Reviewer’s report
Title: 
Understanding the Role of Oncogenic Human Papillomavirus (HPV)
Status on Adherence Behaviors Among Women with Abnormal Cervical
Cytology
Version: 
1 
Date: 
05 Nov 2020
Reviewer's report:
Dear Respectable Editor 
Thank you to give me the opportunity to review the manuscript entitled
(Understanding the Role of Oncogenic Human Papillomavirus (HPV) Status on
Adherence Behaviors Among Women with Abnormal Cervical Cytology).
The study designed to identify if clinical, demographic, or psychosocial factors
predict non-adherence with recommended colposcopy follow-up. Study design:
prospective pilot study included 145 women referred to a large Toronto
colposcopy clinic between December 2013 and September, 2014. 
Demographic, clinical and psychosocial characteristics were collected at three
points in time: 1) at initial colposcopy consultation; 2) 4-6 weeks following
initial consultation, and; 3) at time of follow-up appointment (within 12 months
of initial consultation). The study found that overall, 13% (n=145) of the women
were classified as non-adherent. Older women and those with higher-grade
lesions were less likely to be non-adherent, whereas current smokers were more
likely to be non-adherent. While not statistically significant, variation in rates of
non-adherence amongst the various HPV status groups (untested; 15.3%, HPV
positive; 5.3%, HPV negative; 6.7%) warrants further study.
The study concluded that younger women, those with higher-grade lesions and
current smokers were more likely to be non-adherent to recommended
colposcopy follow-up. While HPV status did not reach statistical significance,
the direction of this finding suggests that testing for HPV may have a positive
reinforcing role on adherence to follow-up. The direction of this finding warrants
further study, and potentially a practical clinical goal as HPV testing for women
becomes standard of care.
The authors provided an informative title for their manuscript, and structured
abstract.
In the introduction (background) section, authors specify the magnitude of the
problem (authors mentioned that failure to adhere with follow-up
recommendations for management of premalignant cervical abnormalities is
among the most notable. Adherence to recommended cervical screening
guidelines is associated with better clinical outcomes, with an inverse association
between exposure to screening and stage of cancer at diagnosis. While adhering
to recommendations for the management of abnormal cytology is proven to
decrease the incidence of cervical cancer, adherence rates remain sub-optimal in
women with premalignant abnormalities. Non-adherence has significant
implications for the effectiveness of cervical screening programs and cancer
prevention as well as for the financial burden of potentially preventable disease).
In addition, they mentioned that a number of socio-demographic, psychosocial
and clinical factors, as well as health system issues are known to influence
adherence to recommended follow-up in women with screening abnormalities.
At the end of the introduction (background) authors specified the aim of their
study.
In the methods section, they mentioned the study design, time, place, patients`
consent and the eligibility criteria. In addition, they mentioned the method and
time of data collection (supported by figure 1). Authors defined the true loss of
follow-up and the non-adherence in their methods section. In addition, authors
mentioned how they evaluate the psychosocial, clinical, and demographic
predictors. They used state anxiety was measured using the Spielberger State
Anxiety Inventory Six item short form to indicate clinically detectable or
significant anxiety. HPV Burden was measured using the self-administered HPV
Impact Profile tool. Knowledge of oncogenic HPV score was determined using a
9-item scale with true-false responses adapted from Kahn & colleagues.
Perceived risk of cervical cancer was measured by Likert scale responses to
questions examining the participant's perceived personal risk. The Impact of
Event Scale29was used to measure current subjective distress in relation to being
at risk of cervical cancer. Self-efficacy was tailored to a behavior-specific unit of
analysis.
In the statistical methods, authors mentioned how they statistically analyzed their
data, and the ethical approval.
In the results section, they mentioned the participants characteristics in tables 1
and 2. 
The prevalence of non-adherence in relation to untested for HPV,
compared to HPV positive and HPV negative groups in table 3. Predictors of
Non-Adherence in tables 4 and 5. 
In the discussion they mentioned the strength and future directed and/or
suggested researches (This work is novel in its approach to examine the
consequences of knowledge of one's HPV status by HPV-DNA testing in the
cervical screening population. Although this finding did not reach statistical
significance, the direction of this finding provides a basis for further study as a
practical clinical goal, as HPV testing for women becomes standard of care.
Further research is needed to examine the HPV status and adherence relationship
and the potential to target at-risk groups of women to encourage adherence with
colposcopy recommendations).
They compared their results to other finding (in contrast to the main hypothesis
and previous work, perceived risk of cervical cancer scores and HPV knowledge
were not related to adherence in this study. Previous work has found that anxiety
is a predictor of non-adherence in women who receive inadequate cytology
results 45 or are asked to return for follow-up).
In addition, authors used relevant references 
The manuscript reflecting great authors` work presented in well-designed way. It
can be accepted for publication after the following minor suggested corrections.
Minor suggested corrections 
1. It will be great if the authors mentioned how the sample size for their study
was calculated.
2. To revise the highlighted references in the attached PDF file and mention for
the internet references the last date in which the authors accessed those
references on the Internet.
3. Please, revise the references section in the manuscript text (One reference not
in proper place 47 in page 7).
Regards 
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Declaration of competing interests
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Is the study design appropriate to answer the research question (including the use
of appropriate controls), and are the conclusions supported by the evidence
presented?
Yes
Are the methods sufficiently described to allow the study to be repeated?
Yes
Is the use of statistics and treatment of uncertainties appropriate?
Yes
Is the presentation of the work clear?
Yes
Are the images in this manuscript (including electrophoretic gels and blots) free
from apparent manipulation?
Yes