Factors Affecting the Cervical Cancer Screening Behaviors of Japanese Women in Their 20s and 30s Using a Health Belief Model: A Cross-Sectional Study
Round 1
Reviewer 1 Report
The manuscript from Dr Zhengai Cui and co-workers report on “Factors affecting the cervical cancer screening behaviours of Japanese women in their 20s and 30s using a health belief model: A cross sectional study”.
This is an interesting study where the authors extensively identified the physiological and personal characteristics associated with CCS (cervical cancer screening) among the youngsters using HBM. I should note that this manuscript is clearly described and summarized to support the authors’ assertions.
The authors clearly mentioned the limitations of the study as well as the conclusion.
Finally, I recommend acceptance of the manuscript after minor revision based on the following comments:
1. The authors should include the internet links used for this study as a supplementary material.
2. There are some typos, please change it accordingly.
Author Response
Response to Reviewer 1 Comments
The manuscript from Dr Zhengai Cui and co-workers report on “Factors affecting the cervical cancer screening behaviours of Japanese women in their 20s and 30s using a health belief model: A cross sectional study”.
This is an interesting study where the authors extensively identified the physiological and personal characteristics associated with CCS (cervical cancer screening) among the youngsters using HBM. I should note that this manuscript is clearly described and summarized to support the authors’ assertions.
The authors clearly mentioned the limitations of the study as well as the conclusion.
Finally, I recommend acceptance of the manuscript after minor revision based on the following comments:
Point 1: The authors should include the internet links used for this study as a supplementary material.
Response 1: Thank you for your advice. All the data (personal characteristics, participation status and reasons for non-participation, and HBM) used in this study are provided as supplementary material (Supplementary Table S1, S2, S3). Revision location in Page 3, line 138-139, 146; in Page 4, line151-152; in Page 14, line 431-433.
Point 2: There are some typos, please change it accordingly.
Response 2: Thank you for that remark. We have corrected the spelling and reformulated some sentences to improve the language.
Reviewer 2 Report
Introduction
Factors affecting the cervical cancer screening behaviors in young people and other age groups as identified in other studies could be discussed in Introduction.
Your selection of Health Belief Model could be justified. Previously, researchers used Transtheoretical Model. Lately, the Behaviour Change Wheel model became popular.
You might find that these references are useful.
Team V, Manderson LH, Markovic M. From state care to self-care: cancer screening behaviours among Russian-speaking Australian women. Aust J Prim Health. 2013;19(2):130-7. doi: 10.1071/PY11158. PMID: 22951044.
Markovic M, Kesic V, Topic L, Matejic B. Barriers to cervical cancer screening: a qualitative study with women in Serbia. Soc Sci Med. 2005 Dec;61(12):2528-35. doi: 10.1016/j.socscimed.2005.05.001. Epub 2005 Jun 13. PMID: 15953668.
Kesic V, Markovic M, Matejic B, Topic L. Awareness of cervical cancer screening among women in Serbia. Gynecol Oncol. 2005 Dec;99(3 Suppl 1):S222-5. doi: 10.1016/j.ygyno.2005.07.092. Epub 2005 Sep 19. PMID: 16169577.
Kelaher M, Gillespie AG, Allotey P, Manderson L, Potts H, Sheldrake M, Young M. The Transtheoretical Model and cervical screening: its application among culturally diverse communities in Queensland, Australia. Ethn Health. 1999 Nov;4(4):259-76. doi: 10.1080/13557859998047. PMID: 10705563.
Methods
Recruitment strategies should be described. How did you get access to women’s personal emails?
Better explanation should be provided on why you’ve excluded women who participated in breast screening.
Data collection instruments should be better described. A table or a figure of the utilised instruments would be helpful. Why you have selected a particular survey instrument? Was it validated?
Have you piloted your own instrument?
It would be nice to discuss how you came us with the list of various reasons for not participating in cervical screening. Some other reasons could have been considered, eg. Opposite gender of a physician, see no benefits in screening, I was vaccinated, I don’t need to be screened, I believe that God will protect me.
Discussion
Discussion could be better structured. A table of barriers and facilitators to cervical cancer screening for various groups could be developed and specific suggestions on how to improve screening developed.
You may discuss youth participation in other types of screening and compare with your findings.
Limitations
More limitations could be identified and discussed, including the instruments’ measurement properties, piloting survey instrument and other.
Tables and Figures
Characteristics column should be Left aligned, not centred.
Some graphs could be developed to improve visual presentation of your findings.
Author Response
Response to Reviewer 2 Comments
Point 1: Factors affecting the cervical cancer screening behaviors in young people and other age groups as identified in other studies could be discussed in Introduction.
Your selection of Health Belief Model could be justified. Previously, researchers used Transtheoretical Model. Lately, the Behaviour Change Wheel model became popular.
You might find that these references are useful.
Team V, Manderson LH, Markovic M. From state care to self-care: cancer screening behaviours among Russian-speaking Australian women. Aust J Prim Health. 2013;19(2):130-7. doi: 10.1071/PY11158. PMID: 22951044.
Markovic M, Kesic V, Topic L, Matejic B. Barriers to cervical cancer screening: a qualitative study with women in Serbia. Soc Sci Med. 2005 Dec;61(12):2528-35. doi: 10.1016/j.socscimed.2005.05.001. Epub 2005 Jun 13. PMID: 15953668.
Kesic V, Markovic M, Matejic B, Topic L. Awareness of cervical cancer screening among women in Serbia. Gynecol Oncol. 2005 Dec;99(3 Suppl 1): S222-5. doi: 10.1016/j.ygyno.2005.07.092. Epub 2005 Sep 19. PMID: 16169577.
Kelaher M, Gillespie AG, Allotey P, Manderson L, Potts H, Sheldrake M, Young M. The Transtheoretical Model and cervical screening: its application among culturally diverse communities in Queensland, Australia. Ethn Health. 1999 Nov;4(4):259-76. doi: 10.1080/13557859998047. PMID: 10705563.
Response 1: We thank the reviewer for this insightful suggestion. We have revised and added the content as follows: “The factors affecting the CCS behaviors in young people and other age groups as identified in other studies were differences in health care policies, inadequate public health education, socio-cultural health beliefs, personal difficulties, and a great lack of knowledge about the necessity of screening [21-23]. Therefore, based on the results of previous studies, it is necessary to identify the reasons why people might not participate in CCS and create a response plan for young people for whom HPV vaccination has been stagnant.” (in Page 2, line 67-73).
“In order to increase the rate of participation in cancer screening, it is necessary to analyze the psychological characteristics that influence screening participation. In Europe and the United States, many studies have been conducted with the aim of improving cancer screening uptake rates using theories of applied behavioral science [24-25]. Therefore, we considered the Transtheoretical Model of Behavior Change [26] and the Health Belief Model (HBM). However, in order to determine individuals’ perceptions of threats posed by health problems, the benefits of avoiding threats and factors influencing decision-making, this research survey was conducted using HBM.” (in Page 2, line 74-81). In addition, the reference list has also been updated.
[21] Team, V.; Manderson, L.H.; Markovic, M. From State Care to Self-Care: Cancer Screening Behaviours among Russian-Speaking Australian Women. Aust. J. Prim. Health 2013, 19, 130, doi:10.1071/PY11158.
[22] Markovic, M.; Kesic, V.; Topic, L.; Matejic, B. Barriers to Cervical Cancer Screening: A Qualitative Study with Women in Serbia. Soc Sci Med 2005, 61, 2528–2535, doi:10.1016/j.socscimed.2005.05.001.
[23] Kesic, V.; Markovic, M.; Matejic, B.; Topic, L. Awareness of Cervical Cancer Screening among Women in Serbia. Gynecol Oncol 2005, 99, S222-225, doi:10.1016/j.ygyno.2005.07.092.
[24] Ahmadian, M.; Samah, A.A. Application of Health Behavior Theories to Breast Cancer Screening among Asian Women. Asian Pac J Cancer Prev 2013, 14, 4005–4013, doi:10.7314/apjcp.2013.14.7.4005.
[25] Champion, V.L. Instrument Refinement for Breast Cancer Screening Behaviors. Nurs Res 1993, 42, 139–143.
[26] Kelaher, M.; Gillespie, A.G.; Allotey, P.; Manderson, L.; Potts, H.; Sheldrake, M.; Young, M. The Transtheoretical Model and Cervical Screening: Its Application among Culturally Diverse Communities in Queensland, Australia. Ethn Health 1999, 4, 259–276, doi:10.1080/13557859998047.
Point 2: Recruitment strategies should be described. How did you get access to women’s personal emails?
Response 2: Thank you very much for your valuable comment. We have added the text as follows: “In this study, the Internet research company made the survey targets of users, and a survey request e-mail was sent out. The survey targets accessed the URL provided in the e-mail and responded to the survey.” (in Page 3, line 118-120).
Point 3: Better explanation should be provided on why you’ve excluded women who participated in breast screening.
Response 3: We thank the reviewers for their valuable suggestions. Breast cancer patients were excluded for 3 reasons: 1. Because the site and age of breast cancer screening were different compared to cervical cancer screening, 2. The purpose of this study is to elucidate the factors that affect cervical cancer screening in women aged 20-30 to facilitate cervical cancer screening, 3. A site-specific breast and cervical cancer screening promotion plan will be developed. A proposal to promote breast cancer screening is currently being prepared.
We have revised and added the text as follows: “The extraction criteria were: (1) only those aged 20-30 years were selected according to the purpose of the study; (2) only those who had participated in cervical cancer screening and those who had never participated in cancer screening were selected because of the difference in screening site and age between breast cancer screening and cervical cancer screening [37]; and (3) only those who had no history of cancer were selected because screening attitudes were related to medical history [38].”(in Page 3, line 124-129). In addition, the reference list has also been updated.
[37] Health status of household members. Available online: https://www.mhlw.go.jp/content/10901000/000342250.pdf (accessed on 18 August 2022).
[38] Schrager, S.; Evaristo, C.; Little, T.; DuBenske, L.; Burnside, E.S. Patient and Clinician Characteristics That Predict Breast Cancer Screening Behavior in 40–49-Year-Old Women. Journal of Patient-Centered Research and Reviews 2021, 8, 331–335, doi:10.17294/2330-0698.1814.
Point 4: Data collection instruments should be better described. A table or a figure of the utilised instruments would be helpful. Why you have selected a particular survey instrument? Was it validated?
Response 4: Many thanks for this comment. We have revised and added a detailed description as follows: “The study, conducted via an internet survey, was designed to investigate in a short period of time the intentions of people who were not screened for cancer in a wide geo-graphic area. At the same time, there are two verification standards for Internet survey companies: 1. Organizations providing services 2. External certification in accordance with national standards.” (in Page 3, line 102-106).
Point 5: Have you piloted your own instrument?
Response 5: Thank you for your comments. We have revised and added the text as follows: “In order to reduce the burden of the respondents, starting from the creation of the online questionnaire, we participate in the design and revision of the questionnaire from time to time. Before the actual survey, in order to ensure the credibility of the participants responses, we actually operated the online questionnaire and measured the shortest time. And set the questionnaires whose answer time is less than the shortest time as meaning-less data.” (in Page 3, line 107-112).
Point 6: It would be nice to discuss how you came us with the list of various reasons for not participating in cervical screening. Some other reasons could have been considered, eg. Opposite gender of a physician, see no benefits in screening, I was vaccinated, I don’t need to be screened, I believe that God will protect me.
Response 6: Thank you for your comments. We have added the explanation as follows: “The CCS participation status: history of screening participation in the past 2 years, types of participation (population-based, workplace-based, individual complete physical examination/hospital visit, and others), and reasons for non-participation (busy, healthy, anxious about the results, did not know about cancer screening, never had a chance to have a cancer screening, forgot to take the test, don't old enough to have a checkup, too much trouble, others) was extracted from the public opinion survey on cancer control [43] (Supplementary Table S2).” (in Page 3, line 140-146).
[43] Outline of the "Public Opinion Survey on Cancer Control. Available online: https://survey.gov-online.go.jp/h28/h28-gantaisaku/gairyaku.pdf (accessed on 22 August 2022).
Point 7: Discussion could be better structured. A table of barriers and facilitators to cervical cancer screening for various groups could be developed and specific suggestions on how to improve screening developed.
Response 7: Thanks for your opinion. We have revised and restructured the Discussion section. We have added Table 5 to make the discussion more organized. (in Page 12, Table5).
We have added the content and rewrote as follows: “In Japan, CCS methods include Cytology alone, HPV testing, and Combined cytology and HPV testing. The target ages for each method were 20-69 years, 30-60 years, and 30-60 years, respectively. Preliminary studies suggest a high incidence of cancer in women under the age of 25 and a high regression rate of CIN2 in this age group, CCS is not recommended for women under the age of 25 [59]. On the other hand, every CCS method is accompanied by the occurrence of false positives [18]. Due to the impact of false positives on the psychological burden, production, and parenting of CCS participants, it is suggested that the target age group of CCS should be changed from 20-39 years to 30-39 years. In addition, paying attention to CCS participants and their children can develop the habit of actively participating in CCS, considering that women in the 30-34 age group are the main focus group. In addition, measures A to C were developed to increase the participation rate of CCS.” (in Page 12-13, line 342-353).
We have added the text as follows: “However, self-collection of cytology is a major decision that must consider existing infrastructure, political will and commitment to implementation, and cultural aspects of the target population [21-23]. Therefore, applying the results of this study to countries other than Japan will depend on the actual situation in each country.” (in Page 13, line 382-386).
[18] Recommendations for Cervical Cancer Screening in Japan Based on Scientific Evidence Updated version of "Guidelines for Cervical Cancer Screening Based on Efficacy Evaluation" released. Available online: https://www.ncc.go.jp/jp/information/pr_release/2020/0729/index.html (accessed on 11 July 2022).
[21] Team, V.; Manderson, L.H.; Markovic, M. From State Care to Self-Care: Cancer Screening Behaviours among Russian-Speaking Australian Women. Aust. J. Prim. Health 2013, 19, 130, doi:10.1071/PY11158.
[22] Markovic, M.; Kesic, V.; Topic, L.; Matejic, B. Barriers to Cervical Cancer Screening: A Qualitative Study with Women in Serbia. Soc Sci Med 2005, 61, 2528–2535, doi: 10.1016/j.socscimed.2005.05.001
[23] Kesic, V.; Markovic, M.; Matejic, B.; Topic, L. Awareness of Cervical Cancer Screening among Women in Serbia. Gynecol Oncol 2005, 99, S222-225, doi: 10.1016/j.ygyno.2005.07.092.
[59] Lee, M. H., Finlayson, S. J., Gukova, K., Hanley, G., Miller, D., & Sadownik, L. A. Outcomes of conservative management of high grade squamous intraepithelial lesions in young women. Journal of Lower Genital Tract Disease 2018, 22(3), 212
Point 8: You may discuss youth participation in other types of screening and compare with your findings.
Response 8: In 2019, the ranking of cancer incidence among Japanese women was breast, colon, lung, stomach, and uterus [1]. We plan to study the breast and uterus separately by the cancer site. Therefore, it can be confusing to discuss participating in other types of screening in the Discussion section. Therefore, we want to omit it in this section for this time.
[1]National Cancer Center (Latest cancer statistics). Available online: https://ganjoho.jp/reg_stat/statistics/stat/summary.html (accessed on 22 August 2022).
Point 9: More limitations could be identified and discussed, including the instruments’ measurement properties, piloting survey instrument and other.
Response 9: Many thanks for your helful comment. We have used this understanding to rewrite the study limitation section. We have also further identified and discussed other limitations within the study.
We have added the text as follows: “Second, because it was an online survey, in some cases, the attributes of respondents registered as monitors may be biased in some cases. Although the bias of survey targets can be adjusted through screening, it is difficult to ensure the reliability and authenticity of the registered attributes themselves. Another issue is that it is impossible to fully confirm the identity of respondents, for example, it is impossible to prevent respondents who are not the actual respondents from answering the survey, so it was not possible to delve deeply into the needs of 20–30-year-olds regarding cancer screening. Therefore, we plan to employ a mixed qualitative and quantitative survey methodology to validate the results of this study.” (in Page 14, line 400-408).
Point 10: Characteristics column should be Left aligned, not centred.
Response 10: We are grateful for the reviewer’s comments on the Table style. The manuscript has been revised accordingly. (in Page 5-6, Table1; in Page 8, Table2; in Page 9, Table3; in Page 10, Table4).
Point 11: Some graphs could be developed to improve visual presentation of your findings.
Response 11: Thank you very much for the suggestion. We have revised the graphs as suggested to improve the visual presentation of the findings. (in Page 5-6, Table1; in Page 8, Table 2; in Page 9, Table 3; in Page 10, Table 4; in Page 12, Table 5).
Reviewer 3 Report
This is an interesting cross-sectional study based on an internet-based survey assessing the participation of young women in the Japanese cervical screening system, using a Health Believe Model and individual’s personal characteristics. With minimal HPV vaccination rates currently in Japan annulling the benefits of primary cervical prevention, participation of individuals in secondary prevention schemes is imperative, however the authors quote a disappointing 33,7% screening rate (row 70).
Cervical cancer rates among Japanese in their 20s to 30s are on the rise (row 43).The appropriate starting age for cervical screening may depend on the natural history of HPV infections in a population, the duration and coverage of the vaccination program, and other factors. Cervical cancer rates begin to increase at the ages of 25 of 29 years, emphasizing the importance of screening for precancers before this age (Fidler MM et al Lancet Oncol 2017/ Moscicki AB et al JLGTD 2018).
Notably there is no clear explanation in the text if cervical screening in Japan is cytology or HPV biomarker-based, as well as possible differences among Japanese prefectures in these particular young age groups.
There is also some confusion over the Inclusion/Exclusion criteria; “being aged 20-69 years” (row 106) is quoted among the inclusion criteria while “participants not in their 20’s and 30’s” are excluded (rows 109-110)
Overall, the study is accurate and well-executed and the concluding remarks are concise.
Row 350-1; “The CCS guideline points out that this method is inappropriate as a screening method”, instead of “inappropriate”, consider instead “suboptimal”. As the authors point (rows 361-2), the ultimate solution might be HPV biomarker-based self sampling in vaginal or urine samples. However, adoption of self sampling techniques is a major decision which has to consider available infrastructures, political will and commitment to enforce the implementation, as well as cultural aspects of the screened population.
Some all too minor language polishing might be beneficial.
REVIEWER’S SUGGESTION: Minor Revision
Author Response
Response to Reviewer 3 Comments
Point 1: This is an interesting cross-sectional study based on an internet-based survey assessing the participation of young women in the Japanese cervical screening system, using a Health Believe Model and individual’s personal characteristics. With minimal HPV vaccination rates currently in Japan annulling the benefits of primary cervical prevention, participation of individuals in secondary prevention schemes is imperative, however the authors quote a disappointing 33,7% screening rate (row 70).
Response 1: We thank the reviewer for this insightful suggestion. We have added and revised the text as follows: “However, the results of the National Cancer Survey in 2019, conducted 9 years later, showed that the CCS participation rate was 43.7% [20].” (in Page 2, line 64-66). In addition, the reference has also been updated.
[20] Health status of generation members. Available online: https://www.mhlw.go.jp/toukei/saikin/hw/k-tyosa/k-tyosa16/dl/04.pdf (accessed on 21 August 2022).
Point 2: Cervical cancer rates among Japanese in their 20s to 30s are on the rise (row 43).The appropriate starting age for cervical screening may depend on the natural history of HPV infections in a population, the duration and coverage of the vaccination program, and other factors. Cervical cancer rates begin to increase at the ages of 25 of 29 years, emphasizing the importance of screening for precancers before this age (Fidler MM et al Lancet Oncol 2017/ Moscicki AB et al JLGTD 2018).
Response 2: Thank you for your comments. We have added the references as follows: “People in their 20s and 30s have different levels of CC morbidity and mortality rates than younger or older adults. As these individuals still have long life expectancies, make significant contributions to the economy, and play an important role in supporting their families, as a consequence, the impact is still huge [5]. Therefore, targeted prevention is needed to reduce CC morbidity and mortality rates in this age group.” (in Page 1, line 35-39).
We have revised and added the content as follows: “In Japan, CCS methods include Cytology alone, HPV testing, and Combined cytology and HPV testing. The target ages for each method were 20-69 years, 30-60 years, and 30-60 years, respectively. Preliminary studies suggest a high incidence of cancer in women under the age of 25 and a high regression rate of CIN2 in this age group, CCS is not recommended for women under the age of 25 [59]. On the other hand, every CCS method is accompanied by the occurrence of false positives [18]. Due to the impact of false positives on the psychological burden, production, and parenting of CCS participants, it is suggested that the target age group of CCS should be changed from 20-39 years to 30-39 years. In addition, paying attention to CCS participants and their children can develop the habit of actively participating in CCS, considering that women in the 30-34 age group are the main focus group. In addition, measures A to C were developed to increase the participation rate of CCS.” (in Page 12-13, line 342-353). In addition, the reference list has also been updated.
[5] Fidler, M.M.; Gupta, S.; Soerjomataram, I.; Ferlay, J.; Steliarova-Foucher, E.; Bray, F. Cancer Incidence and Mortality among Young Adults Aged 20–39 Years Worldwide in 2012: A Population-Based Study. The Lancet Oncology 2017, 18, 1579–1589, doi:10.1016/S1470-2045(17)30677-0.
[18] Recommendations for Cervical Cancer Screening in Japan Based on Scientific Evidence Updated version of "Guidelines for Cervical Cancer Screening Based on Efficacy Evaluation" released. Available online: https://www.ncc.go.jp/jp/information/pr_release/2020/0729/index.html (accessed on 11 July 2022).
[59] Lee, M. H., Finlayson, S. J., Gukova, K., Hanley, G., Miller, D., & Sadownik, L. A. Outcomes of conservative management of high grade squamous intraepithelial lesions in young women. Journal of Lower Genital Tract Disease 2018, 22(3), 212.
Point 3: Notably there is no clear explanation in the text if cervical screening in Japan is cytology or HPV biomarker-based, as well as possible differences among Japanese prefectures in these particular young age groups.
Response 3: Thank you for your comments. We have added and rewrote as: “On the other hand, as a form of secondary prevention in Japan, it has been recommended since 2004 that asymptomatic women over 20 years of age undergo CCS (Cytology alone, HPV testing, and Combined cytology and HPV testing) regularly every 2 years [16-18].” (in Page 2, line 58-61). In addition, the reference list has also been updated.
The Japanese government has been recommending that asymptomatic women over the age of 20 receive regular CCS (Cytology alone, HPV testing, and Combined cytology and HPV testing) every 2 years [18]. In terms of cervical cancer screening methods, there were no differences in screening methods for women across all regions and all age groups.
[16] Cervical Cancer Screening Evidence Report 2019 Edition. Available online: http://canscreen.ncc.go.jp/guideline/shikyukeireport2019.pdf (accessed on 11 July 2022).
[17] Based on Efficacy Evaluation Updated Cervical Cancer Screening Guidelines. Available online: http://canscreen.ncc.go.jp/shikyukeiguide2019.pdf (accessed on 6 July 2022).
[18] Recommendations for Cervical Cancer Screening in Japan Based on Scientific Evidence Updated version of "Guidelines for Cervical Cancer Screening Based on Efficacy Evaluation" released. Available online: https://www.ncc.go.jp/jp/information/pr_release/2020/0729/index.html (accessed on 11 July 2022).
Point 4: There is also some confusion over the Inclusion/Exclusion criteria; “being aged 20-69 years” (row 106) is quoted among the inclusion criteria while “participants not in their 20’s and 30’s” are excluded (rows 109-110).
Overall, the study is accurate and well-executed and the concluding remarks are concise.
Response 4: Thank you for your comments. We have added and rewrote the content as: “The Internet survey inclusion criteria were, as of April 1, 2019, (1) women living in Japan, (2) being aged 20-69 years, and (3) having agreed to complete the questionnaire.
However, in this study, data were extracted from an Internet survey and analyzed and studied. The extraction criteria were: (1) only those aged 20-30 years were selected according to the purpose of the study; (2) only those who had participated in cervical cancer screening and those who had never participated in cancer screening were selected because of the difference in screening site and age between breast cancer screening and cervical cancer screening [37]; and (3) only those who had no history of cancer were selected because screening attitudes were related to medical history [38].” (in Page 3, line 121-129). In addition, the reference list has also been updated.
[37] Health status of household members. Available online: https://www.mhlw.go.jp/content/10901000/000342250.pdf (accessed on 18 August 2022).
[38] Schrager, S.; Evaristo, C.; Little, T.; DuBenske, L.; Burnside, E.S. Patient and Clinician Characteristics That Predict Breast Cancer Screening Behavior in 40–49-Year-Old Women. Journal of Patient-Centered Research and Reviews 2021, 8, 331–335, doi:10.17294/2330-0698.1814.
Point 5: Row 350-1; “The CCS guideline points out that this method is inappropriate as a screening method”, instead of “inappropriate”, consider instead “suboptimal”.
Response 5: Thank you very much for your valuable comment. We have revised it according to your suggestions. Revision location in Page 13, line 368.
Point 6: As the authors point (rows 361-2), the ultimate solution might be HPV biomarker-based self sampling in vaginal or urine samples. However, adoption of self sampling techniques is a major decision which has to consider available infrastructures, political will and commitment to enforce the implementation, as well as cultural aspects of the screened population.
Response 6: Thank you for your comments. We have revised and added the text as follows: “However, self-collection of cytology is a major decision that must consider existing infrastructure, political will and commitment to implementation, and cultural aspects of the target population [21-23]. Therefore, applying the results of this study to countries other than Japan will depend on the actual situation in each country.” (in Page 13, line 382-386).
[21] Team, V.; Manderson, L.H.; Markovic, M. From State Care to Self-Care: Cancer Screening Behaviours among Russian-Speaking Australian Women. Aust. J. Prim. Health 2013, 19, 130, doi:10.1071/PY11158.
[22] Markovic, M.; Kesic, V.; Topic, L.; Matejic, B. Barriers to Cervical Cancer Screening: A Qualitative Study with Women in Serbia. Soc Sci Med 2005, 61, 2528–2535, doi:10.1016/j.socscimed.2005.05.001.
[23] Kesic, V.; Markovic, M.; Matejic, B.; Topic, L. Awareness of Cervical Cancer Screening among Women in Serbia. Gynecol Oncol 2005, 99, S222-225, doi:10.1016/j.ygyno.2005.07.092.
Point 7: Some all too minor language polishing might be beneficial.
Response 7: Thank you for this remark. We have corrected the spelling and reformulated some sentences to improve the language.
Round 2
Reviewer 2 Report
Dear Colleagues
Thank you for addressing my comments and comments of other reviewers. I was satisfied with the nature and scope of your revisions and recommended to accept this article.
I am waiting forwards to see this article in press.
