et al, 2013) and adolescents (Sakou et al, 2011). The exploration of health care professionals perceptions is particularly salient in Greece where HPV vaccines are provided on demand after prescription. To the best of our knowledge, there have been no research studies to date investigating perceptions of health care professionals in Greece since the release of the HPV vaccine in The text between lines 65-88, positions the Greek situation in a broader European context, specifically contrasting school vaccination vs. on demand policy, as well as giving an overview of vaccination coverage percentages across Europe. The and Discussion has now been separated into two different sections. Discussion starts at line 467. The method has been revised according to COREQ guidelines for qualitative research. Please see Method section - Line 151. I note there are no nurses involved - this may be relevant in Greece but nurses play a role in HPV vaccination across Europe so would expect a clear rationale for the sampling of participants. All disciplines involved in the HPV vaccine information, prescription and delivery were included in the sample. Unfortunately nurses in Greece have not been officially involved in the HPV vaccine. However, as this was pointed out by

4 The paper is interesting to read but unfortunately as it stands it does not contribute anything significant to our understanding of how to address this issue. Level of interest: An article of insufficient interest to warrant publication in a scientific/medical journal Quality of written English: Acceptable Statistical review: No, the manuscript does not need to be seen by a statistician. Declaration of competing interests: I declare that I have no competing interests. the study participants and the authors have identified this as a marked difference between Greece and other countries, a recommendation was made to involve nurses who are a valuable albeit currently underutilized resource in this public health effort. The paragraph between lines outlining recommendations has now been further developed to include the implementation of recent health communication methods and use of tools for health professionals which have shown encouraging results, the establishment of certain services, programs or roles as suggested by the study participants and the introduction of the certain changes at state policy level based on the authors comprehensive view of the problem. Based on this, the authors believe that they are making a contribution towards a better understanding of this issue especially for countries offering the HPV vaccine on demand or plan to introduce the vaccine in the future and some recommendations towards addressing it. Furthermore, the presentation of issues surrounding on demand vaccination can act as a comparison measure for countries offering the HPV vaccine in the context of school vaccinations. The authors hope that the changes made to the manuscript will have succeeded in making the article interesting to health care professionals and researchers in this field. The manuscript has been reviewed for language use corrections. Reviewer's report 2 Version:2 Date:1 July 2015 Reviewer: Alice Forster The authors thank the reviewer for the encouraging and insightful comments. The authors present an interview study of health professionals working in two Greek cites. Fifteen interviews were conducted with health professionals from a range of disciplines to understand their perceptions of HPV vaccination, perceptions of state policy recommendations and their own role regarding communicating relevant health information. The authors conclude that some health professionals lack guidance from the state, which has led to health professionals being

5 confused about HPV vaccination and created conflicts between professions. The authors draw useful and appropriate conclusions from their study findings and the study presented is novel in its population of interest. The conclusions are justified based on the findings. The title and abstract are accurate representations of the study as a whole. The manuscript would benefit from greater detail in the methods section (described below), in accordance with COREQ guidelines for reporting qualitative studies. The results and discussion could be more focused and concise. Major Compulsory Revisions Background 1. The authors make some statements in the introduction that should be supported by references. This includes sentence 1 of paragraph 1, sentence 3 of paragraph 1, the last sentence in paragraph 3 and the first sentence in paragraph 6. Method 2. The method section could benefit from greater detail, so that it might be reported in line with COREQ guidelines. In particularly, it would be useful to know: Who conducted the interviews and analysis and what were their personal characteristics? How many researchers conducted the analysis? Triangulation of findings? Were the audio-recordings transcribed in Greek and then translated or transcribed in English? If the audio-recordings were transcribed in Greek, how were the quotes translated from Greek to English (back translation for example)? How can the authors be certain that this is a reliable method? How were the participants sampled and in what way was the sampling stratified? Why did the authors decide to conduct 15 interviews? Major Compulsory Revisions Background 1. A reference has been added at sentence 1 of paragraph 1 Line 50. Sentence 3 of paragraph 1 had a reference (Line 54) but sentence 4 of paragraph 1 did not, so a reference was added - Line 59. A reference was added at the last sentence in paragraph 3 -Line 88. References have also been added at the first sentence in paragraph 6 Line 120. Method 2. The method has been revised according to COREQ guidelines for qualitative research. Please see revised Method section - Line The principal investigator (CK) conducted the interviews. Characteristics are included in authors information section Line Both investigators conducted the analysis. Investigator triangulation was used. Findings were then compared and issues were discussed and resolved. 2.3 The audio-recordings were transcribed in Greek and analyzed in the Greek language. 2.4 Specific quotes and theme titles were subsequently translated in English by the principal investigator (CK). A separate translation was conducted by an Applied Linguist (MA). Disagreements on terminology were negotiated and resolved. This method i.e. translation by two separate translations has been suggested by cross-cultural researchers such as Noreen Esposito (2001). Furthermore, according to recommendations by Fenna van Ness et al (2010) in order to reduce the loss of meaning and thereby enhance the

6 validity of cross-english qualitative research, researchers should stay in the original language as long and as much as possible. The reason for this is that thinking and language are closely related and thus analysis may be influenced if conducted in a language different than your own. Finally, according to a review on social research translation issues Birbili (2000), mentions that among the factors affecting the quality of translation in those cases, where the researcher and the translator are the same person, are: the autobiography of the researcher-translator; the researcher s knowledge of the language and the culture of the people under study and the researcher s fluency in the language of the write-up. In the present case, both authors are Greek, hold PhD degrees, were educated in UK and have conducted qualitative research in numerous occasions in the past. 3. 1st paragraph the authors state that the participants were ambivalent towards the vaccine, but the results presented do not demonstrate this. 4. The results and discussion section are longer than necessary and could be more concise. In particular, some of the quotes are long and do not all match the authors comments. For 2.5 Stratified purposeful sampling was used in the present study. Patton (2001) describes these as samples within samples and suggests that purposeful samples can be stratified or nested by selecting particular units or cases that vary according to a key dimension. In this case the sample was stratified in that participants varied according to discipline/ specialty. A maximum of three participants were selected from each relevant discipline thus resulting to a total sample of 15. It was also purposeful as sample participants were recruited through key institutions which the authors thought ought to be present in the sample specifically the two largest medical schools in the country, the national school of public health and the Hellenic center for diseases control and prevention st paragraph this paragraph has now been reformulated to illustrate the point of ambivalence in a clearer manner. 4. The results and discussion have been revised and certain quotes have been shortened and/ or removed. 5. An effort has been made to revise the results and discussion section according

7 example, the quote from PED 45 under the heading animosity among different medical specialities could be shortened. 5. The analysis is very descriptive and does not really offer any deeper level thinking about what is being said. 6. The authors do not describe the limitations to their work. 7. I am concerned that participants could be identified by the demographic detail provided in Table 1. Minor Essential Revisions (not for publication) 1. Line 55: The sentence cervical cancer has also become an issue for primary level of prevention is unclear. 2. Lines 93-96: I am not clear why the participants subject of study relevant information. 3. Line 51: Specifies that cervical cancer currently ranks as the second most frequent cancer in women. It would be helpful to state whether this is globally or just in Greece. Method: 4. Line 172: Says Fiver rather than five. 5. Line 188: Was consent taken over the phone or at the time of the interview? 6. Line194: It would be helpful if the authors were clearer about what they mean by participants accounts were coded according to the specialty and age of each participant After reading further I can see this means the participant names were replaced by an abbreviated version of their job title and their age, but this is not clear initially. Perhaps this could be clarified ( participant identifies/names were replaced with... ). The age column in Table 1 could be clearer with regards to this comment also. 7. Participants section much of this section currently reads like part of the study results. The to suggestions. 6. A paragraph on limitations has been added at the end of the discussion. 7. Table 1 has been now removed to protect participants identity. Minor Essential Revisions 1. Line 55: This has now been rephrased to enhance clarity. 2. The subject of study was mentioned firstly in an effort to report the study s findings accurately. Also, the authors felt this was relevant as it demonstrated that vaccination coverage percentages are low even among aspiring health professionals, who are in an advantageous position with regards to comprehending the need for the adoption of a health innovation, compared to individuals with non-expert knowledge. It is also important because Papagiannis et al (2013) also suggest that further research, both quantitative and qualitative, is needed to design educational activities targeting female students in the health professions in order to create a positive domino effect and improve the HPV vaccination coverage level in Greece, a recommendation similar to the ones recommended by the authors of the present study. This has now been explained in the text. 3. This concerns Europe, following from the previous sentence of the same paragraph. This has now been specified Line 51. Method 4. This has now been corrected. 5. Consent was taken over the phone. This has now been clarified. 6. This sentence now reads For confidentiality purposes participant names were replaced by an abbreviated version of their discipline and their age. 7. The participants section has now been revised.

8 authors should consider incorporating relevant results into the introduction of the results section. Analysis: 8. Were researchers reflective about the interviews? Analysis 8. The authors were reflective about the design, conduct and analysis of this study. With regards to their conceptual baggage : One investigator is male (CD) and the other female (CK), both are PhD holders and have had experience in conducting qualitative research. Furthermore, neither of them is a health care professional. With regards to the research relationship, the interviewer made an effort to build trust and rapport with study participants. Her personal interest in research and reasons for conducting it were described prior to the interviews. A number of strategies were employed to enhance credibility of the research findings such as acknowledging biases in sampling, investigator triangulation, establishing a comparison case/seeking out similarities and differences across accounts to ensure different perspectives are represented, including rich and thick verbatim descriptions of participants accounts to support findings (Noble & Smith, 2015). 9. The results/discussion section does not integrate the discussion with the results. I would suggest the authors give the results and discussion separate headings. 10. Line 244: How does animosity among different medical specialties affect HPV vaccination? How is this relevant? 11. I noted a number of typographical errors and misuse of language throughout the manuscript. The manuscript would benefit from being reviewed by a native English speaker. Including line 417: a not an and line 424: so not son and line 481: The sentence it was ambivalent that they were ambivalent doesn t make sense. 12. Line 521: What are decision boxes? Perhaps this could be clarified? 13. It would be useful if the authors could make some recommendations for how to improve communication regarding the HPV vaccination, based on the results of the study. 9. The and Discussion has now been separated into two different sections. Discussion starts at line Animosity among specialties is relevant in the authors opinion for a number of reasons: Firstly, because the HPV vaccine created an opportunity for clinicians of all specialties to express their animosity. The lack of inter professional respect and disruptive behavior within health care setting has been well documented (Stecker, 2015) however, it seems that given a specific opportunity animosity is expressed even by individual health professionals regardless of a particular health care setting (some participants worked both in institutions and operated in private practice). The fact, that different opinions are voiced and different approaches to vaccination are followed by health professionals operating in the community, increases the public s distress and can compromise its safety. 11. These errors have now been corrected. 12. According to Giguere et al (2012) the decision box is a tool, intended to help the clinician recognize that a decision needs to be shared with the patient, prepares the clinician to communicate evidence based information to the

9 patient, and assists the clinician in seeking patient s values and preferences regarding the decision to be made. The Decision Box is a short clinical summary that integrates the best available evidence from studies and syntheses to provide quantitative information on management options. More than a summary, though, it is framed in a way to help the user weigh the risks and benefits of all options in light of the patient s individual health status. It also offers guidance on the shared decision-making process. This has now been clarified Line 512. Discretionary Revisions Background 1. Paragraph 5 of the introduction It would be helpful to report (if available) data of uptake among younger girls in Greece. 2. Perhaps the longer quotes could be separated from the main text, to make it clearer to read? 3. Line 238: Could a quote be added here? 4. Line 242: Could a quote be added here? Level of interest: An article whose findings are important to those with closely related research interests Quality of written English: Needs some language corrections before being published Statistical review: No, the manuscript does not need to be seen by a statistician. Declaration of competing interests: I declare that I have no competing interests. 13. The paragraph between lines outlining recommendations has now been further developed to include the implementation of recent health communication methods and use of tools for health professionals which have shown encouraging results, the establishment of certain services, programs or roles as suggested by the study participants and the introduction of the certain changes at state policy level based on the authors comprehensive view of the problem. Discretionary Revisions Background 1. Vaccine coverage data among adolescents has been added at the end of paragraph 4 of the Introduction - Line Longer quotes have not been separated from the main text since some of the shorter ones were embedded in the text while the longer ones made up a whole paragraph and seemed very cut off from the main text as they stood on their own. 3. No extra quote has been added but the paragraph has been re-written to illustrate the point in a better way. 4. No extra quote has been added but the paragraph has been re-written to illustrate the point in a better way. The manuscript has been reviewed for language use corrections.

10 References: Agorastos T, Bontis J, Lambropoulos AF, et al. Epidemiology of human papillomavirus infection in Greek asymptomatic women. Eur J Cancer Prev. 1995;19: Birbili, M. (2000) Translating from one language to another. Social Research Update. 31, 1-7. Esposito, N. (2001) From meaning to meaning: the influence of translation techniques on non-english focus group research. Qual Health Res.11(4): Giguere A., Légaré, F., Grad, R., Pluye, P., Haynes, R.B., Cauchon, M., Rousseau, F., Alvarez Argote, J., Labrecque, M. (2012) Decision boxes for clinicians to support evidence-based practice and shared decision making: the user experience. Implementation Science, 7:72. Mammas I, Maher F, Theodoridou M, Spandidos D. (2011) Human papilloma virus (HPV) vaccination in childhood: challenges and perspectives. Hippokratia 15(4), Noble, H. & Smith, J. (2015) Issues of validity and reliability in qualitative research. Evidence Based Nursing. 18:34-35 doi: /eb Patton, MQ. (2001). Qualitative Research and EvaluationMethods (2nd Edition). Thousand oaks, CA: Sage Publications. Panotopoulou E, Tserekezoglou A, Kouvousi M, et al. Prevalence of human papillomavirus types 6, 11, 16, 18, 31, and 33 in a cohort of Greek Women. J Med Virol. 2007;79: Papagiannis, D., Rachiotis, G., Symvoulakis, E. K., Daponte, A., Grivea, I. N., Syrogiannopoulos, G. A., & Hadjichristodoulou, C. (2013). Vaccination against human papillomavirus among 865 female students from the health professions in central Greece: a questionnaire-based cross-sectional study. Journal of Multidisciplinary Healthcare, 6, Sakou Ikbale I, Tsitsika AK, Papaevangelou V, et al. Vaccination coverage among adolescents and risk factors associated with incomplete immunization. Eur J Pediatr. 2011;170: Sotiriadis A, Dagklis T, Siamanta V, Chtzigeorgiou K, Agorastos T. (2012) and the LYSISTRATA Study Group. (2012) Increasing fear of adverse effects drops intention to vaccinate after introduction of prophylactic HPV vaccine. Archives of Gynecology and Obstetrics 285(6), Stamataki P, Papazafiropoulou A, Elefsiniotis I, Giannakopoulou M, Brokalaki H, Apostolopoulou E, Sarafis P, Saroglou G. (2010) Prevalence of HPV infection among Greek women attending a gynecological outpatient clinic. BMC infectious diseases 10:27. Stecker, M. (2015). Inter- and intraprofessional respect: A dying concept? Surgical Neurology International, 6(Suppl 6), S Tsiodras S, Hatzakis A, Spathis A, Margari N, Meristoudis C, Chranioti A, Kyrgiou M, Panayiotides J, Kassanos D, Petrikkos G, Nasioutziki M, Loufopoulos A, Paraskevaidis E. and Karakitsos P. (2011) Molecular epidemiology of HPV infection using a clinical array methodology in 2952 women in Greece. Clinical Microbiology and Infection, 17: doi: /j x Van Nes, F., Abma, T., Jonsson, H., & Deeg, D. (2010). Language differences in qualitative research: is meaning lost in translation? European Journal of Ageing, 7(4), doi: /s y

11 We thank you again for reviewing and we look forward to hearing from you. Kind regards, Christina Karamanidou and Kostas Dimopoulos