Title: Sociodemographic Factors Associated with HPV Awareness/Knowledge and Cervical
Cancer Screening Behaviors Among Caregivers in the US
Version: 2 Date: 28 Jan 2022
Reviewer's report:
Thank you for the opportunity to review this work. This manuscript describes a novel analysis
of data collected through a publicly available de-identified database of the Health Information
National Trends Survey (HINTS). The study data used present a wealth of opportunity for
different analyses. The authors of this paper have made good use of this data, and highlighted
sociodemographic differences in levels of knowledge of HPV, understanding of HPV and self-
reported cervical screening attendance, among caregivers in the US.  Examining the impact of
caregiving burden on preventative healthcare, such as cervical screening, is an important focus
for understanding caregiving needs and informing initiatives to promote caregiver health.
A limitation of this study is the relatively small sample size, which is skewed towards major cities
which limited some analyses that could be conducted (as acknowledged by the authors of the
paper). In addition the data captured in the study does not allow respondents to quantify the time
spent on caregiving activities, a potential contributing factor to cervical screening attendance,
this could be more explicitly stated in the discussion.
The introduction is very long, and hinders the readability of the paper. I would recommend
making this section for concise, and defining caregiver explicitly in the first few sentences.
A general comment for the authors consideration is whether the changes in cervical cancer
screening guidelines in the US in 2018, which overlapped with the timeframe of HINTS 5, may
have influenced HINTS participants ability to recall HPV knowledge/understanding (perhaps to
be addressed in the discussion)? In addition, I feel the authors should consider addressing the
change of recommendations in the introduction – I believe this would also further communicate
the relevance of this work.
I would recommend double-checking references, as I could not confirm the following statement
with the references provided “Prolonged caregiving causes cumulated stress, including
neurohormonal changes and inflammatory responses in the body, weight loss, and sleep
deprivation. (8,9)” and was unsure this statement could be substantiated “While we can
reasonably assume that subgroups of caregivers are disproportionately low in cervical cancer
screening and HPV knowledge, little is known in this area”
Within the methods, the paragraph on response rate is difficult to follow – suggest amending the
first sentence to clarify the total number of respondents in HINTS 5 (rather than “this study”)
was 16,092. In the analyses the authors have interpreted a response as yes to the question
“pap test within the past 3 years” as within guidelines. However, over the course of HINTS
5, some respondents may have received a hrHPV test – could the question be misinterpreted
by respondents who received a HPV test rather than pap cytology, thereby mis-labelling some
screen compliant participants as non-compliant?
The narrative of the results needs to be revised- particularly for table 1. The response to “never
had a pap smear” has not been included in the results clearly and is included in the discussion.
In the discussion I suggest references to these 2 statements: “One plausible explanation could be
that HPV awareness and HPV vaccination campaigns target younger age groups.” “Healthcare
professionals also focus more on younger age groups to promote HPV vaccine uptake and HPV
awareness.” The first section of the discussion is long, I suggest making this section more concise
and allowing the authors to communicate their key findings in a more succinct manner. The
self-reported pap test attendance is very high, I wonder whether the authors could comment on
this further in the discussion, i.e. do HINTS respondence overall tend to be more engaged in
preventative and healthcare behaviours? In general in the discussion I feel it is an opportunity
missed to not mention the emerging role of HPV testing, and how improving awareness in HPV
may prove very important for cervical screening in the future.