Title: Sociodemographic Factors Associated with HPV Awareness/Knowledge and Cervical
Cancer Screening Behaviors Among Caregivers in the US
Version: 2 Date: 09 Mar 2022
Reviewer's report:
This is a study examining associations between sociodemographic variables of caregivers
and HPV awareness, knowledge, and self-reported guideline-concordant Pap test uptake using
HINTS 5 data. The manuscript is well  written and examines an understudied but important
population of caregivers. I have several suggestions, questions, and comments for the authors
to consider:
- I was surprised that the authors didn’t mention that HINTS does not measure primary
HPV or combination screening behavior in the Limitations. This should be acknowledged and
implications discussed.
- In the Limitations on p. 14, I don’t think the response rate is particularly low for a population-
based survey, and I think the claim that the sample is not representative hurts the relevance and
importance of this study. I recommend the authors refer to the HINTS methodological report to
better understand the strategies used to ensure population representation and consider rephrasing
this limitation.
- In the Limitations on p. 14, the authors suggest that caregiving duty intensity wasn’t considered
in this study; however, HINTS 5 does have items that ask about amount of time spent caregiving
and conditions of the person who receives care. In other words, there are ways to examine
intensity, though they may differ across Cycles.
- I found the “HPV knowledge” as the short form for knowledge that HPV is a cause of cervical
cancer to be confusing. Consider rephrasing to make obvious that the construct is knowledge of
HPV as cause of cervical cancer, not HPV knowledge in general.
- Related to this, make sure to explain that there was a skip pattern such that women who
answered “no” to the first question (awareness) would not have answered the question about
HPV as a cause of cervical cancer. The paragraph discussing this issue in the discussion on p.
11 requires an earlier explanation of the skip pattern.
- How was missing data managed? Was it complete-case analysis? This isn’t included in the
Statistical Analysis section on p. 8.
- The rurality discussion on pp. 14-15 needs shortened and moved into the main part of the
Discussion.
- There is a paragraph spanning more than a page (pp. 11-13). This needs greatly reduced because
it is very hard to read at present.
- On p. 9 of the Results, the final sentence of the HPV awareness/knowledge paragraph describes
the OR for education strangely. I recommend rephrasing that sentence to say that women with
some college or more had more than 3 times the odds of having heard of HPV.
- On p. 4 of the Introduction, the paragraph focused on HPV knowledge is, I think, suggesting
that knowledge is associated with behavior, but it isn’t entirely clear to me whether this is the
authors’ intention. Consider making this paragraph’s point clearer.
- On p. 5 of the Introduction, the final paragraph and particularly the potential study impact need
strengthened. I think the connection is meant to be that the study results might help identify
subgroups that have lower awareness/knowledge/uptake and would potentially benefit from
intervention. Revising these sentences to make the message clearer would help strengthen the
potential impact of the study.
- For the race/ethnicity categories, p. 7 of the Methods lists different categories than the tables.
Specify in the Methods which categories were collapsed.
- HINTS 5, Cycles 1-4 were collected in separate calendar years, and it would be helpful on pp.
5-6 of the Methods to be clearer that these are each separate surveys.
- Could the authors provide a bit more explanation for why age was dichotomized at 50?
- The manuscript needs a read through to ensure that conjunctions are used properly. Several
sentences lack “and” where it should be placed.