Demand-side barriers and economic burden in accessing Human Papillomavirus screening for cervical cancer prevention in rural India: Evidence from a cross-sectional study

Demand-side barriers and economic burden in... | F1000Research "use strict";function _typeof(t){return(_typeof="function"==typeof Symbol&&"symbol"==typeof Symbol.iterator?function(t){return typeof t}:function(t){return t&&"function"==typeof Symbol&&t.constructor===Symbol&&t!==Symbol.prototype?"symbol":typeof t})(t)}!function(){var t=function(){var t,e,o=[],n=window,r=n;for(;r;){try{if(r.frames.__tcfapiLocator){t=r;break}}catch(t){}if(r===n.top)break;r=r.parent}t||(!function t(){var e=n.document,o=!!n.frames.__tcfapiLocator;if(!o)if(e.body){var r=e.createElement("iframe");r.style.cssText="display:none",r.name="__tcfapiLocator",e.body.appendChild(r)}else setTimeout(t,5);return!o}(),n.__tcfapi=function(){for(var t=arguments.length,n=new Array(t),r=0;r 3&&2===parseInt(n[1],10)&&"boolean"==typeof n[3]&&(e=n[3],"function"==typeof n[2]&&n[2]("set",!0)):"ping"===n[0]?"function"==typeof n[2]&&n[2]({gdprApplies:e,cmpLoaded:!1,cmpStatus:"stub"}):o.push(n)},n.addEventListener("message",(function(t){var e="string"==typeof t.data,o={};if(e)try{o=JSON.parse(t.data)}catch(t){}else o=t.data;var n="object"===_typeof(o)&&null!==o?o.__tcfapiCall:null;n&&window.__tcfapi(n.command,n.version,(function(o,r){var a={__tcfapiReturn:{returnValue:o,success:r,callId:n.callId}};t&&t.source&&t.source.postMessage&&t.source.postMessage(e?JSON.stringify(a):a,"*")}),n.parameter)}),!1))};"undefined"!=typeof module?module.exports=t:t()}(); dataLayer = dataLayer || []; // Standard GTM initialization - Google Consent Mode handles consent automatically (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start': new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0], j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src= 'https://www.googletagmanager.com/gtm.js?id='+i+dl+ '>m_auth=hzk0Vc3qFsQYhCrIoHz68A>m_preview=env-1>m_cookies_win=x';f.parentNode.insertBefore(j,f); })(window,document,'script','dataLayer','GTM-MWFK8L5J'); ;window.NREUM||(NREUM={});NREUM.init={distributed_tracing:{enabled:true},privacy:{cookies_enabled:true},ajax:{deny_list:["bam.nr-data.net"]}}; ;NREUM.loader_config={accountID:"438030",trustKey:"438030",agentID:"772317073",licenseKey:"97f8f67f26",applicationID:"772317073"} ;NREUM.info={beacon:"bam.nr-data.net",errorBeacon:"bam.nr-data.net",licenseKey:"97f8f67f26",applicationID:"772317073",sa:1} ;/*! For license information please see nr-loader-spa-1.236.0.min.js.LICENSE.txt */ (()=>{"use strict";var e,t,r={5763:(e,t,r)=>{r.d(t,{P_:()=>l,Mt:()=>g,C5:()=>s,DL:()=>v,OP:()=>T,lF:()=>D,Yu:()=>y,Dg:()=>h,CX:()=>c,GE:()=>b,sU:()=>_});var n=r(8632),i=r(9567);const o={beacon:n.ce.beacon,errorBeacon:n.ce.errorBeacon,licenseKey:void 0,applicationID:void 0,sa:void 0,queueTime:void 0,applicationTime:void 0,ttGuid:void 0,user:void 0,account:void 0,product:void 0,extra:void 0,jsAttributes:{},userAttributes:void 0,atts:void 0,transactionName:void 0,tNamePlain:void 0},a={};function s(e){if(!e)throw new Error("All info objects require an agent identifier!");if(!a[e])throw new Error("Info for ".concat(e," was never set"));return a[e]}function c(e,t){if(!e)throw new Error("All info objects require an agent identifier!");a[e]=(0,i.D)(t,o),(0,n.Qy)(e,a[e],"info")}var u=r(7056);const d=()=>{const e={blockSelector:"[data-nr-block]",maskInputOptions:{password:!0}};return{allow_bfcache:!0,privacy:{cookies_enabled:!0},ajax:{deny_list:void 0,enabled:!0,harvestTimeSeconds:10},distributed_tracing:{enabled:void 0,exclude_newrelic_header:void 0,cors_use_newrelic_header:void 0,cors_use_tracecontext_headers:void 0,allowed_origins:void 0},session:{domain:void 0,expiresMs:u.oD,inactiveMs:u.Hb},ssl:void 0,obfuscate:void 0,jserrors:{enabled:!0,harvestTimeSeconds:10},metrics:{enabled:!0},page_action:{enabled:!0,harvestTimeSeconds:30},page_view_event:{enabled:!0},page_view_timing:{enabled:!0,harvestTimeSeconds:30,long_task:!1},session_trace:{enabled:!0,harvestTimeSeconds:10},harvest:{tooManyRequestsDelay:60},session_replay:{enabled:!1,harvestTimeSeconds:60,sampleRate:.1,errorSampleRate:.1,maskTextSelector:"*",maskAllInputs:!0,get blockClass(){return"nr-block"},get ignoreClass(){return"nr-ignore"},get maskTextClass(){return"nr-mask"},get blockSelector(){return e.blockSelector},set blockSelector(t){e.blockSelector+=",".concat(t)},get maskInputOptions(){return e.maskInputOptions},set maskInputOptions(t){e.maskInputOptions={...t,password:!0}}},spa:{enabled:!0,harvestTimeSeconds:10}}},f={};function l(e){if(!e)throw new Error("All configuration objects require an agent identifier!");if(!f[e])throw new Error("Configuration for ".concat(e," was never set"));return f[e]}function h(e,t){if(!e)throw new Error("All configuration objects require an agent identifier!");f[e]=(0,i.D)(t,d()),(0,n.Qy)(e,f[e],"config")}function g(e,t){if(!e)throw new Error("All configuration objects require an agent identifier!");var r=l(e);if(r){for(var n=t.split("."),i=0;i {r.d(t,{D:()=>i});var n=r(50);function i(e,t){try{if(!e||"object"!=typeof e)return(0,n.Z)("Setting a Configurable requires an object as input");if(!t||"object"!=typeof t)return(0,n.Z)("Setting a Configurable requires a model to set its initial properties");const r=Object.create(Object.getPrototypeOf(t),Object.getOwnPropertyDescriptors(t)),o=0===Object.keys(r).length?e:r;for(let a in o)if(void 0!==e[a])try{"object"==typeof e[a]&&"object"==typeof t[a]?r[a]=i(e[a],t[a]):r[a]=e[a]}catch(e){(0,n.Z)("An error occurred while setting a property of a Configurable",e)}return r}catch(e){(0,n.Z)("An error occured while setting a Configurable",e)}}},6818:(e,t,r)=>{r.d(t,{Re:()=>i,gF:()=>o,q4:()=>n});const n="1.236.0",i="PROD",o="CDN"},385:(e,t,r)=>{r.d(t,{FN:()=>a,IF:()=>u,Nk:()=>f,Tt:()=>s,_A:()=>o,il:()=>n,pL:()=>c,v6:()=>i,w1:()=>d});const n="undefined"!=typeof window&&!!window.document,i="undefined"!=typeof WorkerGlobalScope&&("undefined"!=typeof self&&self instanceof WorkerGlobalScope&&self.navigator instanceof WorkerNavigator||"undefined"!=typeof globalThis&&globalThis instanceof WorkerGlobalScope&&globalThis.navigator instanceof WorkerNavigator),o=n?window:"undefined"!=typeof WorkerGlobalScope&&("undefined"!=typeof self&&self instanceof WorkerGlobalScope&&self||"undefined"!=typeof globalThis&&globalThis instanceof WorkerGlobalScope&&globalThis),a=""+o?.location,s=/iPad|iPhone|iPod/.test(navigator.userAgent),c=s&&"undefined"==typeof SharedWorker,u=(()=>{const e=navigator.userAgent.match(/Firefox[/\s](\d+\.\d+)/);return Array.isArray(e)&&e.length>=2?+e[1]:0})(),d=Boolean(n&&window.document.documentMode),f=!!navigator.sendBeacon},1117:(e,t,r)=>{r.d(t,{w:()=>o});var n=r(50);const i={agentIdentifier:"",ee:void 0};class o{constructor(e){try{if("object"!=typeof e)return(0,n.Z)("shared context requires an object as input");this.sharedContext={},Object.assign(this.sharedContext,i),Object.entries(e).forEach((e=>{let[t,r]=e;Object.keys(i).includes(t)&&(this.sharedContext[t]=r)}))}catch(e){(0,n.Z)("An error occured while setting SharedContext",e)}}}},8e3:(e,t,r)=>{r.d(t,{L:()=>d,R:()=>c});var n=r(2177),i=r(1284),o=r(4322),a=r(3325);const s={};function c(e,t){const r={staged:!1,priority:a.p[t]||0};u(e),s[e].get(t)||s[e].set(t,r)}function u(e){e&&(s[e]||(s[e]=new Map))}function d(){let e=arguments.length>0&&void 0!==arguments[0]?arguments[0]:"",t=arguments.length>1&&void 0!==arguments[1]?arguments[1]:"feature";if(u(e),!e||!s[e].get(t))return a(t);s[e].get(t).staged=!0;const r=[...s[e]];function a(t){const r=e?n.ee.get(e):n.ee,a=o.X.handlers;if(r.backlog&&a){var s=r.backlog[t],c=a[t];if(c){for(var u=0;s&&u {let[t,r]=e;return r.staged}))&&(r.sort(((e,t)=>e[1].priority-t[1].priority)),r.forEach((e=>{let[t]=e;a(t)})))}function f(e,t){var r=e[1];(0,i.D)(t[r],(function(t,r){var n=e[0];if(r[0]===n){var i=r[1],o=e[3],a=e[2];i.apply(o,a)}}))}},2177:(e,t,r)=>{r.d(t,{c:()=>f,ee:()=>u});var n=r(8632),i=r(2210),o=r(1284),a=r(5763),s="nr@context";let c=(0,n.fP)();var u;function d(){}function f(e){return(0,i.X)(e,s,l)}function l(){return new d}function h(){u.aborted=!0,u.backlog={}}c.ee?u=c.ee:(u=function e(t,r){var n={},c={},f={},g=!1;try{g=16===r.length&&(0,a.OP)(r).isolatedBacklog}catch(e){}var p={on:b,addEventListener:b,removeEventListener:y,emit:v,get:x,listeners:w,context:m,buffer:A,abort:h,aborted:!1,isBuffering:E,debugId:r,backlog:g?{}:t&&"object"==typeof t.backlog?t.backlog:{}};return p;function m(e){return e&&e instanceof d?e:e?(0,i.X)(e,s,l):l()}function v(e,r,n,i,o){if(!1!==o&&(o=!0),!u.aborted||i){t&&o&&t.emit(e,r,n);for(var a=m(n),s=w(e),d=s.length,f=0;fn,p:()=>i});var n=r(2177).ee.get("handle");function i(e,t,r,i,o){o?(o.buffer([e],i),o.emit(e,t,r)):(n.buffer([e],i),n.emit(e,t,r))}},4322:(e,t,r)=>{r.d(t,{X:()=>o});var n=r(5546);o.on=a;var i=o.handlers={};function o(e,t,r,o){a(o||n.E,i,e,t,r)}function a(e,t,r,i,o){o||(o="feature"),e||(e=n.E);var a=t[o]=t[o]||{};(a[r]=a[r]||[]).push([e,i])}},3239:(e,t,r)=>{r.d(t,{bP:()=>s,iz:()=>c,m$:()=>a});var n=r(385);let i=!1,o=!1;try{const e={get passive(){return i=!0,!1},get signal(){return o=!0,!1}};n._A.addEventListener("test",null,e),n._A.removeEventListener("test",null,e)}catch(e){}function a(e,t){return i||o?{capture:!!e,passive:i,signal:t}:!!e}function s(e,t){let r=arguments.length>2&&void 0!==arguments[2]&&arguments[2],n=arguments.length>3?arguments[3]:void 0;window.addEventListener(e,t,a(r,n))}function c(e,t){let r=arguments.length>2&&void 0!==arguments[2]&&arguments[2],n=arguments.length>3?arguments[3]:void 0;document.addEventListener(e,t,a(r,n))}},4402:(e,t,r)=>{r.d(t,{Ht:()=>u,M:()=>c,Rl:()=>a,ky:()=>s});var n=r(385);const i="xxxxxxxx-xxxx-4xxx-yxxx-xxxxxxxxxxxx";function o(e,t){return e?15&e[t]:16*Math.random()|0}function a(){const e=n._A?.crypto||n._A?.msCrypto;let t,r=0;return e&&e.getRandomValues&&(t=e.getRandomValues(new Uint8Array(31))),i.split("").map((e=>"x"===e?o(t,++r).toString(16):"y"===e?(3&o()|8).toString(16):e)).join("")}function s(e){const t=n._A?.crypto||n._A?.msCrypto;let r,i=0;t&&t.getRandomValues&&(r=t.getRandomValues(new Uint8Array(31)));const a=[];for(var s=0;s {r.d(t,{Bq:()=>n,Hb:()=>o,oD:()=>i});const n="NRBA",i=144e5,o=18e5},7894:(e,t,r)=>{function n(){return Math.round(performance.now())}r.d(t,{z:()=>n})},7243:(e,t,r)=>{r.d(t,{e:()=>o});var n=r(385),i={};function o(e){if(e in i)return i[e];if(0===(e||"").indexOf("data:"))return{protocol:"data"};let t;var r=n._A?.location,o={};if(n.il)t=document.createElement("a"),t.href=e;else try{t=new URL(e,r.href)}catch(e){return o}o.port=t.port;var a=t.href.split("://");!o.port&&a[1]&&(o.port=a[1].split("/")[0].split("@").pop().split(":")[1]),o.port&&"0"!==o.port||(o.port="https"===a[0]?"443":"80"),o.hostname=t.hostname||r.hostname,o.pathname=t.pathname,o.protocol=a[0],"/"!==o.pathname.charAt(0)&&(o.pathname="/"+o.pathname);var s=!t.protocol||":"===t.protocol||t.protocol===r.protocol,c=t.hostname===r.hostname&&t.port===r.port;return o.sameOrigin=s&&(!t.hostname||c),"/"===o.pathname&&(i[e]=o),o}},50:(e,t,r)=>{function n(e,t){"function"==typeof console.warn&&(console.warn("New Relic: ".concat(e)),t&&console.warn(t))}r.d(t,{Z:()=>n})},2587:(e,t,r)=>{r.d(t,{N:()=>c,T:()=>u});var n=r(2177),i=r(5546),o=r(8e3),a=r(3325);const s={stn:[a.D.sessionTrace],err:[a.D.jserrors,a.D.metrics],ins:[a.D.pageAction],spa:[a.D.spa],sr:[a.D.sessionReplay,a.D.sessionTrace]};function c(e,t){const r=n.ee.get(t);e&&"object"==typeof e&&(Object.entries(e).forEach((e=>{let[t,n]=e;void 0===u[t]&&(s[t]?s[t].forEach((e=>{n?(0,i.p)("feat-"+t,[],void 0,e,r):(0,i.p)("block-"+t,[],void 0,e,r),(0,i.p)("rumresp-"+t,[Boolean(n)],void 0,e,r)})):n&&(0,i.p)("feat-"+t,[],void 0,void 0,r),u[t]=Boolean(n))})),Object.keys(s).forEach((e=>{void 0===u[e]&&(s[e]?.forEach((t=>(0,i.p)("rumresp-"+e,[!1],void 0,t,r))),u[e]=!1)})),(0,o.L)(t,a.D.pageViewEvent))}const u={}},2210:(e,t,r)=>{r.d(t,{X:()=>i});var n=Object.prototype.hasOwnProperty;function i(e,t,r){if(n.call(e,t))return e[t];var i=r();if(Object.defineProperty&&Object.keys)try{return Object.defineProperty(e,t,{value:i,writable:!0,enumerable:!1}),i}catch(e){}return e[t]=i,i}},1284:(e,t,r)=>{r.d(t,{D:()=>n});const n=(e,t)=>Object.entries(e||{}).map((e=>{let[r,n]=e;return t(r,n)}))},4351:(e,t,r)=>{r.d(t,{P:()=>o});var n=r(2177);const i=()=>{const e=new WeakSet;return(t,r)=>{if("object"==typeof r&&null!==r){if(e.has(r))return;e.add(r)}return r}};function o(e){try{return JSON.stringify(e,i())}catch(e){try{n.ee.emit("internal-error",[e])}catch(e){}}}},3960:(e,t,r)=>{r.d(t,{K:()=>a,b:()=>o});var n=r(3239);function i(){return"undefined"==typeof document||"complete"===document.readyState}function o(e,t){if(i())return e();(0,n.bP)("load",e,t)}function a(e){if(i())return e();(0,n.iz)("DOMContentLoaded",e)}},8632:(e,t,r)=>{r.d(t,{EZ:()=>u,Qy:()=>c,ce:()=>o,fP:()=>a,gG:()=>d,mF:()=>s});var n=r(7894),i=r(385);const o={beacon:"bam.nr-data.net",errorBeacon:"bam.nr-data.net"};function a(){return i._A.NREUM||(i._A.NREUM={}),void 0===i._A.newrelic&&(i._A.newrelic=i._A.NREUM),i._A.NREUM}function s(){let e=a();return e.o||(e.o={ST:i._A.setTimeout,SI:i._A.setImmediate,CT:i._A.clearTimeout,XHR:i._A.XMLHttpRequest,REQ:i._A.Request,EV:i._A.Event,PR:i._A.Promise,MO:i._A.MutationObserver,FETCH:i._A.fetch}),e}function c(e,t,r){let i=a();const o=i.initializedAgents||{},s=o[e]||{};return Object.keys(s).length||(s.initializedAt={ms:(0,n.z)(),date:new Date}),i.initializedAgents={...o,[e]:{...s,[r]:t}},i}function u(e,t){a()[e]=t}function d(){return function(){let e=a();const t=e.info||{};e.info={beacon:o.beacon,errorBeacon:o.errorBeacon,...t}}(),function(){let e=a();const t=e.init||{};e.init={...t}}(),s(),function(){let e=a();const t=e.loader_config||{};e.loader_config={...t}}(),a()}},7956:(e,t,r)=>{r.d(t,{N:()=>i});var n=r(3239);function i(e){let t=arguments.length>1&&void 0!==arguments[1]&&arguments[1],r=arguments.length>2?arguments[2]:void 0,i=arguments.length>3?arguments[3]:void 0;return void(0,n.iz)("visibilitychange",(function(){if(t)return void("hidden"==document.visibilityState&&e());e(document.visibilityState)}),r,i)}},1214:(e,t,r)=>{r.d(t,{em:()=>v,u5:()=>N,QU:()=>S,_L:()=>I,Gm:()=>L,Lg:()=>M,gy:()=>U,BV:()=>Q,Kf:()=>ee});var n=r(2177);const i="nr@original";var o=Object.prototype.hasOwnProperty,a=!1;function s(e,t){return e||(e=n.ee),r.inPlace=function(e,t,n,i,o){n||(n="");var a,s,c,u="-"===n.charAt(0);for(c=0;c 2?n-2:0),o=2;o {r(A[T],e,w),r(E[T],e,w)})),r(l._A,"fetch",y),t.on(y+"end",(function(e,r){var n=this;if(r){var i=r.headers.get("content-length");null!==i&&(n.rxSize=i),t.emit(y+"done",[null,r],n)}else t.emit(y+"done",[e],n)})),t}const O={},j=["pushState","replaceState"];function S(e){const t=function(e){return(e||n.ee).get("history")}(e);return!l.il||O[t.debugId]++||(O[t.debugId]=1,s(t).inPlace(window.history,j,"-")),t}var P=r(3239);const C={},R=["appendChild","insertBefore","replaceChild"];function I(e){const t=function(e){return(e||n.ee).get("jsonp")}(e);if(!l.il||C[t.debugId])return t;C[t.debugId]=!0;var r=s(t),i=/[?&](?:callback|cb)=([^&#]+)/,o=/(.*)\.([^.]+)/,a=/^(\w+)(\.|$)(.*)$/;function c(e,t){var r=e.match(a),n=r[1],i=r[3];return i?c(i,t[n]):t[n]}return r.inPlace(Node.prototype,R,"dom-"),t.on("dom-start",(function(e){!function(e){if(!e||"string"!=typeof e.nodeName||"script"!==e.nodeName.toLowerCase())return;if("function"!=typeof e.addEventListener)return;var n=(a=e.src,s=a.match(i),s?s[1]:null);var a,s;if(!n)return;var u=function(e){var t=e.match(o);if(t&&t.length>=3)return{key:t[2],parent:c(t[1],window)};return{key:e,parent:window}}(n);if("function"!=typeof u.parent[u.key])return;var d={};function f(){t.emit("jsonp-end",[],d),e.removeEventListener("load",f,(0,P.m$)(!1)),e.removeEventListener("error",l,(0,P.m$)(!1))}function l(){t.emit("jsonp-error",[],d),t.emit("jsonp-end",[],d),e.removeEventListener("load",f,(0,P.m$)(!1)),e.removeEventListener("error",l,(0,P.m$)(!1))}r.inPlace(u.parent,[u.key],"cb-",d),e.addEventListener("load",f,(0,P.m$)(!1)),e.addEventListener("error",l,(0,P.m$)(!1)),t.emit("new-jsonp",[e.src],d)}(e[0])})),t}var k=r(5763);const H={};function L(e){const t=function(e){return(e||n.ee).get("mutation")}(e);if(!l.il||H[t.debugId])return t;H[t.debugId]=!0;var r=s(t),i=k.Yu.MO;return i&&(window.MutationObserver=function(e){return this instanceof i?new i(r(e,"fn-")):i.apply(this,arguments)},MutationObserver.prototype=i.prototype),t}const z={};function M(e){const t=function(e){return(e||n.ee).get("promise")}(e);if(z[t.debugId])return t;z[t.debugId]=!0;var r=n.c,o=s(t),a=k.Yu.PR;return a&&function(){function e(r){var n=t.context(),i=o(r,"executor-",n,null,!1);const s=Reflect.construct(a,[i],e);return t.context(s).getCtx=function(){return n},s}l._A.Promise=e,Object.defineProperty(e,"name",{value:"Promise"}),e.toString=function(){return a.toString()},Object.setPrototypeOf(e,a),["all","race"].forEach((function(r){const n=a[r];e[r]=function(e){let i=!1;[...e||[]].forEach((e=>{this.resolve(e).then(a("all"===r),a(!1))}));const o=n.apply(this,arguments);return o;function a(e){return function(){t.emit("propagate",[null,!i],o,!1,!1),i=i||!e}}}})),["resolve","reject"].forEach((function(r){const n=a[r];e[r]=function(e){const r=n.apply(this,arguments);return e!==r&&t.emit("propagate",[e,!0],r,!1,!1),r}})),e.prototype=a.prototype;const n=a.prototype.then;a.prototype.then=function(){var e=this,i=r(e);i.promise=e;for(var a=arguments.length,s=new Array(a),c=0;c e())),t};function m(e,t){i.inPlace(t,["onreadystatechange"],"fn-",E)}function b(){var e=this,t=r.context(e);e.readyState>3&&!t.resolved&&(t.resolved=!0,r.emit("xhr-resolved",[],e)),i.inPlace(e,f,"fn-",E)}if(function(e,t){for(var r in e)t[r]=e[r]}(o,p),p.prototype=o.prototype,i.inPlace(p.prototype,J,"-xhr-",E),r.on("send-xhr-start",(function(e,t){m(e,t),function(e){h.push(e),a&&(y?y.then(A):u?u(A):(w=-w,x.data=w))}(t)})),r.on("open-xhr-start",m),a){var y=c&&c.resolve();if(!u&&!c){var w=1,x=document.createTextNode(w);new a(A).observe(x,{characterData:!0})}}else t.on("fn-end",(function(e){e[0]&&e[0].type===d||A()}));function A(){for(var e=0;e {r.d(t,{t:()=>n});const n=r(3325).D.ajax},6660:(e,t,r)=>{r.d(t,{A:()=>i,t:()=>n});const n=r(3325).D.jserrors,i="nr@seenError"},3081:(e,t,r)=>{r.d(t,{gF:()=>o,mY:()=>i,t9:()=>n,vz:()=>s,xS:()=>a});const n=r(3325).D.metrics,i="sm",o="cm",a="storeSupportabilityMetrics",s="storeEventMetrics"},4649:(e,t,r)=>{r.d(t,{t:()=>n});const n=r(3325).D.pageAction},7633:(e,t,r)=>{r.d(t,{Dz:()=>i,OJ:()=>a,qw:()=>o,t9:()=>n});const n=r(3325).D.pageViewEvent,i="firstbyte",o="domcontent",a="windowload"},9251:(e,t,r)=>{r.d(t,{t:()=>n});const n=r(3325).D.pageViewTiming},3614:(e,t,r)=>{r.d(t,{BST_RESOURCE:()=>i,END:()=>s,FEATURE_NAME:()=>n,FN_END:()=>u,FN_START:()=>c,PUSH_STATE:()=>d,RESOURCE:()=>o,START:()=>a});const n=r(3325).D.sessionTrace,i="bstResource",o="resource",a="-start",s="-end",c="fn"+a,u="fn"+s,d="pushState"},7836:(e,t,r)=>{r.d(t,{BODY:()=>A,CB_END:()=>E,CB_START:()=>u,END:()=>x,FEATURE_NAME:()=>i,FETCH:()=>_,FETCH_BODY:()=>v,FETCH_DONE:()=>m,FETCH_START:()=>p,FN_END:()=>c,FN_START:()=>s,INTERACTION:()=>l,INTERACTION_API:()=>d,INTERACTION_EVENTS:()=>o,JSONP_END:()=>b,JSONP_NODE:()=>g,JS_TIME:()=>T,MAX_TIMER_BUDGET:()=>a,REMAINING:()=>f,SPA_NODE:()=>h,START:()=>w,originalSetTimeout:()=>y});var n=r(5763);const i=r(3325).D.spa,o=["click","submit","keypress","keydown","keyup","change"],a=999,s="fn-start",c="fn-end",u="cb-start",d="api-ixn-",f="remaining",l="interaction",h="spaNode",g="jsonpNode",p="fetch-start",m="fetch-done",v="fetch-body-",b="jsonp-end",y=n.Yu.ST,w="-start",x="-end",A="-body",E="cb"+x,T="jsTime",_="fetch"},5938:(e,t,r)=>{r.d(t,{W:()=>o});var n=r(5763),i=r(2177);class o{constructor(e,t,r){this.agentIdentifier=e,this.aggregator=t,this.ee=i.ee.get(e,(0,n.OP)(this.agentIdentifier).isolatedBacklog),this.featureName=r,this.blocked=!1}}},9144:(e,t,r)=>{r.d(t,{j:()=>m});var n=r(3325),i=r(5763),o=r(5546),a=r(2177),s=r(7894),c=r(8e3),u=r(3960),d=r(385),f=r(50),l=r(3081),h=r(8632);function g(){const e=(0,h.gG)();["setErrorHandler","finished","addToTrace","inlineHit","addRelease","addPageAction","setCurrentRouteName","setPageViewName","setCustomAttribute","interaction","noticeError","setUserId"].forEach((t=>{e[t]=function(){for(var r=arguments.length,n=new Array(r),i=0;i 1?r-1:0),i=1;i {e.exposed&&e.api[t]&&o.push(e.api[t](...n))})),o.length>1?o:o[0]}(t,...n)}}))}var p=r(2587);function m(e){let t=arguments.length>1&&void 0!==arguments[1]?arguments[1]:{},m=arguments.length>2?arguments[2]:void 0,v=arguments.length>3?arguments[3]:void 0,{init:b,info:y,loader_config:w,runtime:x={loaderType:m},exposed:A=!0}=t;const E=(0,h.gG)();y||(b=E.init,y=E.info,w=E.loader_config),(0,i.Dg)(e,b||{}),(0,i.GE)(e,w||{}),(0,i.sU)(e,x),y.jsAttributes??={},d.v6&&(y.jsAttributes.isWorker=!0),(0,i.CX)(e,y),g();const T=function(e,t){t||(0,c.R)(e,"api");const h={};var g=a.ee.get(e),p=g.get("tracer"),m="api-",v=m+"ixn-";function b(t,r,n,o){const a=(0,i.C5)(e);return null===r?delete a.jsAttributes[t]:(0,i.CX)(e,{...a,jsAttributes:{...a.jsAttributes,[t]:r}}),x(m,n,!0,o||null===r?"session":void 0)(t,r)}function y(){}["setErrorHandler","finished","addToTrace","inlineHit","addRelease"].forEach((e=>h[e]=x(m,e,!0,"api"))),h.addPageAction=x(m,"addPageAction",!0,n.D.pageAction),h.setCurrentRouteName=x(m,"routeName",!0,n.D.spa),h.setPageViewName=function(t,r){if("string"==typeof t)return"/"!==t.charAt(0)&&(t="/"+t),(0,i.OP)(e).customTransaction=(r||"http://custom.transaction")+t,x(m,"setPageViewName",!0)()},h.setCustomAttribute=function(e,t){let r=arguments.length>2&&void 0!==arguments[2]&&arguments[2];if("string"==typeof e){if(["string","number"].includes(typeof t)||null===t)return b(e,t,"setCustomAttribute",r);(0,f.Z)("Failed to execute setCustomAttribute.\nNon-null value must be a string or number type, but a type of was provided."))}else(0,f.Z)("Failed to execute setCustomAttribute.\nName must be a string type, but a type of was provided."))},h.setUserId=function(e){if("string"==typeof e||null===e)return b("enduser.id",e,"setUserId",!0);(0,f.Z)("Failed to execute setUserId.\nNon-null value must be a string type, but a type of was provided."))},h.interaction=function(){return(new y).get()};var w=y.prototype={createTracer:function(e,t){var r={},i=this,a="function"==typeof t;return(0,o.p)(v+"tracer",[(0,s.z)(),e,r],i,n.D.spa,g),function(){if(p.emit((a?"":"no-")+"fn-start",[(0,s.z)(),i,a],r),a)try{return t.apply(this,arguments)}catch(e){throw p.emit("fn-err",[arguments,this,"string"==typeof e?new Error(e):e],r),e}finally{p.emit("fn-end",[(0,s.z)()],r)}}}};function x(e,t,r,i){return function(){return(0,o.p)(l.xS,["API/"+t+"/called"],void 0,n.D.metrics,g),i&&(0,o.p)(e+t,[(0,s.z)(),...arguments],r?null:this,i,g),r?void 0:this}}function A(){r.e(439).then(r.bind(r,7438)).then((t=>{let{setAPI:r}=t;r(e),(0,c.L)(e,"api")})).catch((()=>(0,f.Z)("Downloading runtime APIs failed...")))}return["actionText","setName","setAttribute","save","ignore","onEnd","getContext","end","get"].forEach((e=>{w[e]=x(v,e,void 0,n.D.spa)})),h.noticeError=function(e,t){"string"==typeof e&&(e=new Error(e)),(0,o.p)(l.xS,["API/noticeError/called"],void 0,n.D.metrics,g),(0,o.p)("err",[e,(0,s.z)(),!1,t],void 0,n.D.jserrors,g)},d.il?(0,u.b)((()=>A()),!0):A(),h}(e,v);return(0,h.Qy)(e,T,"api"),(0,h.Qy)(e,A,"exposed"),(0,h.EZ)("activatedFeatures",p.T),T}},3325:(e,t,r)=>{r.d(t,{D:()=>n,p:()=>i});const n={ajax:"ajax",jserrors:"jserrors",metrics:"metrics",pageAction:"page_action",pageViewEvent:"page_view_event",pageViewTiming:"page_view_timing",sessionReplay:"session_replay",sessionTrace:"session_trace",spa:"spa"},i={[n.pageViewEvent]:1,[n.pageViewTiming]:2,[n.metrics]:3,[n.jserrors]:4,[n.ajax]:5,[n.sessionTrace]:6,[n.pageAction]:7,[n.spa]:8,[n.sessionReplay]:9}}},n={};function i(e){var t=n[e];if(void 0!==t)return t.exports;var o=n[e]={exports:{}};return r[e](o,o.exports,i),o.exports}i.m=r,i.d=(e,t)=>{for(var r in t)i.o(t,r)&&!i.o(e,r)&&Object.defineProperty(e,r,{enumerable:!0,get:t[r]})},i.f={},i.e=e=>Promise.all(Object.keys(i.f).reduce(((t,r)=>(i.f[r](e,t),t)),[])),i.u=e=>(({78:"page_action-aggregate",147:"metrics-aggregate",242:"session-manager",317:"jserrors-aggregate",348:"page_view_timing-aggregate",412:"lazy-feature-loader",439:"async-api",538:"recorder",590:"session_replay-aggregate",675:"compressor",733:"session_trace-aggregate",786:"page_view_event-aggregate",873:"spa-aggregate",898:"ajax-aggregate"}[e]||e)+"."+{78:"ac76d497",147:"3dc53903",148:"1a20d5fe",242:"2a64278a",317:"49e41428",348:"bd6de33a",412:"2f55ce66",439:"30bd804e",538:"1b18459f",590:"cf0efb30",675:"ae9f91a8",733:"83105561",786:"06482edd",860:"03a8b7a5",873:"e6b09d52",898:"998ef92b"}[e]+"-1.236.0.min.js"),i.o=(e,t)=>Object.prototype.hasOwnProperty.call(e,t),e={},t="NRBA:",i.l=(r,n,o,a)=>{if(e[r])e[r].push(n);else{var s,c;if(void 0!==o)for(var u=document.getElementsByTagName("script"),d=0;d {s.onerror=s.onload=null,clearTimeout(h);var i=e[r];if(delete e[r],s.parentNode&&s.parentNode.removeChild(s),i&&i.forEach((e=>e(n))),t)return t(n)},h=setTimeout(l.bind(null,void 0,{type:"timeout",target:s}),12e4);s.onerror=l.bind(null,s.onerror),s.onload=l.bind(null,s.onload),c&&document.head.appendChild(s)}},i.r=e=>{"undefined"!=typeof Symbol&&Symbol.toStringTag&&Object.defineProperty(e,Symbol.toStringTag,{value:"Module"}),Object.defineProperty(e,"__esModule",{value:!0})},i.j=364,i.p="https://js-agent.newrelic.com/",(()=>{var e={364:0,953:0};i.f.j=(t,r)=>{var n=i.o(e,t)?e[t]:void 0;if(0!==n)if(n)r.push(n[2]);else{var o=new Promise(((r,i)=>n=e[t]=[r,i]));r.push(n[2]=o);var a=i.p+i.u(t),s=new Error;i.l(a,(r=>{if(i.o(e,t)&&(0!==(n=e[t])&&(e[t]=void 0),n)){var o=r&&("load"===r.type?"missing":r.type),a=r&&r.target&&r.target.src;s.message="Loading chunk "+t+" failed.\n("+o+": "+a+")",s.name="ChunkLoadError",s.type=o,s.request=a,n[1](s)}}),"chunk-"+t,t)}};var t=(t,r)=>{var n,o,[a,s,c]=r,u=0;if(a.some((t=>0!==e[t]))){for(n in s)i.o(s,n)&&(i.m[n]=s[n]);if(c)c(i)}for(t&&t(r);u {i.r(o);var e=i(3325),t=i(5763);const r=Object.values(e.D);function n(e){const n={};return r.forEach((r=>{n[r]=function(e,r){return!1!==(0,t.Mt)(r,"".concat(e,".enabled"))}(r,e)})),n}var a=i(9144);var s=i(5546),c=i(385),u=i(8e3),d=i(5938),f=i(3960),l=i(50);class h extends d.W{constructor(e,t,r){let n=!(arguments.length>3&&void 0!==arguments[3])||arguments[3];super(e,t,r),this.auto=n,this.abortHandler,this.featAggregate,this.onAggregateImported,n&&(0,u.R)(e,r)}importAggregator(){let e=arguments.length>0&&void 0!==arguments[0]?arguments[0]:{};if(this.featAggregate||!this.auto)return;const r=c.il&&!0===(0,t.Mt)(this.agentIdentifier,"privacy.cookies_enabled");let n;this.onAggregateImported=new Promise((e=>{n=e}));const o=async()=>{let t;try{if(r){const{setupAgentSession:e}=await Promise.all([i.e(860),i.e(242)]).then(i.bind(i,3228));t=e(this.agentIdentifier)}}catch(e){(0,l.Z)("A problem occurred when starting up session manager. This page will not start or extend any session.",e)}try{if(!this.shouldImportAgg(this.featureName,t))return void(0,u.L)(this.agentIdentifier,this.featureName);const{lazyFeatureLoader:r}=await i.e(412).then(i.bind(i,8582)),{Aggregate:o}=await r(this.featureName,"aggregate");this.featAggregate=new o(this.agentIdentifier,this.aggregator,e),n(!0)}catch(e){(0,l.Z)("Downloading and initializing ".concat(this.featureName," failed..."),e),this.abortHandler?.(),n(!1)}};c.il?(0,f.b)((()=>o()),!0):o()}shouldImportAgg(r,n){return r!==e.D.sessionReplay||!1!==(0,t.Mt)(this.agentIdentifier,"session_trace.enabled")&&(!!n?.isNew||!!n?.state.sessionReplay)}}var g=i(7633),p=i(7894);class m extends h{static featureName=g.t9;constructor(r,n){let i=!(arguments.length>2&&void 0!==arguments[2])||arguments[2];if(super(r,n,g.t9,i),("undefined"==typeof PerformanceNavigationTiming||c.Tt)&&"undefined"!=typeof PerformanceTiming){const n=(0,t.OP)(r);n[g.Dz]=Math.max(Date.now()-n.offset,0),(0,f.K)((()=>n[g.qw]=Math.max((0,p.z)()-n[g.Dz],0))),(0,f.b)((()=>{const t=(0,p.z)();n[g.OJ]=Math.max(t-n[g.Dz],0),(0,s.p)("timing",["load",t],void 0,e.D.pageViewTiming,this.ee)}))}this.importAggregator()}}var v=i(1117),b=i(1284);class y extends v.w{constructor(e){super(e),this.aggregatedData={}}store(e,t,r,n,i){var o=this.getBucket(e,t,r,i);return o.metrics=function(e,t){t||(t={count:0});return t.count+=1,(0,b.D)(e,(function(e,r){t[e]=w(r,t[e])})),t}(n,o.metrics),o}merge(e,t,r,n,i){var o=this.getBucket(e,t,n,i);if(o.metrics){var a=o.metrics;a.count+=r.count,(0,b.D)(r,(function(e,t){if("count"!==e){var n=a[e],i=r[e];i&&!i.c?a[e]=w(i.t,n):a[e]=function(e,t){if(!t)return e;t.c||(t=x(t.t));return t.min=Math.min(e.min,t.min),t.max=Math.max(e.max,t.max),t.t+=e.t,t.sos+=e.sos,t.c+=e.c,t}(i,a[e])}}))}else o.metrics=r}storeMetric(e,t,r,n){var i=this.getBucket(e,t,r);return i.stats=w(n,i.stats),i}getBucket(e,t,r,n){this.aggregatedData[e]||(this.aggregatedData[e]={});var i=this.aggregatedData[e][t];return i||(i=this.aggregatedData[e][t]={params:r||{}},n&&(i.custom=n)),i}get(e,t){return t?this.aggregatedData[e]&&this.aggregatedData[e][t]:this.aggregatedData[e]}take(e){for(var t={},r="",n=!1,i=0;i t.max&&(t.max=e),e 2&&void 0!==arguments[2])||arguments[2];super(e,r,j.t,n),c.il&&((0,t.OP)(e).initHidden=Boolean("hidden"===document.visibilityState),(0,N.N)((()=>(0,s.p)("docHidden",[(0,p.z)()],void 0,j.t,this.ee)),!0),(0,O.bP)("pagehide",(()=>(0,s.p)("winPagehide",[(0,p.z)()],void 0,j.t,this.ee))),this.importAggregator())}}var P=i(3081);class C extends h{static featureName=P.t9;constructor(e,t){let r=!(arguments.length>2&&void 0!==arguments[2])||arguments[2];super(e,t,P.t9,r),this.importAggregator()}}var R,I=i(2210),k=i(1214),H=i(2177),L={};try{R=localStorage.getItem("__nr_flags").split(","),console&&"function"==typeof console.log&&(L.console=!0,-1!==R.indexOf("dev")&&(L.dev=!0),-1!==R.indexOf("nr_dev")&&(L.nrDev=!0))}catch(e){}function z(e){try{L.console&&z(e)}catch(e){}}L.nrDev&&H.ee.on("internal-error",(function(e){z(e.stack)})),L.dev&&H.ee.on("fn-err",(function(e,t,r){z(r.stack)})),L.dev&&(z("NR AGENT IN DEVELOPMENT MODE"),z("flags: "+(0,b.D)(L,(function(e,t){return e})).join(", ")));var M=i(6660);class B extends h{static featureName=M.t;constructor(r,n){let i=!(arguments.length>2&&void 0!==arguments[2])||arguments[2];super(r,n,M.t,i),this.skipNext=0;try{this.removeOnAbort=new AbortController}catch(e){}const o=this;o.ee.on("fn-start",(function(e,t,r){o.abortHandler&&(o.skipNext+=1)})),o.ee.on("fn-err",(function(t,r,n){o.abortHandler&&!n[M.A]&&((0,I.X)(n,M.A,(function(){return!0})),this.thrown=!0,(0,s.p)("err",[n,(0,p.z)()],void 0,e.D.jserrors,o.ee))})),o.ee.on("fn-end",(function(){o.abortHandler&&!this.thrown&&o.skipNext>0&&(o.skipNext-=1)})),o.ee.on("internal-error",(function(t){(0,s.p)("ierr",[t,(0,p.z)(),!0],void 0,e.D.jserrors,o.ee)})),this.origOnerror=c._A.onerror,c._A.onerror=this.onerrorHandler.bind(this),c._A.addEventListener("unhandledrejection",(t=>{const r=function(e){let t="Unhandled Promise Rejection: ";if(e instanceof Error)try{return e.message=t+e.message,e}catch(t){return e}if(void 0===e)return new Error(t);try{return new Error(t+(0,D.P)(e))}catch(e){return new Error(t)}}(t.reason);(0,s.p)("err",[r,(0,p.z)(),!1,{unhandledPromiseRejection:1}],void 0,e.D.jserrors,this.ee)}),(0,O.m$)(!1,this.removeOnAbort?.signal)),(0,k.gy)(this.ee),(0,k.BV)(this.ee),(0,k.em)(this.ee),(0,t.OP)(r).xhrWrappable&&(0,k.Kf)(this.ee),this.abortHandler=this.#e,this.importAggregator()}#e(){this.removeOnAbort?.abort(),this.abortHandler=void 0}onerrorHandler(t,r,n,i,o){"function"==typeof this.origOnerror&&this.origOnerror(...arguments);try{this.skipNext?this.skipNext-=1:(0,s.p)("err",[o||new F(t,r,n),(0,p.z)()],void 0,e.D.jserrors,this.ee)}catch(t){try{(0,s.p)("ierr",[t,(0,p.z)(),!0],void 0,e.D.jserrors,this.ee)}catch(e){}}return!1}}function F(e,t,r){this.message=e||"Uncaught error with no additional information",this.sourceURL=t,this.line=r}let U=1;const q="nr@id";function G(e){const t=typeof e;return!e||"object"!==t&&"function"!==t?-1:e===c._A?0:(0,I.X)(e,q,(function(){return U++}))}function V(e){if("string"==typeof e&&e.length)return e.length;if("object"==typeof e){if("undefined"!=typeof ArrayBuffer&&e instanceof ArrayBuffer&&e.byteLength)return e.byteLength;if("undefined"!=typeof Blob&&e instanceof Blob&&e.size)return e.size;if(!("undefined"!=typeof FormData&&e instanceof FormData))try{return(0,D.P)(e).length}catch(e){return}}}var X=i(7243);class W{constructor(e){this.agentIdentifier=e,this.generateTracePayload=this.generateTracePayload.bind(this),this.shouldGenerateTrace=this.shouldGenerateTrace.bind(this)}generateTracePayload(e){if(!this.shouldGenerateTrace(e))return null;var r=(0,t.DL)(this.agentIdentifier);if(!r)return null;var n=(r.accountID||"").toString()||null,i=(r.agentID||"").toString()||null,o=(r.trustKey||"").toString()||null;if(!n||!i)return null;var a=(0,_.M)(),s=(0,_.Ht)(),c=Date.now(),u={spanId:a,traceId:s,timestamp:c};return(e.sameOrigin||this.isAllowedOrigin(e)&&this.useTraceContextHeadersForCors())&&(u.traceContextParentHeader=this.generateTraceContextParentHeader(a,s),u.traceContextStateHeader=this.generateTraceContextStateHeader(a,c,n,i,o)),(e.sameOrigin&&!this.excludeNewrelicHeader()||!e.sameOrigin&&this.isAllowedOrigin(e)&&this.useNewrelicHeaderForCors())&&(u.newrelicHeader=this.generateTraceHeader(a,s,c,n,i,o)),u}generateTraceContextParentHeader(e,t){return"00-"+t+"-"+e+"-01"}generateTraceContextStateHeader(e,t,r,n,i){return i+"@nr=0-1-"+r+"-"+n+"-"+e+"----"+t}generateTraceHeader(e,t,r,n,i,o){if(!("function"==typeof c._A?.btoa))return null;var a={v:[0,1],d:{ty:"Browser",ac:n,ap:i,id:e,tr:t,ti:r}};return o&&n!==o&&(a.d.tk=o),btoa((0,D.P)(a))}shouldGenerateTrace(e){return this.isDtEnabled()&&this.isAllowedOrigin(e)}isAllowedOrigin(e){var r=!1,n={};if((0,t.Mt)(this.agentIdentifier,"distributed_tracing")&&(n=(0,t.P_)(this.agentIdentifier).distributed_tracing),e.sameOrigin)r=!0;else if(n.allowed_origins instanceof Array)for(var i=0;i 2&&void 0!==arguments[2])||arguments[2];super(r,n,Z.t,i),(0,t.OP)(r).xhrWrappable&&(this.dt=new W(r),this.handler=(e,t,r,n)=>(0,s.p)(e,t,r,n,this.ee),(0,k.u5)(this.ee),(0,k.Kf)(this.ee),function(r,n,i,o){function a(e){var t=this;t.totalCbs=0,t.called=0,t.cbTime=0,t.end=E,t.ended=!1,t.xhrGuids={},t.lastSize=null,t.loadCaptureCalled=!1,t.params=this.params||{},t.metrics=this.metrics||{},e.addEventListener("load",(function(r){_(t,e)}),(0,O.m$)(!1)),c.IF||e.addEventListener("progress",(function(e){t.lastSize=e.loaded}),(0,O.m$)(!1))}function s(e){this.params={method:e[0]},T(this,e[1]),this.metrics={}}function u(e,n){var i=(0,t.DL)(r);i.xpid&&this.sameOrigin&&n.setRequestHeader("X-NewRelic-ID",i.xpid);var a=o.generateTracePayload(this.parsedOrigin);if(a){var s=!1;a.newrelicHeader&&(n.setRequestHeader("newrelic",a.newrelicHeader),s=!0),a.traceContextParentHeader&&(n.setRequestHeader("traceparent",a.traceContextParentHeader),a.traceContextStateHeader&&n.setRequestHeader("tracestate",a.traceContextStateHeader),s=!0),s&&(this.dt=a)}}function d(e,t){var r=this.metrics,i=e[0],o=this;if(r&&i){var a=V(i);a&&(r.txSize=a)}this.startTime=(0,p.z)(),this.listener=function(e){try{"abort"!==e.type||o.loadCaptureCalled||(o.params.aborted=!0),("load"!==e.type||o.called===o.totalCbs&&(o.onloadCalled||"function"!=typeof t.onload)&&"function"==typeof o.end)&&o.end(t)}catch(e){try{n.emit("internal-error",[e])}catch(e){}}};for(var s=0;s 1?e[1]=i:e.push(i)}else e[0]&&e[0].headers&&s(e[0].headers,n)&&(this.dt=n);function s(e,t){var r=!1;return t.newrelicHeader&&(e.set("newrelic",t.newrelicHeader),r=!0),t.traceContextParentHeader&&(e.set("traceparent",t.traceContextParentHeader),t.traceContextStateHeader&&e.set("tracestate",t.traceContextStateHeader),r=!0),r}}function x(e,t){this.params={},this.metrics={},this.startTime=(0,p.z)(),this.dt=t,e.length>=1&&(this.target=e[0]),e.length>=2&&(this.opts=e[1]);var r,n=this.opts||{},i=this.target;"string"==typeof i?r=i:"object"==typeof i&&i instanceof Y?r=i.url:c._A?.URL&&"object"==typeof i&&i instanceof URL&&(r=i.href),T(this,r);var o=(""+(i&&i instanceof Y&&i.method||n.method||"GET")).toUpperCase();this.params.method=o,this.txSize=V(n.body)||0}function A(t,r){var n;this.endTime=(0,p.z)(),this.params||(this.params={}),this.params.status=r?r.status:0,"string"==typeof this.rxSize&&this.rxSize.length>0&&(n=+this.rxSize);var o={txSize:this.txSize,rxSize:n,duration:(0,p.z)()-this.startTime};i("xhr",[this.params,o,this.startTime,this.endTime,"fetch"],this,e.D.ajax)}function E(t){var r=this.params,n=this.metrics;if(!this.ended){this.ended=!0;for(var o=0;o 2&&void 0!==arguments[2])||arguments[2];super(e,t,we.t,r),this.importAggregator()}}new class{constructor(e){let t=arguments.length>1&&void 0!==arguments[1]?arguments[1]:(0,_.ky)(16);c._A?(this.agentIdentifier=t,this.sharedAggregator=new y({agentIdentifier:this.agentIdentifier}),this.features={},this.desiredFeatures=new Set(e.features||[]),this.desiredFeatures.add(m),Object.assign(this,(0,a.j)(this.agentIdentifier,e,e.loaderType||"agent")),this.start()):(0,l.Z)("Failed to initial the agent. Could not determine the runtime environment.")}get config(){return{info:(0,t.C5)(this.agentIdentifier),init:(0,t.P_)(this.agentIdentifier),loader_config:(0,t.DL)(this.agentIdentifier),runtime:(0,t.OP)(this.agentIdentifier)}}start(){const t="features";try{const r=n(this.agentIdentifier),i=[...this.desiredFeatures];i.sort(((t,r)=>e.p[t.featureName]-e.p[r.featureName])),i.forEach((t=>{if(r[t.featureName]||t.featureName===e.D.pageViewEvent){const n=function(t){switch(t){case e.D.ajax:return[e.D.jserrors];case e.D.sessionTrace:return[e.D.ajax,e.D.pageViewEvent];case e.D.sessionReplay:return[e.D.sessionTrace];case e.D.pageViewTiming:return[e.D.pageViewEvent];default:return[]}}(t.featureName);n.every((e=>r[e]))||(0,l.Z)("".concat(t.featureName," is enabled but one or more dependent features has been disabled (").concat((0,D.P)(n),"). This may cause unintended consequences or missing data...")),this.features[t.featureName]=new t(this.agentIdentifier,this.sharedAggregator)}})),(0,T.Qy)(this.agentIdentifier,this.features,t)}catch(e){(0,l.Z)("Failed to initialize all enabled instrument classes (agent aborted) -",e);for(const e in this.features)this.features[e].abortHandler?.();const r=(0,T.fP)();return delete r.initializedAgents[this.agentIdentifier]?.api,delete r.initializedAgents[this.agentIdentifier]?.[t],delete this.sharedAggregator,r.ee?.abort(),delete r.ee?.get(this.agentIdentifier),!1}}}({features:[J,m,S,class extends h{static featureName=oe;constructor(t,r){if(super(t,r,oe,!(arguments.length>2&&void 0!==arguments[2])||arguments[2]),!c.il)return;const n=this.ee;let i;(0,k.QU)(n),this.eventsEE=(0,k.em)(n),this.eventsEE.on(se,(function(e,t){this.bstStart=(0,p.z)()})),this.eventsEE.on(ae,(function(t,r){(0,s.p)("bst",[t[0],r,this.bstStart,(0,p.z)()],void 0,e.D.sessionTrace,n)})),n.on(ce+ne,(function(e){this.time=(0,p.z)(),this.startPath=location.pathname+location.hash})),n.on(ce+ie,(function(t){(0,s.p)("bstHist",[location.pathname+location.hash,this.startPath,this.time],void 0,e.D.sessionTrace,n)}));try{i=new PerformanceObserver((t=>{const r=t.getEntries();(0,s.p)(te,[r],void 0,e.D.sessionTrace,n)})),i.observe({type:re,buffered:!0})}catch(e){}this.importAggregator({resourceObserver:i})}},C,xe,B,class extends h{static featureName=de;constructor(e,r){if(super(e,r,de,!(arguments.length>2&&void 0!==arguments[2])||arguments[2]),!c.il)return;if(!(0,t.OP)(e).xhrWrappable)return;try{this.removeOnAbort=new AbortController}catch(e){}let n,i=0;const o=this.ee.get("tracer"),a=(0,k._L)(this.ee),s=(0,k.Lg)(this.ee),u=(0,k.BV)(this.ee),d=(0,k.Kf)(this.ee),f=this.ee.get("events"),l=(0,k.u5)(this.ee),h=(0,k.QU)(this.ee),g=(0,k.Gm)(this.ee);function m(e,t){h.emit("newURL",[""+window.location,t])}function v(){i++,n=window.location.hash,this[ve]=(0,p.z)()}function b(){i--,window.location.hash!==n&&m(0,!0);var e=(0,p.z)();this[pe]=~~this[pe]+e-this[ve],this[ye]=e}function y(e,t){e.on(t,(function(){this[t]=(0,p.z)()}))}this.ee.on(ve,v),s.on(be,v),a.on(be,v),this.ee.on(ye,b),s.on(ge,b),a.on(ge,b),this.ee.buffer([ve,ye,"xhr-resolved"],this.featureName),f.buffer([ve],this.featureName),u.buffer(["setTimeout"+le,"clearTimeout"+fe,ve],this.featureName),d.buffer([ve,"new-xhr","send-xhr"+fe],this.featureName),l.buffer([me+fe,me+"-done",me+he+fe,me+he+le],this.featureName),h.buffer(["newURL"],this.featureName),g.buffer([ve],this.featureName),s.buffer(["propagate",be,ge,"executor-err","resolve"+fe],this.featureName),o.buffer([ve,"no-"+ve],this.featureName),a.buffer(["new-jsonp","cb-start","jsonp-error","jsonp-end"],this.featureName),y(l,me+fe),y(l,me+"-done"),y(a,"new-jsonp"),y(a,"jsonp-end"),y(a,"cb-start"),h.on("pushState-end",m),h.on("replaceState-end",m),window.addEventListener("hashchange",m,(0,O.m$)(!0,this.removeOnAbort?.signal)),window.addEventListener("load",m,(0,O.m$)(!0,this.removeOnAbort?.signal)),window.addEventListener("popstate",(function(){m(0,i>1)}),(0,O.m$)(!0,this.removeOnAbort?.signal)),this.abortHandler=this.#e,this.importAggregator()}#e(){this.removeOnAbort?.abort(),this.abortHandler=void 0}}],loaderType:"spa"})})(),window.NRBA=o})(); window.jQuery || document.write(' ') CKEDITOR_BASEPATH='https://f1000research.com/js/vendor/ckeditor/' window.reactTheme = 'research'; window.MathJax = { CommonHTML: { linebreaks: { automatic: true } }, 'HTML-CSS': { linebreaks: { automatic: true } }, SVG: { linebreaks: { automatic: true } }, AuthorInit: function() { MathJax.Hub.Register.MessageHook('End Process', function () { let timeout = false; // holder for timeout id const delay = 250; // delay after event is "complete" to run callback const reflowMath = function() { const dispFormulas = document.querySelectorAll('.disp-formula.panel'); if (!dispFormulas) { return; } for (const dispFormula of dispFormulas) { const child = dispFormula.querySelector('.MathJax_Preview').nextSibling.firstChild; const isMultiline = MathJax.Hub.getAllJax(dispFormula)[0].root.isMultiline; if (dispFormula.offsetWidth < child.offsetWidth || isMultiline) { MathJax.Hub.Queue(['Rerender', MathJax.Hub, dispFormula]); } } }; window.addEventListener('resize', function() { clearTimeout(timeout); // clear the timeout timeout = setTimeout(reflowMath, delay); // start timing for event "completion" }); }); }, }; if (window.location.hash == '#_=_'){ window.location = window.location.href.split('#')[0] } !function(f,b,e,v,n,t,s){if(f.fbq)return;n=f.fbq=function() {n.callMethod? n.callMethod.apply(n,arguments):n.queue.push(arguments)} ;if(!f._fbq)f._fbq=n; n.push=n;n.loaded=!0;n.version='2.0';n.queue=[];t=b.createElement(e);t.async=!0; t.src=v;s=b.getElementsByTagName(e)[0];s.parentNode.insertBefore(t,s)}(window, document,'script','https://connect.facebook.net/en_US/fbevents.js'); fbq('init', '1641728616063202'); fbq('track', "PixelInitialized", {}); (function(h,o,t,j,a,r){ h.hj=h.hj||function(){(h.hj.q=h.hj.q||[]).push(arguments)}; h._hjSettings={hjid:2318163,hjsv:6}; a=o.getElementsByTagName('head')[0]; r=o.createElement('script');r.async=1; r.src=t+h._hjSettings.hjid+j+h._hjSettings.hjsv; a.appendChild(r); })(window,document,'https://static.hotjar.com/c/hotjar-','.js?sv='); search file_upload Submit your research search menu close search Browse Gateways & Collections How to Publish Submit your Research My Submissions Article Guidelines Article Guidelines (New Versions) Open Data, Software and Code Guidelines Open Data and Accessible Source Materials Guidelines (HSS) Open Data, Software and Code Guidelines (PSE) Prepublication Checks Production Process Posters and Slides Guidelines Document Guidelines Article Processing Charges Peer Review Finding Article Reviewers About How it Works For Reviewers Our Advisors Policies Glossary FAQs For Developers Newsroom Contact My Research Submissions Content and Tracking Alerts My Details Sign In file_upload Submit your research { "@context": "https://schema.org", "@type": "ScholarlyArticle", "mainEntityOfPage": { "@type": "WebPage", "@id": "https://f1000research.com/articles/13-630" }, "headline": "Demand-side barriers and economic burden in accessing Human Papillomavirus screening for cervical cancer...", "datePublished": "2024-06-13T17:14:43", "dateModified": "2025-02-17T13:42:35", "author": [ { "@type": "Person", "name": "Shyamkumar Sriram" }, { "@type": "Person", "name": "Arun Daniel Jayakumar" }, { "@type": "Person", "name": "Pavan Kumar Gollapalli" }, { "@type": "Person", "name": "Swetha Chandrasekar" } ], "publisher": { "@type": "Organization", "name": "F1000Research", "logo": { "@type": "ImageObject", "url": "https://f1000research.com/img/AMP/F1000Research_image.png", "height": 480, "width": 60 } }, "image": { "@type": "ImageObject", "url": "https://f1000research.com/img/AMP/F1000Research_image.png", "height": 1200, "width": 150 }, "description": " Introduction Cervical cancer is a significant global health concern, especially in low- and middle-income countries with limited access to preventive healthcare. India’s vast rural population amplifies the challenge, demanding immediate action. Despite advancements, cervical cancer remains prevalent among underserved rural communities, hindered by barriers to Human Papillomavirus (HPV) screening uptake, including socioeconomic and financial constraints. This study aims to evaluate the economic challenges encountered by rural women when accessing HPV screening. Methods A cross-sectional survey was conducted among 1502 women aged 30 to 45 in Pondicherry, India, utilizing the Andersen Model as a conceptual framework. Household questionnaires gathered data on HPV screening expenses, including patient travel costs, productivity loss, and companion costs. The analysis utilized regression models, to identify the factors impacting the economic challenges associated with accessing HPV screening. Results The study found that employment status significantly influenced healthcare costs, with employed women incurring ₹65.78 more than unemployed women (p < 0.001). Education level was also a significant predictor, with each additional year of education leading to a ₹108.45 increase in costs (p < 0.001). Travel time had a positive association with healthcare costs, with every additional minute spent traveling increasing costs by ₹5.98 (p < 0.001). Income and companion accompaniment were also significant predictors, while distance to the PHC and age did not show significant associations with total healthcare. Conclusions The study highlights the multifaceted economic challenges faced by rural populations accessing HPV screening for cervical cancer prevention in India. Notwithstanding diverse demographics and varying proximity to healthcare facilities, individuals encounter significant barriers such as travel time and associated costs. Addressing these challenges necessitates targeted interventions to reduce socioeconomic disparities and improve healthcare accessibility for vulnerable populations, thereby advancing cervical cancer prevention efforts and promoting health equity in rural communities. " } { "@context": "http://schema.org", "@type": "BreadcrumbList", "itemListElement": [ { "@type": "ListItem", "position": "1", "item": { "@id": "https://f1000research.com/", "name": "Home" } }, { "@type": "ListItem", "position": "2", "item": { "@id": "https://f1000research.com/browse/articles", "name": "Browse" } }, { "@type": "ListItem", "position": "3", "item": { "@id": "https://f1000research.com/articles/13-630/v2", "name": "Demand-side barriers and economic burden in accessing Human Papillomavirus..." } } ] } Home Browse Demand-side barriers and economic burden in accessing Human Papillomavirus... ALL Metrics - Views Downloads Get PDF Get XML Cite How to cite this article Sriram S, Jayakumar AD, Gollapalli PK and Chandrasekar S. Demand-side barriers and economic burden in accessing Human Papillomavirus screening for cervical cancer prevention in rural India: Evidence from a cross-sectional study [version 2; peer review: 1 approved, 2 approved with reservations, 2 not approved] . F1000Research 2025, 13 :630 ( https://doi.org/10.12688/f1000research.150361.2 ) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. Close Copy Citation Details Export Export Citation Sciwheel EndNote Ref. Manager Bibtex ProCite Sente EXPORT Select a format first Track Share ▬ ✚ Research Article Revised Demand-side barriers and economic burden in accessing Human Papillomavirus screening for cervical cancer prevention in rural India: Evidence from a cross-sectional study [version 2; peer review: 1 approved, 2 approved with reservations, 2 not approved] Shyamkumar Sriram https://orcid.org/0000-0003-4906-1405 1,2 , Arun Daniel Jayakumar https://orcid.org/0000-0001-5196-6735 3 , Pavan Kumar Gollapalli https://orcid.org/0000-0002-0080-1639 4 , Swetha Chandrasekar https://orcid.org/0009-0005-7561-612X 5 Shyamkumar Sriram https://orcid.org/0000-0003-4906-1405 1,2 , Arun Daniel Jayakumar https://orcid.org/0000-0001-5196-6735 3 , Pavan Kumar Gollapalli https://orcid.org/0000-0002-0080-1639 4 , Swetha Chandrasekar https://orcid.org/0009-0005-7561-612X 5 PUBLISHED 17 Feb 2025 Author details Author details 1 Department of Social and Public Health, Ohio University, Athens, Ohio, 45701, USA 2 Department of Rehabilitation and Health Services, College of Health and Public Service, University of North Texas, Denton, Texas, USA 3 Department of Community Medicine, Aarupadai Veedu Medical College, Pondicherry, 607402, India 4 Department of Community Medicine, Chettinad Academy of Research and Education, Kelambakkam, 603103, India 5 Department of Obstetrics and Gynaecology, Shri Sathya Sai Medical College and Research Institute, Ammapettai, 603108, India Shyamkumar Sriram Roles: Conceptualization, Data Curation, Formal Analysis, Funding Acquisition, Investigation, Methodology, Project Administration, Resources, Software, Supervision, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing Arun Daniel Jayakumar Roles: Data Curation, Investigation, Methodology, Project Administration, Software, Supervision, Validation, Visualization, Writing – Review & Editing Pavan Kumar Gollapalli Roles: Data Curation, Investigation, Methodology, Project Administration, Software, Supervision, Writing – Original Draft Preparation Swetha Chandrasekar Roles: Data Curation, Investigation, Methodology, Project Administration, Resources, Validation, Visualization, Writing – Review & Editing OPEN PEER REVIEW DETAILS REVIEWER STATUS This article is included in the Oncology gateway. This article is included in the Sociology of Health gateway. Abstract Introduction Cervical cancer is a significant global health concern, especially in low- and middle-income countries with limited access to preventive healthcare. India’s vast rural population amplifies the challenge, demanding immediate action. Despite advancements, cervical cancer remains prevalent among underserved rural communities, hindered by barriers to Human Papillomavirus (HPV) screening uptake, including socioeconomic and financial constraints. This study aims to evaluate the economic challenges encountered by rural women when accessing HPV screening. Methods A cross-sectional survey was conducted among 1502 women aged 30 to 45 in Pondicherry, India, utilizing the Andersen Model as a conceptual framework. Household questionnaires gathered data on HPV screening expenses, including patient travel costs, productivity loss, and companion costs. The analysis utilized regression models, to identify the factors impacting the economic challenges associated with accessing HPV screening. Results The study found that employment status significantly influenced healthcare costs, with employed women incurring ₹65.78 more than unemployed women (p < 0.001). Education level was also a significant predictor, with each additional year of education leading to a ₹108.45 increase in costs (p < 0.001). Travel time had a positive association with healthcare costs, with every additional minute spent traveling increasing costs by ₹5.98 (p < 0.001). Income and companion accompaniment were also significant predictors, while distance to the PHC and age did not show significant associations with total healthcare. Conclusions The study highlights the multifaceted economic challenges faced by rural populations accessing HPV screening for cervical cancer prevention in India. Notwithstanding diverse demographics and varying proximity to healthcare facilities, individuals encounter significant barriers such as travel time and associated costs. Addressing these challenges necessitates targeted interventions to reduce socioeconomic disparities and improve healthcare accessibility for vulnerable populations, thereby advancing cervical cancer prevention efforts and promoting health equity in rural communities. READ ALL READ LESS Keywords HPV screening, cervical cancer prevention, rural India, healthcare accessibility, economic burden, healthcare costs Corresponding Author(s) Shyamkumar Sriram ( [email protected] ) Close Corresponding author: Shyamkumar Sriram Competing interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. Grant information: The research was funded by the internal funding support made available to the first and corresponding author Dr. Shyamkumar Sriram from Ohio University College of Health Sciences and Professions, Ohio University, USA The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Copyright: © 2025 Sriram S et al . This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. How to cite: Sriram S, Jayakumar AD, Gollapalli PK and Chandrasekar S. Demand-side barriers and economic burden in accessing Human Papillomavirus screening for cervical cancer prevention in rural India: Evidence from a cross-sectional study [version 2; peer review: 1 approved, 2 approved with reservations, 2 not approved] . F1000Research 2025, 13 :630 ( https://doi.org/10.12688/f1000research.150361.2 ) First published: 13 Jun 2024, 13 :630 ( https://doi.org/10.12688/f1000research.150361.1 ) Latest published: 17 Feb 2025, 13 :630 ( https://doi.org/10.12688/f1000research.150361.2 ) Revised Amendments from Version 1 The minor revisions suggested by Dr. Shabana Tharkar has been addressed in this new version. Methods section has been revised according to STROBE. Outlier in Table 6 has been removed, and the analysis has been re-run for the table. The discussion has been updated accordingly. The minor revisions suggested by Dr. Shabana Tharkar has been addressed in this new version. Methods section has been revised according to STROBE. Outlier in Table 6 has been removed, and the analysis has been re-run for the table. The discussion has been updated accordingly. See the authors' detailed response to the review by Shabana Tharkar READ REVIEWER RESPONSES Introduction Cervical cancer remains a significant global health burden, particularly in low- and middle-income countries (LMICs) where access to preventive healthcare services is often limited. 1 As the fourth most prevalent cancer among women worldwide, it recorded approximately 660,000 new cases and 350,000 fatalities in 2022. 2 India harbours a substantial population of approximately 511.4 million women aged 15 years and older who are at risk of developing cervical cancer, emphasizing the pressing need to address this health challenge. 3 Annually, an estimated 123,907 women are diagnosed with cervical cancer, and 77,348 succumb to the disease. Cervical cancer ranks as the second most common cancer among Indian women, particularly those aged 15 to 44 years, exerting a profound impact nationwide. The prevalence of cervical Human Papillomavirus (HPV) – 16/18 infection among the general female population is estimated to be around 5.0%, with HPV types 16 or 18 accounting for approximately 83.2% of invasive cervical cancer cases. This data highlights the pivotal role of HPV vaccination and screening programs in combating the disease. 4 Although females make up slightly over 48% of India’s rural population, only 1.7% of rural women participated in cervical cancer screening according to data from the National Family Health Survey 5 (NFHS-5). Cervical cancer disproportionately affects rural areas where healthcare access is limited, and awareness of preventive measures is lacking. It is crucial to address these disparities in healthcare access and education to effectively reduce the impact of cervical cancer in India. 5 HPV screening has emerged as a promising tool for early detection and prevention of cervical cancer. However, the uptake of HPV screening services in rural India is hindered by a myriad of demand-side barriers, including socioeconomic challenges and the financial burdens linked to HPV screening. These include both direct costs, such as transportation fees, lost income due to missed work, and out-of-pocket expenditures for healthcare services, as well as indirect expenses. 6 India, with its vast rural population and diverse socio-cultural landscape, faces a particularly daunting burden of cervical cancer. 7 Nevertheless, advances in screening and prevention methods, the disease continues to exact a heavy toll, disproportionately affecting women in underserved rural communities. 8 , 9 HPV testing presents distinct advantages over traditional cytology-based methods like Pap smear, with higher sensitivity, lower false-negative rates, and the capability to detect HPV infection prior to cytological abnormalities, making it advantageous for cervical cancer prevention especially in resource-limited settings. 10 Regardless of the potential benefits of HPV screening, its uptake in rural India is hampered by a range of demand-side barriers that impede access to screening services and contribute to disparities in cervical cancer outcomes. 11 Socio-economic factors play a significant role in shaping access to healthcare services, including HPV screening, in rural India. Poverty, lack of health insurance, and financial constraints often limit women’s ability to seek preventive care, including cervical cancer screening. In many rural households, healthcare expenses are perceived as a luxury rather than a necessity, leading women to prioritize other household needs over their own health. 12 Moreover, the cost of HPV testing and follow-up procedures, such as colposcopy and biopsy, can be prohibitive for women in rural areas, particularly those belonging to marginalized communities. Even when screening services are available free of charge or at subsidized rates, indirect costs such as transportation and lost wages may pose significant barriers to utilization, especially for women residing in remote villages with limited access to healthcare facilities. 13 In rural areas, socioeconomic factors intertwine to create formidable financial barriers for women seeking HPV screening for cervical cancer prevention. 14 The direct costs associated with accessing HPV screening services, including transportation expenses, pose significant challenges for rural residents, particularly those in remote areas. Additionally, the necessity of taking time off work to travel to healthcare facilities results in lost wages for many hourly or daily wage earners, further exacerbating the financial burden. 15 Beyond tangible costs, intangible yet impactful indirect expenses such as the opportunity cost of forgoing work or household responsibilities and psychological stress also deter rural women from seeking screening. These financial burdens contribute to decreased utilization of preventive healthcare services among rural women, exacerbating existing health inequities. 16 Addressing these barriers requires a comprehensive approach encompassing policy reforms, targeted interventions, and community engagement strategies to ensure equitable access to cervical cancer screening services and improve the health outcomes of rural women globally. 17 The conceptual framework ( Figure 1 ) for this study draws upon the Andersen Model, 18 a well-established framework in healthcare research. The Andersen Model emphasizes the interplay between predisposing factors, enabling resources, and need factors in shaping healthcare access and utilization. This model provides a comprehensive framework for understanding the various determinants of healthcare-seeking behaviour and utilization patterns. Figure 1. Conceptual framework for understanding healthcare access and utilization. Predisposing factors: These are characteristics that predispose individuals to seek or avoid healthcare services. In this study, predisposing factors include socio-demographic characteristics such as age, gender, marital status, and household composition. Enabling resources: Enabling resources encompass economic aspects that facilitate or hinder healthcare access and utilization. This includes household consumption expenditures like travel costs, patient time, companion costs, childcare expenses, income level, source of income, and education level. Need factors: Need factors represent the perceived or actual need for healthcare services. This includes healthcare payments, health status, usage patterns, proximity to health facilities, and district of residence. Therefore, the study aims to analyse the economic challenges faced by rural Indian women when accessing HPV screening for cervical cancer prevention. It aims to quantify the costs involved, including transportation expenses, lost wages due to time off work, and other financial implications. Methods Study design: This was a cross-sectional study conducted among women aged 30 to 45 years in Pondicherry, India. Study setting and participants: Pondicherry, a Union Territory of India, was selected as the study area due to its manageable size and diverse population of approximately 898,000 individuals. The study population consisted of women aged 30 to 45 years residing within the catchment areas of selected Primary Health Centers (PHCs) in Pondicherry. Sampling strategy: A three-stage random sampling method was used to select 1,500 participants from 15 PHCs in Pondicherry. • Stage 1: A list of all PHCs in Pondicherry was obtained from the District Public Health Office. Fifteen PHCs were randomly selected using simple random sampling. The selected PHCs included Abishegapakkam, Ariyankuppam, Bahour, Gorimedu, Karikalampakkam, Kirumambakkam, Koodapakkam, Mettupalayam, Nettapakkam, Reddiarpalayam, Thavalakuppam, Villianur, Ariyur, Sedarapet, and Karayamputhur. • Stage 2: Within each selected PHC, five Anganwadi Centers (AWCs) were randomly chosen. • Stage 3: From each selected AWC, 20 women aged 30 to 45 years were randomly sampled from beneficiary lists, resulting in 100 women per PHC and a total sample size of 1,500 women. Data collection: Data were collected using the Household Cost Questionnaire (HCQ), which captured socio-demographic variables such as age, education level, income level, source of income, and district of residence. Healthcare cost-related data were also collected, including patient travel expenses, time spent on travel, companion expenses, childcare expenses, and productivity losses. Exposure and outcome variables: • Exposure variables: Employment status (employed/unemployed), education level (ranging from primary education to postgraduate level), and income level (categorized into different household income brackets). • Outcome variable: Total healthcare costs incurred for accessing HPV screening, including: ○ Patient travel expenses (round-trip costs for various transportation modes) ○ Companion expenses (travel costs and time off work) ○ Childcare expenses (costs for dependent care during the visit) ○ Productivity loss (earnings lost due to time off work, calculated based on the average daily wage of ₹265 for rural female workers, as per the National Statistical Office, 2022) 19 Covariates and bias handling: To minimize bias and improve the validity of findings, several methodological safeguards were implemented: • Selection bias: A three-stage random sampling method ensured that participants were chosen randomly from eligible women within the PHC catchment areas, enhancing representativeness and reducing systematic differences. • Information bias: Data were collected using a standardized HCQ administered by trained interviewers to ensure consistency and minimize recall bias. Travel cost estimates were cross-validated with local fare structures to improve data accuracy. • Confounding control: Covariates such as age, distance from home to the PHC, travel time, and whether a companion accompanied the participant were included in the multivariable regression analysis to control for confounding factors. • Data quality and outlier management: Extreme values in cost-related variables were examined, and any inconsistencies were addressed before analysis to ensure data reliability. Ethical considerations: Institutional ethical approval was obtained from the Institutional Review Board of Ohio University (IRB project 23-E-101), titled Supply-side and Demand-side Barriers to Access HPV Screening and the Cost-effectiveness Analysis of Human Papillomavirus (HPV) Screening for the Prevention of Cervical Cancer Screening in India . The study was deemed exempt from review as no interventions were conducted. Data analysis: Data were analyzed using STATA 16. Descriptive statistics (means, medians, standard deviations, and ranges) were used to summarize demographic characteristics and healthcare access variables. To assess the association between exposure variables (employment status, education level, and income level) and total healthcare costs incurred for HPV screening, multivariable regression models were employed. Results The demographic breakdown of the surveyed population ( Table 1 ) consisting of 1502 individuals, showcases a varied distribution across female age groups, with the highest percentage falling between 31 to 40 years (34.75%), closely followed by the 21 to 30 years range (30.89%). The majority of respondents are married (85.62%). Employment status displays diversity, with homemakers representing the largest segment (70.64%), followed by those engaged in full-time (10.19%) and part-time (13.05%) work. Education levels range from primary to post-graduate university, with a noteworthy proportion having attained some secondary education (32.42%). Annual household incomes comprise a significant proportion falling below 50,000 INR (28.03%). The majority of households accommodate four or fewer adults (86.82%) and two or fewer children (96.40%). Table 1. Demographic characteristics of the study variables. Variables Categories Frequency (N = 1502) Percentage (%) Age in years 15 to 20 108 7.19 21 to 30 464 30.89 31 to 40 522 34.75 More than 40 408 27.16 Marital status Single 195 12.98 Married 1286 85.62 Separated 5 0.33 Divorced 2 0.13 Widowed 11 0.73 Other (Specify) 3 0.20 Employment status In full-time work 153 10.19 In part-time work 196 13.05 Currently seeking work 26 1.73 Homemaker 1061 70.64 Retired 1 0.07 Both in part-time & full-time 1 0.07 Other (Specify) 64 4.26 Education level All secondary 338 22.50 College 297 19.77 Post-graduate university 3 0.20 Primary 351 23.37 Primary, University 1 0.07 Some secondary 487 32.42 Some secondary University 1 0.07 University 24 1.60 Annual household income (INR) Less than 50,000 INR 421 28.03 More than 50,000 INR & less than 100,000 INR 349 23.24 More than 100,000 INR and less than 200,000 INR 416 27.70 More than 200,000 INR 316 21.04 Adults in household 4 and less than 4 adults in household 1304 86.82 More than 4 adults in household 198 13.18 Table 2 provides essential demographic and geographic variables pertaining to healthcare access. The mean annual household income is 155,560 INR, with a median of 100,000 INR and a substantial range spanning 6,000,000 INR. This discrepancy between the mean and median suggests a positively skewed distribution influenced by high-income outliers. Age distribution, with a mean of 34.08 years and a median of 34 years, appears relatively symmetric, indicating a balanced spread across age groups. The number of adults in households has a mean of 2.96 and a median of 3, with a range extending to 10, reflecting moderate variability in household composition. Similarly, the number of children in households shows a mean of 1.07 and a median of 1, with a range of 15, suggesting varied family sizes. Geographic metrics reveal wider disparities, with a mean distance from home to the Primary Health Center (PHC) of 3.64 kilometers and a median of 2 kilometers. This disparity between mean and median distances indicates significant variability, possibly reflecting urban-rural disparities in accessibility. Additionally, the distances traveled by private car or motorbike, reaching up to 299 km one-way, provide insights into transportation needs and possibly lifestyle preferences. Collectively, these data points infer a multifaceted picture of households, highlighting disparities in income, demographics, and geographic access, crucial for understanding and addressing diverse societal needs and challenges. Table 2. Summary of household characteristics and geographic proximity to PHCs. Variables Mean Median Range SD Annual Household Income (INR) 155,560 100,000 6,000,000 202,103.80 Age 34.08 34 43 8.91 Number of adults in household 2.96 3 10 1.43 Number of children in household 1.07 1 15 0.99 Distance from home to the PHC (km) 3.64 2 500 15.39 Distance traveled by private car or motorbike (one-way) (km) 22.06 3 299 43.50 Table 3 presents frequencies and percentages related to various variables associated with households’ interactions with Primary Health Centers (PHCs). Notably, a significant majority of households, comprising 80.36%, reside within a 3-kilometer radius from a PHC, suggesting relatively close proximity for accessing healthcare services. However, a notable proportion, 15.85%, live farther, between 3 and 10 kilometers from the nearest PHC. Moreover, a smaller percentage, 2.60%, reside beyond 10 kilometers, indicating potential challenges in accessing healthcare for these households. Table 3. Variables related to access and utilization of PHC services. Variables Categories Frequency (N = 1502) Percentage (%) Distance from home to the PHC (km) Less than or equal to 3 km 1207 80.36 More than 3 km and less than 10 km 238 15.85 More than 10 km and less than 20 km 39 2.60 More than 10 minutes & less than 20 minutes 666 44.34 More than 20 minutes & less than 30 minutes 151 10.05 Travelled by public transport No 1255 83.56 Yes 247 16.44 Returned home using the same form of transport Yes 1414 94.14 No 88 5.86 Companion accompanied the person to the PHC Yes 186 12.38 No 1316 87.62 In terms of travel duration, a considerable portion of individuals, accounting for 44.34%, reported travel times of more than 10 minutes but less than 20 minutes to reach the PHC, with 10.05% enduring journeys lasting between 20 and 30 minutes. This infers varying degrees of travel inconvenience potentially experienced by households when seeking healthcare. Regarding transportation modes, a majority, comprising 83.56%, did not utilize public transport, suggesting a reliance on private means of transportation. Additionally, a significant majority, 94.14%, returned home using the same mode of transport, indicating consistency in transportation choices. Furthermore, the data reveals insights into social dynamics, with only 12.38% of individuals being accompanied by a companion to the PHC. This indicates that for the majority, healthcare-seeking behaviour occurs independently. Table 4 offers insights into various time-related aspects concerning individuals’ interactions with PHCs and related responsibilities. Table 4. Factors influencing time management and work obligations during visits to PHCs. Variables Categories Frequency (N = 1502) Percentage (%) Time spent in the PHC (waiting time & consultation time) 5 and less than 5 minutes 129 8.59 More than 5 minutes & less than 10 minutes 122 8.12 More than 10 minutes & less than 20 minutes 254 16.91 More than 20 minutes & less than 60 minutes 964 64.18 More than 60 minutes 33 2.20 Time taken from paid work to come to the PHC (minutes) More than 10 mins & less than 30 mins 4 6.35 More than 30 mins & less than 60 mins 21 33.33 Number of days in a week, an individual works Less than 4 days 4 3.51 More than 4 days & less than 5 days 39 34.21 More than 5 days & less than 7 days 71 62.28 Number of hours in a week, on average, the individual works (hours) 10 hours and less than 10 hours per week 44 38.60 More than 10 hours and less than 20 hours per week 6 5.26 More than 20 hours and less than 40 hours per week 37 32.46 More than 40 hours and less than 72 hours per week 27 23.68 Time taken from work to visit the Primary Health Center (minutes) 10 minutes or less 27 23.68 More than 10 mins & less than 30 mins 33 28.95 More than 30 mins & less than 60 mins 38 33.33 More than 60 mins & less than 120 mins 16 14.04 Time spent by the companion both in travel time and time spent at the PHC (minutes) 10 minutes or less 50 26.88 More than 10 mins & less than 30 mins 41 22.04 More than 30 mins & less than 60 mins 74 39.78 More than 60 mins & less than 120 mins 21 11.29 Amount of time taken off from paid work to accompany the individual to the PHC (minutes) 10 minutes or less 149 80.11 More than 10 mins & less than 30 mins 6 3.23 More than 30 mins & less than 60 mins 13 6.99 More than 60 mins & less than 120 mins 12 6.45 More than 120 mins & less than 300 mins 6 3.23 Time spent looking after the children/dependents by the caregiver when the individual visited the PHC 15 minutes or less 22 34.92 More than 15 mins & less than 30 mins 16 25.40 More than 30 mins & less than 60 mins 21 33.33 More than 60 mins & less than 120 mins 4 6.35 Firstly, concerning the time spent at the PHC, the majority of individuals, constituting 64.18%, reported durations of more than 20 minutes but less than 60 minutes, emphasizing potentially significant waiting and consultation times. Moreover, 8.12% and 16.91% experienced shorter durations, while a smaller proportion, 2.20%, endured waits exceeding 60 minutes. In terms of time allocation from paid work to visit the PHC, there’s a distribution across various durations, with 33.33% spending more than 30 minutes but less than 60 minutes, indicating potential disruptions to work schedules for healthcare visits. Furthermore, data regarding work schedules reveals that the majority, comprising 62.28%, work more than 5 days but less than 7 days per week, underscoring potential challenges in balancing work commitments with healthcare needs. Regarding time spent by companions, there’s variability, with 39.78% spending more than 30 minutes but less than 60 minutes, possibly reflecting the support provided by companions in accompanying individuals to PHCs. Moreover, data on time taken off from paid work to accompany individuals to PHCs highlights that a significant majority, at 80.11%, reported durations of 10 minutes or less, indicating minimal disruptions to work for caregiving responsibilities. Lastly, concerning caregiving responsibilities, caregivers spent varying durations looking after children/dependents during individuals’ visits to PHCs, with 33.33% spending more than 30 minutes but less than 60 minutes, reflecting the impact of healthcare visits on caregiving duties. Overall, these insights shed light on the time-related challenges and dynamics individuals and their companions face when accessing healthcare services, highlighting areas where interventions or improvements may be necessary to streamline processes and reduce burdens on individuals and their support networks. Table 5 presents a detailed overview of various time-related factors associated with individuals’ engagements with PHCs and their corresponding duties. Table 5. Time-related challenges that the individuals and their companions encounter when accessing healthcare services. Variables Mean Median Range SD Time taken to travel from home to the PHC (minutes) 16.12 15 70 9.84 Time taken from paid work to come to the PHC (minutes) 52.52 60 120 45.18 Time spent by the companion both in travel time and time spent at the PHC (minutes) 36.18 40 120 27.44 Amount of time taken off from paid work to accompany the individual to the PHC (minutes) 62.05 47.50 299 67.13 Time spent looking after the children/dependents by the caregiver when the individual visited the PHC (minutes) 30.30 30 120 28.03 Time taken from work to visit the Primary Health Center (minutes) 41.71 30 120 35.81 For the duration of travel from home to the PHC, the mean time is 16.12 minutes, with a median of 15 minutes, indicating generally consistent travel times for most individuals. However, there is notable variability, with travel durations ranging from 0 to 70 minutes, and a standard deviation of 9.84 suggests moderate dispersion around the mean. Regarding the time taken from paid work to reach the PHC, the mean duration is higher at 52.52 minutes, with a median of 60 minutes, reflecting potentially longer commutes for those traveling from their workplaces. The range spans from 0 to 120 minutes, indicating diverse commuting times, with a considerable standard deviation of 45.18. Companions’ time commitments, including travel and time spent at the PHC, show a mean duration of 36.18 minutes, with a median of 40 minutes, suggesting moderate consistency. However, there is variability, with durations ranging from 0 to 120 minutes and a standard deviation of 27.44. Individuals taking time off from work to accompany others to the PHC experience a mean duration of 62.05 minutes, with a median of 47.50 minutes, highlighting significant disruptions to work schedules. The range is wide, from 0 to 299 minutes, with a considerable standard deviation of 67.13. Lastly, caregivers spend an average of 30.30 minutes looking after children/dependents during PHC visits, with a median of 30 minutes, showcasing consistent caregiving responsibilities. Variability exists, with durations ranging from 0 to 120 minutes and a standard deviation of 28.03. Table 6 presents detailed insights into the various costs and time implications associated with patient travel, companion expenses, childcare, and productivity losses related to visits to the PHC. Table 6. Patient’s comprehensive expenses for rural PHC treatment access. Variables Mean Median Range SD Patient travel costs Cost of one-way fare if traveled by public transport (INR) 55.34 20 20 - 500 2064.14 Cost of one-way taxi fare (INR) 58.46 50 50 - 198 37.64 Cost of tolls if travel by private car or motorbike (INR) 52.42 50 50 - 199 39.94 Patient time costs Amount of earnings lost due to time taken off work to go to the PHC (INR) 99.20 50 50 -500 129.35 Companion costs Cost of one-way fare if the companion traveled by public transport with the patient (INR) 54.60 50 50 -298 56.79 Childcare and other dependent costs Amount paid to that person to look after children/dependents when the individual visited the PHC (INR) 3.66 0 0 - 20 8.04 Productivity losses Number of days a week individual works (days) 5.06 6 5 - 6 0.74 Number of hours a week, on average the individual works (hours) 27.23 34 10 - 70 18.50 The average one-way fare for public transport was 55.34 INR (median: 20 INR, range: 20–500 INR), while the cost of a one-way taxi fare averaged 58.46 INR (median: 50 INR). Additional travel costs, such as tolls for private vehicles, had a mean value of 52.42 INR. The earnings lost due to time off work to visit the PHC averaged 99.20 INR, with a median loss of 50 INR. Companion travel costs averaged 54.60 INR, and childcare costs were minimal, with a mean of 3.66 INR. Productivity losses indicate that individuals worked an average of 5.06 days per week (median: 6 days) and 27.23 hours per week (median: 34 hours). Table 7 presented the multivariable regression analysis to understand the relationship between various socio-economic factors and Total Healthcare Costs (THC) incurred for HPV screening. The model explained 5.9% of the variance (R 2 = 0.059, Adjusted R 2 = 0.056), indicating that the included predictors had a modest effect on THC. The Durbin-Watson statistic (1.705) suggested no strong autocorrelation in the residuals, and Variance Inflation Factors (VIF < 1.3) confirmed no severe multicollinearity among variables. Table 7. Factors impacting total healthcare costs: Insights from Regression analysis. Variable B (Unstandardized Coefficient) SE (Standard Error) Beta (Standardized Coefficient) t p-value VIF (Constant) -250.45 78.92 — -3.17 0.002** — Employment (1=Employed) 65.78 16.45 0.098 3.99 0.000** 1.055 Distance to PHC (km) -0.285 0.690 -0.009 -0.41 0.680 1.003 Education (years) 108.45 19.87 0.150 5.46 0.000** 1.222 Income (INR) 0.000 0.000 0.075 2.89 0.004** 1.113 Travel Time (minutes) 5.98 1.24 0.122 4.81 0.000** 1.052 Companion Accompanied (1=Yes) 109.87 36.91 0.075 2.98 0.003** 1.023 Age (years) 0.94 1.39 0.017 0.68 0.497 1.102 Among the key findings, employed women spent ₹65.78 more on healthcare costs than unemployed women (p < 0.001). Higher education levels were associated to increased costs, with each additional year of education increasing THC by ₹108.45 (p < 0.001). Income also had a small but significant impact, with higher income levels slightly increasing THC (p = 0.004). Travel time significantly affected costs, with each additional minute increasing THC by ₹5.98 (p < 0.001). Women who traveled with a companion incurred additional ₹109.87 expenses than those who traveled alone (p = 0.003). However, distance to the PHC (₹-0.285, p = 0.680) and age (₹0.94, p = 0.497) were not significant cost factors. Discussion The study emphasizes the significant impact of socioeconomic factors on healthcare accessibility and affordability. The above findings highlight those indirect costs, such as productivity loss and transportation expenses, substantially contribute to the economic burden of HPV screening. Variables like employment status, educational attainment, and income level are pivotal in determining the financial strain associated with accessing HPV screening services. Those with higher socioeconomic status typically face fewer obstacles due to their greater financial means and enhanced access to healthcare facilities. The specific finding that employment status is a significant predictor of the economic hurdles in accessing HPV screening in rural India highlights the intricate interplay between socioeconomic factors and healthcare utilization. This observation is in line with the research conducted by Srivatsa et al., which suggests that women hailing from households with a higher income are significantly more inclined to undergo cervical cancer screening compared to those from lower-income households. 20 , 21 Additional studies such as Kaneko, 2018, and Keetile et al., 2021 have similarly argued that disadvantaged households are often less informed and thus less likely to prioritize cervical cancer screening. 22 , 23 A notable finding underlines the influence of travel-related variables on overall expenses. Extended travel duration to the PHC and having a companion during PHC visits are associated with increased total costs. These results are consistent with prior research conducted by Rocque (2019) and Kornelson (2021), 24 , 25 highlighting the significant contribution of travel-related expenses, to the economic burden experienced by individuals accessing HPV screening in rural areas. This observation is further supported by Wu et al. (2020) and Srinath et al (2023). 26 , 27 Addressing transportation barriers and providing assistance for travel expenses could prove instrumental in easing the economic burden on vulnerable populations. 28 , 29 Sriram et al. emphasized the role of healthcare efficiency in reducing patient costs. Longer wait times at PHCs increase total expenses, highlighting the need for streamlined processes and better resource management. Enhancing infrastructure and implementing efficient appointment systems can improve HPV screening accessibility while lowering costs. Their study also found that for-profit hospitals have shorter wait times, attracting wealthier patients. To ensure equitable access, public hospitals must reduce delays. Addressing sociodemographic and community factors can further enhance screening uptake within local healthcare settings. 30 – 32 Initiatives to enhance access to HPV screening should not only address geographical barriers but also consider the socioeconomic determinants that may deter individuals from seeking preventive care. By addressing these disparities, policymakers and healthcare providers can strive toward ensuring equitable access to vital healthcare services, thereby alleviating the burden of preventable diseases like cervical cancer in rural India and beyond. 4 , 15 , 33 The findings of the study have important policy implications for cervical cancer prevention efforts in rural India. Policy interventions aimed at improving employment opportunities, promoting education, and enhancing transportation infrastructure can help alleviate the socioeconomic barriers to accessing HPV screening services. Additionally, targeted financial assistance programs for low-income individuals and those living in remote areas can help reduce the economic burden associated with seeking healthcare services. 11 , 34 The study acknowledges several limitations, such as its cross-sectional design and potential confounding factors. Future research could explore longitudinal data to assess the long-term economic impact of accessing HPV screening. Moreover, qualitative studies could provide deeper insights into the lived experiences of individuals accessing HPV screening services and the factors influencing their decision-making processes. In conclusion, recognizing the key socioeconomic factors and travel-related expenses that impact total healthcare costs, implementing strategies to lower travel costs and alleviate financial barriers especially for lower-income and unemployed women could enhance the accessibility and affordability of screening, thereby improving public health outcomes. Ethics approval and consent to participate Institutional Ethical approval was obtained from the Institutional Review Board of Ohio University on 05.17.2023. IRB project 23-E-101, titled ‘Supply-side and Demand-side Barriers to Access HPV Screening and the Cost-effectiveness analysis of Human Papilloma Virus (HPV) Screening for the Prevention of Cervical Cancer Screening in India. Ohio University’s Institutional Review Board deemed it exempt from review since no interventions were carried out. Informed written consent was obtained from all study participants before data collection. Consent for publication Not applicable. Data availability statement Underlying data Harvard Dataverse : Demand-side Barriers and Economic Burden in Accessing Human Papillomavirus Screening for Cervical Cancer Prevention in Rural India: Evidence from a Cross-sectional Study, https://doi.org/10.7910/DVN/H9DB7B . 35 This project contains the following underlying data: - Microsoft Excel Spreadsheet Data are available under the terms of the Creative Commons Zero “No rights reserved” data waiver (CC0 1.0 Public domain dedication) Extended data Harvard Dataverse: Demand-side Barriers and Economic Burden in Accessing Human Papillomavirus Screening for Cervical Cancer Prevention in Rural India: Evidence from a Cross-sectional Study, https://doi.org/10.7910/DVN/H9DB7B . 35 This project contains the following extended data: - Questionnaire Data are available under the terms of the Creative Commons Zero “No rights reserved” data waiver (CC0 1.0 Public domain dedication). References 1. Singh D, Vignat J, Lorenzoni V, et al. : Global estimates of incidence and mortality of cervical cancer in 2020: a baseline analysis of the WHO Global Cervical Cancer Elimination Initiative. Lancet Glob. Health. 2023 Feb 1 [cited 2024 Mar 14]; 11 (2): e197–e206. PubMed Abstract | Publisher Full Text | Free Full Text Reference Source 2. Cervical cancer: [cited 2024 Mar 14]. Reference Source 3. Reichheld A, Mukherjee PK, Rahman SMF, et al. : Prevalence of cervical cancer screening and awareness among women in an urban community in South India—a cross sectional study. Ann. Glob. Health. 2020; 86 (1): 30. PubMed Abstract | Publisher Full Text | Free Full Text 4. Complementary data on cervical cancer prevention.[cited 2024 Mar 14]. Reference Source 5. Zhetpisbayeva I, Kassymbekova F, Sarmuldayeva S, et al. : Cervical Cancer Prevention in Rural Areas. Ann. Glob. Health. 2023 [cited 2024 Mar 14]; 89 (1): 75. PubMed Abstract | Publisher Full Text | Free Full Text 6. Srivastava AN, Misra JS, Srivastava S, et al. : Cervical cancer screening in rural India: Status & current concepts. Indian J. Med. Res. 2018 Dec 1 [cited 2024 Mar 14]; 148 (6): 687–696. PubMed Abstract | Publisher Full Text | Free Full Text 7. Cervical cancer screening in rural India: Status & current concepts - PMC.[cited 2024 Mar 14]. Reference Source 8. Cervical Cancer Elimination Initiative: [cited 2024 Mar 14]. Reference Source 9. Human Papillomavirus (HPV) Infection - STI Treatment Guidelines.[cited 2024 Mar 14]. Reference Source 10. Swid MA, Monaco SE: Should screening for cervical cancer go to primary human papillomavirus testing and eliminate cytology? Mod. Pathol. 2022 Jul 1; 35 (7): 858–864. PubMed Abstract | Publisher Full Text 11. Petersen Z, Jaca A, Ginindza TG, et al. : Barriers to uptake of cervical cancer screening services in low-and-middle-income countries: a systematic review. BMC Womens Health. 2022 Dec 1 [cited 2024 Mar 14]; 22 (1): 420–486. PubMed Abstract | Publisher Full Text | Free Full Text 12. Chauhan AS, Prinja S, Srinivasan R, et al. : Cost effectiveness of strategies for cervical cancer prevention in India. PLoS One. 2020 Sep 1 [cited 2024 Mar 14]; 15 (9): e0238291. PubMed Abstract | Publisher Full Text | Free Full Text 13. Cost effectiveness of strategies for cervical cancer prevention in India - PMC.[cited 2024 Mar 14]. Reference Source 14. Vega Crespo B, Neira VA, Ortíz Segarra J, et al. : Barriers and facilitators to cervical cancer screening among under-screened women in Cuenca, Ecuador: the perspectives of women and health professionals. BMC Public Health. 2022 Dec 1 [cited 2024 Mar 14]; 22 (1): 2114–2144. PubMed Abstract | Publisher Full Text | Free Full Text 15. Kurani S, MacLaughlin KL, Jacobson RM, et al. : Socioeconomic Disadvantage and Human Papillomavirus (HPV) Vaccination Uptake. Vaccine. 2022 Jan 1 [cited 2024 Mar 14]; 40 (3): 471–476. PubMed Abstract | Publisher Full Text | Free Full Text 16. Felsher M, Setiawan D, Varga S, et al. : Economic and humanistic burden of HPV-related disease in Indonesia: A qualitative analysis. Glob. Public Health. 2023 Jan 2 [cited 2024 Mar 14]; 18 (1). PubMed Abstract | Publisher Full Text 17. Casas CPR, de Albuquerque R d CR , Loureiro RB, et al. : Cervical cancer screening in low- and middle-income countries: A systematic review of economic evaluation studies. Clinics. 2022 Jan 1; 77 : 100080. PubMed Abstract | Publisher Full Text | Free Full Text 18. Nagdev P, Iyer MR, Naik S, et al. : Andersen health care utilization model: A survey on factors affecting the utilization of dental health services among school children. PLoS One. 2023 Jun 15; 18 (6): e0286945. PubMed Abstract | Publisher Full Text | Free Full Text 19. Women and Men in India 2022 WOMEN AND MEN IN INDIA.[cited 2024 Apr 9]. Reference Source 20. Srivastava S, Kurian K, Garg PR, et al. : Prevalence and predictors of cervical cancer screening among reproductive age group women: evidence from cross-sectional study in Rohtak and Delhi. Asian Pac. J. Cancer Prev. 2022 Aug; 23 (8): 2771–2777. PubMed Abstract | Publisher Full Text | Free Full Text 21. Chao DYS, Clark M, Carson E, et al. : Economic Analysis.2019 [cited 2024 Apr 9]. Reference Source 22. Kaneko N: Factors associated with cervical cancer screening among young unmarried Japanese women: results from an internet-based survey. BMC Woman’s Health. 2018 Jul 31 [cited 2024 Apr 9]; 18 (1). Publisher Full Text | Free Full Text 23. Keetile M, Ndlovu K, Letamo G, et al. : Factors associated with and socioeconomic inequalities in breast and cervical cancer screening among women aged 15–64 years in Botswana. PLoS One. 2021 Aug 1 [cited 2024 Apr 9]; 16 (8): e0255581. PubMed Abstract | Publisher Full Text | Free Full Text 24. Rocque GB, Williams CP, Miller HD, et al. : Impact of travel time on health care costs and resource use by phase of care for older patients with cancer. J. Clin. Oncol. 2019 Aug 8; 37 (22): 1935–1945. PubMed Abstract | Publisher Full Text | Free Full Text 25. Kornelsen J, Khowaja AR, Av-Gay G, et al. : The rural tax: comprehensive out-of-pocket costs associated with patient travel in British Columbia. BMC Health Serv. Res. 2021 Aug 21; 21 (1): 854. PubMed Abstract | Publisher Full Text | Free Full Text 26. Wu Q, Jia M, Chen H, et al. : The economic burden of cervical cancer from diagnosis to one year after final discharge in Henan Province, China: A retrospective case series study. PLoS One. 2020 May 7; 15 (5): e0232129. PubMed Abstract | Publisher Full Text | Free Full Text 27. Srinath A, van Merode F , Rao SV, et al. : Barriers to cervical cancer and breast cancer screening uptake in low- and middle-income countries: a systematic review. Health Policy Plan. 2023 Apr 11; 38 (4): 509–527. PubMed Abstract | Publisher Full Text | Free Full Text 28. Oluyede L, Cochran AL, Wolfe M, et al. : Addressing transportation barriers to health care during the COVID-19 pandemic: Perspectives of care coordinators. Transp. Res. Part A Policy Pract. 2022 May; 159 : 157–168. Epub 2022 Mar 7. PubMed Abstract | Publisher Full Text | Free Full Text 29. Syed ST, Gerber BS, Sharp LK: Traveling towards disease: transportation barriers to health care access. J. Community Health. 2013 Oct; 38 (5): 976–993. PubMed Abstract | Publisher Full Text | Free Full Text 30. Sriram S, Noochpoung R: Determinants of hospital waiting time for outpatient care in India: how demographic characteristics, hospital ownership, and ambulance arrival affect waiting time. Int. J. Commun. Med. Public Health. 2018 Jul; 5 (7): 2692. Publisher Full Text 31. Sriram S, Ranganathan R: Why human papilloma virus vaccination coverage is low among adolescents in the US? A study of barriers for vaccination uptake. J. Family Med. Prim. Care. 2019 Mar; 8 (3): 866–870. PubMed Abstract | Publisher Full Text | Free Full Text 32. Sriram S, Verma VR, Gollapalli PK, et al. : Decomposing the inequalities in the catastrophic health expenditures on the hospitalization in India: empirical evidence from national sample survey data. Front. Public Health. 2024 Apr 4; 12 : 1329447. PubMed Abstract | Publisher Full Text | Free Full Text 33. NCI Cervical Cancer ‘Last Mile’ Initiative|Division of Cancer Prevention.[cited 2024 Apr 9]. Reference Source 34. Lott BE, Trejo MJ, Baum C, et al. : Interventions to increase uptake of cervical screening in sub-Saharan Africa: a scoping review using the integrated behavioral model. BMC Public Health. 2020 Dec; 20 : 1–8. Publisher Full Text 35. Sriram S: Demand-side Barriers and Economic Burden in Accessing Human Papillomavirus Screening for Cervical Cancer Prevention in Rural India: Evidence from a Cross-sectional Study. Harvard Dataverse. V2 . Publisher Full Text Comments on this article Comments (0) Version 2 VERSION 2 PUBLISHED 13 Jun 2024 ADD YOUR COMMENT Comment Author details Author details 1 Department of Social and Public Health, Ohio University, Athens, Ohio, 45701, USA 2 Department of Rehabilitation and Health Services, College of Health and Public Service, University of North Texas, Denton, Texas, USA 3 Department of Community Medicine, Aarupadai Veedu Medical College, Pondicherry, 607402, India 4 Department of Community Medicine, Chettinad Academy of Research and Education, Kelambakkam, 603103, India 5 Department of Obstetrics and Gynaecology, Shri Sathya Sai Medical College and Research Institute, Ammapettai, 603108, India Shyamkumar Sriram Roles: Conceptualization, Data Curation, Formal Analysis, Funding Acquisition, Investigation, Methodology, Project Administration, Resources, Software, Supervision, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing Arun Daniel Jayakumar Roles: Data Curation, Investigation, Methodology, Project Administration, Software, Supervision, Validation, Visualization, Writing – Review & Editing Pavan Kumar Gollapalli Roles: Data Curation, Investigation, Methodology, Project Administration, Software, Supervision, Writing – Original Draft Preparation Swetha Chandrasekar Roles: Data Curation, Investigation, Methodology, Project Administration, Resources, Validation, Visualization, Writing – Review & Editing Competing interests The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. Grant information The research was funded by the internal funding support made available to the first and corresponding author Dr. Shyamkumar Sriram from Ohio University College of Health Sciences and Professions, Ohio University, USA The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Article Versions (2) version 2 Revised Published: 17 Feb 2025, 13:630 https://doi.org/10.12688/f1000research.150361.2 version 1 Published: 13 Jun 2024, 13:630 https://doi.org/10.12688/f1000research.150361.1 Copyright © 2025 Sriram S et al . This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Download Export To Sciwheel Bibtex EndNote ProCite Ref. Manager (RIS) Sente metrics Views Downloads F1000Research - - PubMed Central info_outline Data from PMC are received and updated monthly. - - Citations open_in_new 0 open_in_new 0 open_in_new SEE MORE DETAILS CITE how to cite this article Sriram S, Jayakumar AD, Gollapalli PK and Chandrasekar S. Demand-side barriers and economic burden in accessing Human Papillomavirus screening for cervical cancer prevention in rural India: Evidence from a cross-sectional study [version 2; peer review: 1 approved, 2 approved with reservations, 2 not approved] . F1000Research 2025, 13 :630 ( https://doi.org/10.12688/f1000research.150361.2 ) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS track receive updates on this article Track an article to receive email alerts on any updates to this article. TRACK THIS ARTICLE Share Open Peer Review Current Reviewer Status: ? Key to Reviewer Statuses VIEW HIDE Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Version 2 VERSION 2 PUBLISHED 17 Feb 2025 Revised Views 0 Cite How to cite this report: Dhamanti I. Reviewer Report For: Demand-side barriers and economic burden in accessing Human Papillomavirus screening for cervical cancer prevention in rural India: Evidence from a cross-sectional study [version 2; peer review: 1 approved, 2 approved with reservations, 2 not approved] . F1000Research 2025, 13 :630 ( https://doi.org/10.5256/f1000research.177813.r385439 ) The direct URL for this report is: https://f1000research.com/articles/13-630/v2#referee-response-385439 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 03 Jun 2025 Inge Dhamanti , Universitas Airlangga, Surabaya, Indonesia Approved with Reservations VIEWS 0 https://doi.org/10.5256/f1000research.177813.r385439 The discussion and conclusion are too short; the authors could add some actionable steps or practical recommendations for relevant stakeholders, such as policymakers, healthcare providers, and community organization. The authors need to acknowledge the limitations of the ... Continue reading READ ALL The discussion and conclusion are too short; the authors could add some actionable steps or practical recommendations for relevant stakeholders, such as policymakers, healthcare providers, and community organization. The authors need to acknowledge the limitations of the study or methodological constraints in the study and also suggest areas for future research. Is the work clearly and accurately presented and does it cite the current literature? Yes Is the study design appropriate and is the work technically sound? Yes Are sufficient details of methods and analysis provided to allow replication by others? Yes If applicable, is the statistical analysis and its interpretation appropriate? Yes Are all the source data underlying the results available to ensure full reproducibility? Yes Are the conclusions drawn adequately supported by the results? Partly Competing Interests: No competing interests were disclosed. Reviewer Expertise: Public Health, Safety and Quality I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Dhamanti I. Reviewer Report For: Demand-side barriers and economic burden in accessing Human Papillomavirus screening for cervical cancer prevention in rural India: Evidence from a cross-sectional study [version 2; peer review: 1 approved, 2 approved with reservations, 2 not approved] . F1000Research 2025, 13 :630 ( https://doi.org/10.5256/f1000research.177813.r385439 ) The direct URL for this report is: https://f1000research.com/articles/13-630/v2#referee-response-385439 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Respond or Comment COMMENT ON THIS REPORT Views 0 Cite How to cite this report: Cruz-Valdez A. Reviewer Report For: Demand-side barriers and economic burden in accessing Human Papillomavirus screening for cervical cancer prevention in rural India: Evidence from a cross-sectional study [version 2; peer review: 1 approved, 2 approved with reservations, 2 not approved] . F1000Research 2025, 13 :630 ( https://doi.org/10.5256/f1000research.177813.r379656 ) The direct URL for this report is: https://f1000research.com/articles/13-630/v2#referee-response-379656 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 30 May 2025 Aurelio Cruz-Valdez , Instituto Nacional de Salud Pública, Cuernavaca, Mexico Not Approved VIEWS 0 https://doi.org/10.5256/f1000research.177813.r379656 The topic is important. Social and economic determinants are crucial for cancer mortality. The article addresses an essential aspect of identifying the association with economic determinants in a country rife with social contrasts. However, I believe there are several ... Continue reading READ ALL The topic is important. Social and economic determinants are crucial for cancer mortality. The article addresses an essential aspect of identifying the association with economic determinants in a country rife with social contrasts. However, I believe there are several aspects that need to be clarified: In the Introduction section: 1) It is lengthy and imprecise, and the reader loses the thread between the justification and the objective of the study. This situation is straightforward in the first six sentences of this section. We can consider the Andersen model a guide for this section study’s approach. 2) The argument for the study of aim is not remains identified. Methods Section: 1) Selection of the study population: We solicit to State the method for calculating the sample size. How did you calculate the variability across these many stages? This allows you to observe the internal and external inferences of the results. 2) What were the selection and exclusion criteria for the study population? 3) Variable Selection: The authors note a series of “exposure and outcome” variables, but they not show which variables measure each construct in Andersen’s model. By not mentioning them which concepts each variable measures, which would don’t allow us to understand the creation of the statistical model used in the analysis, and the control of confounding variables. 4) Regarding the management of covariates and biases, this section is unnecessary. Detailing the data quality and the steps taken to address inconsistencies, particularly in measuring the outcome and economic variables, would be better. Why they did not create indices for the different variables measuring different dimensions of the same construct, such as economic variables, time management, or the access. This results in too many tables, which prevents the author from integrating the results. It is striking that the model’s prediction is very low (R2 = 5.9%). Discussion Section: 1) The authors should emphasize the findings comparing to other authors and other contexts. This causes that we don’t identify the importance of results, and this section does not contribute new knowledge. We suggest a more thorough review that considers Andersen’s model, since it is which they used in their theoretical framework from the start. Is the work clearly and accurately presented and does it cite the current literature? Yes Is the study design appropriate and is the work technically sound? No Are sufficient details of methods and analysis provided to allow replication by others? No If applicable, is the statistical analysis and its interpretation appropriate? Partly Are all the source data underlying the results available to ensure full reproducibility? Partly Are the conclusions drawn adequately supported by the results? No Competing Interests: No competing interests were disclosed. Reviewer Expertise: Public Health; Cervical cancer epidemiology; HPV infection and cancer I confirm that I have read this submission and believe that I have an appropriate level of expertise to state that I do not consider it to be of an acceptable scientific standard, for reasons outlined above. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Cruz-Valdez A. Reviewer Report For: Demand-side barriers and economic burden in accessing Human Papillomavirus screening for cervical cancer prevention in rural India: Evidence from a cross-sectional study [version 2; peer review: 1 approved, 2 approved with reservations, 2 not approved] . F1000Research 2025, 13 :630 ( https://doi.org/10.5256/f1000research.177813.r379656 ) The direct URL for this report is: https://f1000research.com/articles/13-630/v2#referee-response-379656 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Respond or Comment COMMENT ON THIS REPORT Version 1 VERSION 1 PUBLISHED 13 Jun 2024 Views 0 Cite How to cite this report: Tharkar S. Reviewer Report For: Demand-side barriers and economic burden in accessing Human Papillomavirus screening for cervical cancer prevention in rural India: Evidence from a cross-sectional study [version 2; peer review: 1 approved, 2 approved with reservations, 2 not approved] . F1000Research 2025, 13 :630 ( https://doi.org/10.5256/f1000research.164926.r347336 ) The direct URL for this report is: https://f1000research.com/articles/13-630/v1#referee-response-347336 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 29 Jan 2025 Shabana Tharkar , King Saud University, Riyadh, Saudi Arabia Approved with Reservations VIEWS 0 https://doi.org/10.5256/f1000research.164926.r347336 This research" Demand-side barriers and economic burden in accessing Human Papillomavirus screening for cervical cancer prevention in rural India: Evidence from a cross-sectional study" addresses an important issue of recognizing barriers to cancer screening in the rural sector of a developing ... Continue reading READ ALL This research" Demand-side barriers and economic burden in accessing Human Papillomavirus screening for cervical cancer prevention in rural India: Evidence from a cross-sectional study" addresses an important issue of recognizing barriers to cancer screening in the rural sector of a developing country. However, only economic challenges have been addressed. The paper is well- written and the results are well-presented. Major points Introduction and rationale are acceptable but the methods need revision. Can revise methods according to STROBE Please remove outlier in Table 6, (cost of one way fare) and re -run the stats. The paper can be accepted after revision. Is the work clearly and accurately presented and does it cite the current literature? Yes Is the study design appropriate and is the work technically sound? Yes Are sufficient details of methods and analysis provided to allow replication by others? Yes If applicable, is the statistical analysis and its interpretation appropriate? Yes Are all the source data underlying the results available to ensure full reproducibility? Yes Are the conclusions drawn adequately supported by the results? Yes Competing Interests: No competing interests were disclosed. Reviewer Expertise: Epidemiology of non communicable diseases I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Tharkar S. Reviewer Report For: Demand-side barriers and economic burden in accessing Human Papillomavirus screening for cervical cancer prevention in rural India: Evidence from a cross-sectional study [version 2; peer review: 1 approved, 2 approved with reservations, 2 not approved] . F1000Research 2025, 13 :630 ( https://doi.org/10.5256/f1000research.164926.r347336 ) The direct URL for this report is: https://f1000research.com/articles/13-630/v1#referee-response-347336 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Author Response 04 Feb 2025 Shyamkumar Sriram , Department of Social and Public Health, Ohio University, Athens, 45701, USA 04 Feb 2025 Author Response The revisions have been made according to the suggestion by Dr. Shabana Tharkar. Methods have been revised according to STROBE. Outlier has been removed in Table 6 and the statistics ... Continue reading The revisions have been made according to the suggestion by Dr. Shabana Tharkar. Methods have been revised according to STROBE. Outlier has been removed in Table 6 and the statistics have been rerun. The discussion section is also updated. Thanks for the feedback and offering to accept the paper after revisions. The revisions have been made according to the suggestion by Dr. Shabana Tharkar. Methods have been revised according to STROBE. Outlier has been removed in Table 6 and the statistics have been rerun. The discussion section is also updated. Thanks for the feedback and offering to accept the paper after revisions. Competing Interests: No conflicts of interest Close Report a concern Respond or Comment COMMENTS ON THIS REPORT Author Response 04 Feb 2025 Shyamkumar Sriram , Department of Social and Public Health, Ohio University, Athens, 45701, USA 04 Feb 2025 Author Response The revisions have been made according to the suggestion by Dr. Shabana Tharkar. Methods have been revised according to STROBE. Outlier has been removed in Table 6 and the statistics ... Continue reading The revisions have been made according to the suggestion by Dr. Shabana Tharkar. Methods have been revised according to STROBE. Outlier has been removed in Table 6 and the statistics have been rerun. The discussion section is also updated. Thanks for the feedback and offering to accept the paper after revisions. The revisions have been made according to the suggestion by Dr. Shabana Tharkar. Methods have been revised according to STROBE. Outlier has been removed in Table 6 and the statistics have been rerun. The discussion section is also updated. Thanks for the feedback and offering to accept the paper after revisions. Competing Interests: No conflicts of interest Close Report a concern COMMENT ON THIS REPORT Views 0 Cite How to cite this report: Anand A. Reviewer Report For: Demand-side barriers and economic burden in accessing Human Papillomavirus screening for cervical cancer prevention in rural India: Evidence from a cross-sectional study [version 2; peer review: 1 approved, 2 approved with reservations, 2 not approved] . F1000Research 2025, 13 :630 ( https://doi.org/10.5256/f1000research.164926.r332791 ) The direct URL for this report is: https://f1000research.com/articles/13-630/v1#referee-response-332791 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 29 Oct 2024 Ankit Anand , Population Research Centre,, Institute for Social and Economic Change, Karnataka, India Not Approved VIEWS 0 https://doi.org/10.5256/f1000research.164926.r332791 The topic is very interesting and relevant, but the analysis does not add much value to the topic. Need to provide details on the estimation of the cost and income levels. Introduction is very generic and does not ... Continue reading READ ALL The topic is very interesting and relevant, but the analysis does not add much value to the topic. Need to provide details on the estimation of the cost and income levels. Introduction is very generic and does not add why this data and analysis was needed. It states a lot of generic statement and facts which need to be inline why such study is required. For example: Author stated “only 1.7% of rural women participated in cervical cancer screening according to data from the National Family Health Survey 5 (NFHS-5).” “Addressing these barriers requires a comprehensive approach encompassing policy reforms, targeted interventions, and community engagement strategies to ensure equitable access to cervical cancer screening services and improve the health outcomes of rural women globally” Study may be needed to explore barriers among female in rural areas. Why Author selected Puducherry which is one of the urban Union Territory of India? There seems to a lot of reporting bias and This statement make no sense "Public transport one-way fares exhibit a wide range, spanning from 20 INR to 79,999 INR." 70,000 is a lot of cost for public transport in India. Data need to cleaned (check for outliers and validation before analysing it). How was the data quality ensured? It needs to be added. The analysis and variables are not well though of. There needs a detail description of how the economic related variables were collected and analysed. Most of the variables seem to be correlated in table 7. Distance from facility will be co-related with traveling time and cost of traveling. this is obvious. Having a companion significant increase the cost. this is obvious too, hardly a finding Why local ethical board not consulted for the study? Why the first author is not from India or Puducherry where the study was performed. Conclusion is also generic and does not add any value to the research on HPV screening. Is the work clearly and accurately presented and does it cite the current literature? Yes Is the study design appropriate and is the work technically sound? Yes Are sufficient details of methods and analysis provided to allow replication by others? Partly If applicable, is the statistical analysis and its interpretation appropriate? No Are all the source data underlying the results available to ensure full reproducibility? Partly Are the conclusions drawn adequately supported by the results? Yes Competing Interests: No competing interests were disclosed. Reviewer Expertise: Health services research, Women's health, Maternal health, Survey research, Socioeconomic aspects of health I confirm that I have read this submission and believe that I have an appropriate level of expertise to state that I do not consider it to be of an acceptable scientific standard, for reasons outlined above. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Anand A. Reviewer Report For: Demand-side barriers and economic burden in accessing Human Papillomavirus screening for cervical cancer prevention in rural India: Evidence from a cross-sectional study [version 2; peer review: 1 approved, 2 approved with reservations, 2 not approved] . F1000Research 2025, 13 :630 ( https://doi.org/10.5256/f1000research.164926.r332791 ) The direct URL for this report is: https://f1000research.com/articles/13-630/v1#referee-response-332791 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Respond or Comment COMMENT ON THIS REPORT Views 0 Cite How to cite this report: Duppala SK. Reviewer Report For: Demand-side barriers and economic burden in accessing Human Papillomavirus screening for cervical cancer prevention in rural India: Evidence from a cross-sectional study [version 2; peer review: 1 approved, 2 approved with reservations, 2 not approved] . F1000Research 2025, 13 :630 ( https://doi.org/10.5256/f1000research.164926.r332790 ) The direct URL for this report is: https://f1000research.com/articles/13-630/v1#referee-response-332790 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 25 Oct 2024 Santosh Kumari Duppala , Lovely Professional University, Phagwara, Punjab, India Approved VIEWS 0 https://doi.org/10.5256/f1000research.164926.r332790 The manuscript effectively outlines the accessibility challenges rural populations face in accessing HPV screening services. The discussion on the economic implications of HPV screening for rural residents is compelling. Thorough Research by the authors have conducted a comprehensive review of ... Continue reading READ ALL The manuscript effectively outlines the accessibility challenges rural populations face in accessing HPV screening services. The discussion on the economic implications of HPV screening for rural residents is compelling. Thorough Research by the authors have conducted a comprehensive review of the literature, demonstrating a deep understanding of the complexities surrounding HPV screening in rural settings. The manuscript is well-organized and clearly written, making complex information accessible to a broad audience. The authors have done an excellent job of presenting their findings. The authors offer innovative and practical solutions to address the economic and travel barriers faced by rural populations, showcasing their forward-thinking approach to public health challenges. Strong Evidence Base where the authors have backed their claims with robust data and evidence, enhancing the credibility of their findings and recommendations. "The statistical analysis of the economic burden related to HPV screening is insightful and provides a nuanced understanding of the challenges rural residents face. The discussion section is particularly engaging, as the authors effectively connect their research to real-world implications, demonstrating the importance of addressing HPV screening in rural communities. Recommendations for future manuscript: Comparative Analysis : "A comparison of HPV screening rates between urban and rural populations would strengthen it. Highlighting these disparities can underscore the need for targeted interventions." Policy Recommendations : "It would be beneficial give recommendations on policy changes that could alleviate the economic and travel burdens associated with HPV screening in rural areas in future manuscript. Telehealth Solutions : "A small suggestion of tele-health as a potential solution for HPV screening in rural communities could be added in future perspectives and a practical approach to overcome travel and cost barriers." Is the work clearly and accurately presented and does it cite the current literature? Yes Is the study design appropriate and is the work technically sound? Yes Are sufficient details of methods and analysis provided to allow replication by others? Yes If applicable, is the statistical analysis and its interpretation appropriate? Yes Are all the source data underlying the results available to ensure full reproducibility? Yes Are the conclusions drawn adequately supported by the results? Yes Competing Interests: No competing interests were disclosed. Reviewer Expertise: Cancer biology, Next generation sequencing technologies, Bioinformatics, Cervical cancer and HPV, Molecular biology, Microbiology. I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Duppala SK. Reviewer Report For: Demand-side barriers and economic burden in accessing Human Papillomavirus screening for cervical cancer prevention in rural India: Evidence from a cross-sectional study [version 2; peer review: 1 approved, 2 approved with reservations, 2 not approved] . F1000Research 2025, 13 :630 ( https://doi.org/10.5256/f1000research.164926.r332790 ) The direct URL for this report is: https://f1000research.com/articles/13-630/v1#referee-response-332790 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Respond or Comment COMMENT ON THIS REPORT Comments on this article Comments (0) Version 2 VERSION 2 PUBLISHED 13 Jun 2024 ADD YOUR COMMENT Comment keyboard_arrow_left keyboard_arrow_right Open Peer Review Reviewer Status info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Reviewer Reports Invited Reviewers 1 2 3 4 5 Version 2 (revision) 17 Feb 25 read read Version 1 13 Jun 24 read read read Santosh Kumari Duppala , Lovely Professional University, Phagwara, India Ankit Anand , Institute for Social and Economic Change, Karnataka, India Shabana Tharkar , King Saud University, Riyadh, Saudi Arabia Aurelio Cruz-Valdez , Instituto Nacional de Salud Pública, Cuernavaca, Mexico Inge Dhamanti , Universitas Airlangga, Surabaya, Indonesia Comments on this article All Comments (0) Add a comment Sign up for content alerts Sign Up You are now signed up to receive this alert Browse by related subjects keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2025 Dhamanti I. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 03 Jun 2025 | for Version 2 Inge Dhamanti , Universitas Airlangga, Surabaya, Indonesia 0 Views copyright © 2025 Dhamanti I. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (0) Approved With Reservations info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions The discussion and conclusion are too short; the authors could add some actionable steps or practical recommendations for relevant stakeholders, such as policymakers, healthcare providers, and community organization. The authors need to acknowledge the limitations of the study or methodological constraints in the study and also suggest areas for future research. Is the work clearly and accurately presented and does it cite the current literature? Yes Is the study design appropriate and is the work technically sound? Yes Are sufficient details of methods and analysis provided to allow replication by others? Yes If applicable, is the statistical analysis and its interpretation appropriate? Yes Are all the source data underlying the results available to ensure full reproducibility? Yes Are the conclusions drawn adequately supported by the results? Partly Competing Interests No competing interests were disclosed. Reviewer Expertise Public Health, Safety and Quality I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. reply Respond to this report Responses (0) Dhamanti I. Peer Review Report For: Demand-side barriers and economic burden in accessing Human Papillomavirus screening for cervical cancer prevention in rural India: Evidence from a cross-sectional study [version 2; peer review: 1 approved, 2 approved with reservations, 2 not approved] . F1000Research 2025, 13 :630 ( https://doi.org/10.5256/f1000research.177813.r385439) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://f1000research.com/articles/13-630/v2#referee-response-385439 keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2025 Cruz-Valdez A. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 30 May 2025 | for Version 2 Aurelio Cruz-Valdez , Instituto Nacional de Salud Pública, Cuernavaca, Mexico 0 Views copyright © 2025 Cruz-Valdez A. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (0) Not Approved info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions The topic is important. Social and economic determinants are crucial for cancer mortality. The article addresses an essential aspect of identifying the association with economic determinants in a country rife with social contrasts. However, I believe there are several aspects that need to be clarified: In the Introduction section: 1) It is lengthy and imprecise, and the reader loses the thread between the justification and the objective of the study. This situation is straightforward in the first six sentences of this section. We can consider the Andersen model a guide for this section study’s approach. 2) The argument for the study of aim is not remains identified. Methods Section: 1) Selection of the study population: We solicit to State the method for calculating the sample size. How did you calculate the variability across these many stages? This allows you to observe the internal and external inferences of the results. 2) What were the selection and exclusion criteria for the study population? 3) Variable Selection: The authors note a series of “exposure and outcome” variables, but they not show which variables measure each construct in Andersen’s model. By not mentioning them which concepts each variable measures, which would don’t allow us to understand the creation of the statistical model used in the analysis, and the control of confounding variables. 4) Regarding the management of covariates and biases, this section is unnecessary. Detailing the data quality and the steps taken to address inconsistencies, particularly in measuring the outcome and economic variables, would be better. Why they did not create indices for the different variables measuring different dimensions of the same construct, such as economic variables, time management, or the access. This results in too many tables, which prevents the author from integrating the results. It is striking that the model’s prediction is very low (R2 = 5.9%). Discussion Section: 1) The authors should emphasize the findings comparing to other authors and other contexts. This causes that we don’t identify the importance of results, and this section does not contribute new knowledge. We suggest a more thorough review that considers Andersen’s model, since it is which they used in their theoretical framework from the start. Is the work clearly and accurately presented and does it cite the current literature? Yes Is the study design appropriate and is the work technically sound? No Are sufficient details of methods and analysis provided to allow replication by others? No If applicable, is the statistical analysis and its interpretation appropriate? Partly Are all the source data underlying the results available to ensure full reproducibility? Partly Are the conclusions drawn adequately supported by the results? No Competing Interests No competing interests were disclosed. Reviewer Expertise Public Health; Cervical cancer epidemiology; HPV infection and cancer I confirm that I have read this submission and believe that I have an appropriate level of expertise to state that I do not consider it to be of an acceptable scientific standard, for reasons outlined above. reply Respond to this report Responses (0) Cruz-Valdez A. Peer Review Report For: Demand-side barriers and economic burden in accessing Human Papillomavirus screening for cervical cancer prevention in rural India: Evidence from a cross-sectional study [version 2; peer review: 1 approved, 2 approved with reservations, 2 not approved] . F1000Research 2025, 13 :630 ( https://doi.org/10.5256/f1000research.177813.r379656) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://f1000research.com/articles/13-630/v2#referee-response-379656 keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2025 Tharkar S. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 29 Jan 2025 | for Version 1 Shabana Tharkar , King Saud University, Riyadh, Saudi Arabia 0 Views copyright © 2025 Tharkar S. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (1) Approved With Reservations info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions This research" Demand-side barriers and economic burden in accessing Human Papillomavirus screening for cervical cancer prevention in rural India: Evidence from a cross-sectional study" addresses an important issue of recognizing barriers to cancer screening in the rural sector of a developing country. However, only economic challenges have been addressed. The paper is well- written and the results are well-presented. Major points Introduction and rationale are acceptable but the methods need revision. Can revise methods according to STROBE Please remove outlier in Table 6, (cost of one way fare) and re -run the stats. The paper can be accepted after revision. Is the work clearly and accurately presented and does it cite the current literature? Yes Is the study design appropriate and is the work technically sound? Yes Are sufficient details of methods and analysis provided to allow replication by others? Yes If applicable, is the statistical analysis and its interpretation appropriate? Yes Are all the source data underlying the results available to ensure full reproducibility? Yes Are the conclusions drawn adequately supported by the results? Yes Competing Interests No competing interests were disclosed. Reviewer Expertise Epidemiology of non communicable diseases I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. reply Respond to this report Responses (1) Author Response 04 Feb 2025 Shyamkumar Sriram, Department of Social and Public Health, Ohio University, Athens, 45701, USA The revisions have been made according to the suggestion by Dr. Shabana Tharkar. Methods have been revised according to STROBE. Outlier has been removed in Table 6 and the statistics have been rerun. The discussion section is also updated. Thanks for the feedback and offering to accept the paper after revisions. View more View less Competing Interests No conflicts of interest reply Respond Report a concern Tharkar S. Peer Review Report For: Demand-side barriers and economic burden in accessing Human Papillomavirus screening for cervical cancer prevention in rural India: Evidence from a cross-sectional study [version 2; peer review: 1 approved, 2 approved with reservations, 2 not approved] . F1000Research 2025, 13 :630 ( https://doi.org/10.5256/f1000research.164926.r347336) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://f1000research.com/articles/13-630/v1#referee-response-347336 keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2024 Anand A. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 29 Oct 2024 | for Version 1 Ankit Anand , Population Research Centre,, Institute for Social and Economic Change, Karnataka, India 0 Views copyright © 2024 Anand A. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (0) Not Approved info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions The topic is very interesting and relevant, but the analysis does not add much value to the topic. Need to provide details on the estimation of the cost and income levels. Introduction is very generic and does not add why this data and analysis was needed. It states a lot of generic statement and facts which need to be inline why such study is required. For example: Author stated “only 1.7% of rural women participated in cervical cancer screening according to data from the National Family Health Survey 5 (NFHS-5).” “Addressing these barriers requires a comprehensive approach encompassing policy reforms, targeted interventions, and community engagement strategies to ensure equitable access to cervical cancer screening services and improve the health outcomes of rural women globally” Study may be needed to explore barriers among female in rural areas. Why Author selected Puducherry which is one of the urban Union Territory of India? There seems to a lot of reporting bias and This statement make no sense "Public transport one-way fares exhibit a wide range, spanning from 20 INR to 79,999 INR." 70,000 is a lot of cost for public transport in India. Data need to cleaned (check for outliers and validation before analysing it). How was the data quality ensured? It needs to be added. The analysis and variables are not well though of. There needs a detail description of how the economic related variables were collected and analysed. Most of the variables seem to be correlated in table 7. Distance from facility will be co-related with traveling time and cost of traveling. this is obvious. Having a companion significant increase the cost. this is obvious too, hardly a finding Why local ethical board not consulted for the study? Why the first author is not from India or Puducherry where the study was performed. Conclusion is also generic and does not add any value to the research on HPV screening. Is the work clearly and accurately presented and does it cite the current literature? Yes Is the study design appropriate and is the work technically sound? Yes Are sufficient details of methods and analysis provided to allow replication by others? Partly If applicable, is the statistical analysis and its interpretation appropriate? No Are all the source data underlying the results available to ensure full reproducibility? Partly Are the conclusions drawn adequately supported by the results? Yes Competing Interests No competing interests were disclosed. Reviewer Expertise Health services research, Women's health, Maternal health, Survey research, Socioeconomic aspects of health I confirm that I have read this submission and believe that I have an appropriate level of expertise to state that I do not consider it to be of an acceptable scientific standard, for reasons outlined above. reply Respond to this report Responses (0) Anand A. Peer Review Report For: Demand-side barriers and economic burden in accessing Human Papillomavirus screening for cervical cancer prevention in rural India: Evidence from a cross-sectional study [version 2; peer review: 1 approved, 2 approved with reservations, 2 not approved] . F1000Research 2025, 13 :630 ( https://doi.org/10.5256/f1000research.164926.r332791) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://f1000research.com/articles/13-630/v1#referee-response-332791 keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2024 Duppala S. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 25 Oct 2024 | for Version 1 Santosh Kumari Duppala , Lovely Professional University, Phagwara, Punjab, India 0 Views copyright © 2024 Duppala S. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (0) Approved info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions The manuscript effectively outlines the accessibility challenges rural populations face in accessing HPV screening services. The discussion on the economic implications of HPV screening for rural residents is compelling. Thorough Research by the authors have conducted a comprehensive review of the literature, demonstrating a deep understanding of the complexities surrounding HPV screening in rural settings. The manuscript is well-organized and clearly written, making complex information accessible to a broad audience. The authors have done an excellent job of presenting their findings. The authors offer innovative and practical solutions to address the economic and travel barriers faced by rural populations, showcasing their forward-thinking approach to public health challenges. Strong Evidence Base where the authors have backed their claims with robust data and evidence, enhancing the credibility of their findings and recommendations. "The statistical analysis of the economic burden related to HPV screening is insightful and provides a nuanced understanding of the challenges rural residents face. The discussion section is particularly engaging, as the authors effectively connect their research to real-world implications, demonstrating the importance of addressing HPV screening in rural communities. Recommendations for future manuscript: Comparative Analysis : "A comparison of HPV screening rates between urban and rural populations would strengthen it. Highlighting these disparities can underscore the need for targeted interventions." Policy Recommendations : "It would be beneficial give recommendations on policy changes that could alleviate the economic and travel burdens associated with HPV screening in rural areas in future manuscript. Telehealth Solutions : "A small suggestion of tele-health as a potential solution for HPV screening in rural communities could be added in future perspectives and a practical approach to overcome travel and cost barriers." Is the work clearly and accurately presented and does it cite the current literature? Yes Is the study design appropriate and is the work technically sound? Yes Are sufficient details of methods and analysis provided to allow replication by others? Yes If applicable, is the statistical analysis and its interpretation appropriate? Yes Are all the source data underlying the results available to ensure full reproducibility? Yes Are the conclusions drawn adequately supported by the results? Yes Competing Interests No competing interests were disclosed. Reviewer Expertise Cancer biology, Next generation sequencing technologies, Bioinformatics, Cervical cancer and HPV, Molecular biology, Microbiology. I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. reply Respond to this report Responses (0) Duppala SK. Peer Review Report For: Demand-side barriers and economic burden in accessing Human Papillomavirus screening for cervical cancer prevention in rural India: Evidence from a cross-sectional study [version 2; peer review: 1 approved, 2 approved with reservations, 2 not approved] . F1000Research 2025, 13 :630 ( https://doi.org/10.5256/f1000research.164926.r332790) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://f1000research.com/articles/13-630/v1#referee-response-332790 Alongside their report, reviewers assign a status to the article: Approved - the paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations - A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved - fundamental flaws in the paper seriously undermine the findings and conclusions Adjust parameters to alter display View on desktop for interactive features Includes Interactive Elements View on desktop for interactive features Competing Interests Policy Provide sufficient details of any financial or non-financial competing interests to enable users to assess whether your comments might lead a reasonable person to question your impartiality. Consider the following examples, but note that this is not an exhaustive list: Examples of 'Non-Financial Competing Interests' Within the past 4 years, you have held joint grants, published or collaborated with any of the authors of the selected paper. You have a close personal relationship (e.g. parent, spouse, sibling, or domestic partner) with any of the authors. You are a close professional associate of any of the authors (e.g. scientific mentor, recent student). You work at the same institute as any of the authors. You hope/expect to benefit (e.g. favour or employment) as a result of your submission. You are an Editor for the journal in which the article is published. Examples of 'Financial Competing Interests' You expect to receive, or in the past 4 years have received, any of the following from any commercial organisation that may gain financially from your submission: a salary, fees, funding, reimbursements. You expect to receive, or in the past 4 years have received, shared grant support or other funding with any of the authors. You hold, or are currently applying for, any patents or significant stocks/shares relating to the subject matter of the paper you are commenting on. Stay Updated Sign up for content alerts and receive a weekly or monthly email with all newly published articles Register with F1000Research Already registered? Sign in Not now, thanks close PLEASE NOTE If you are an AUTHOR of this article, please check that you signed in with the account associated with this article otherwise we cannot automatically identify your role as an author and your comment will be labelled as a “User Comment”. If you are a REVIEWER of this article, please check that you have signed in with the account associated with this article and then go to your account to submit your report, please do not post your review here. If you do not have access to your original account, please contact us . All commenters must hold a formal affiliation as per our Policies . The information that you give us will be displayed next to your comment. User comments must be in English, comprehensible and relevant to the article under discussion. We reserve the right to remove any comments that we consider to be inappropriate, offensive or otherwise in breach of the User Comment Terms and Conditions . Commenters must not use a comment for personal attacks. When criticisms of the article are based on unpublished data, the data should be made available. I accept the User Comment Terms and Conditions Please confirm that you accept the User Comment Terms and Conditions. Affiliation ✕ refresh Please enter your institution. Note: To add your institution or organisation, start typing the name and then select the correct name from the list. Where applicable, the name will appear in both the original language and in English. Do not paste in the name. If the name does not appear in the drop-down list, we will display the information you have entered. ✕ refresh Country/Region * USA UK Canada China France Germany Afghanistan Aland Islands Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory British Virgin Islands Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Cote d'Ivoire Croatia Cuba Cyprus Czech Republic Democratic Republic of the Congo Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands Faroe Islands Federated States of Micronesia Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Heard Island and Mcdonald Islands Holy See (Vatican City State) Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Kosovo (Serbia and Montenegro) Kuwait Kyrgyzstan Lao People's Democratic Republic Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macao Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Minor Outlying Islands of the United States Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Korea North Macedonia Northern Mariana Islands Norway Oman Pakistan Palau Palestinian Territory Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Reunion Romania Russian Federation Rwanda Saint Helena Saint Kitts and Nevis Saint Lucia Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Is South Korea South Sudan Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand The Gambia The Netherlands Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu UK USA Uganda Ukraine United Arab Emirates United States Virgin Islands Uruguay Uzbekistan Vanuatu Venezuela Vietnam Wallis and Futuna West Bank and Gaza Strip Western Sahara Yemen Zambia Zimbabwe Please select your country/region. You must enter a comment. Competing Interests Please disclose any competing interests that might be construed to influence your judgment of the article's or peer review report's validity or importance. Competing Interests Policy Provide sufficient details of any financial or non-financial competing interests to enable users to assess whether your comments might lead a reasonable person to question your impartiality. Consider the following examples, but note that this is not an exhaustive list: Examples of 'Non-Financial Competing Interests' Within the past 4 years, you have held joint grants, published or collaborated with any of the authors of the selected paper. You have a close personal relationship (e.g. parent, spouse, sibling, or domestic partner) with any of the authors. You are a close professional associate of any of the authors (e.g. scientific mentor, recent student). You work at the same institute as any of the authors. You hope/expect to benefit (e.g. favour or employment) as a result of your submission. You are an Editor for the journal in which the article is published. Examples of 'Financial Competing Interests' You expect to receive, or in the past 4 years have received, any of the following from any commercial organisation that may gain financially from your submission: a salary, fees, funding, reimbursements. You expect to receive, or in the past 4 years have received, shared grant support or other funding with any of the authors. You hold, or are currently applying for, any patents or significant stocks/shares relating to the subject matter of the paper you are commenting on. Please state your competing interests The comment has been saved. An error has occurred. Please try again. Cancel Post var lTitle = "Demand-side barriers and economic burden...".replace("'", ''); var linkedInUrl = "http://www.linkedin.com/shareArticle?url=https://f1000research.com/articles/13-630/v2" + "&title=" + encodeURIComponent(lTitle) + "&summary=" + encodeURIComponent('Read the article by '); var deliciousUrl = "https://del.icio.us/post?url=https://f1000research.com/articles/13-630/v2&title=" + encodeURIComponent(lTitle); var redditUrl = "http://reddit.com/submit?url=https://f1000research.com/articles/13-630/v2" + "&title=" + encodeURIComponent(lTitle); linkedInUrl += encodeURIComponent('Sriram S et al.'); var offsetTop = /chrome/i.test( navigator.userAgent ) ? 4 : -10; var addthis_config = { ui_offset_top: offsetTop, services_compact : "facebook,twitter,www.linkedin.com,www.mendeley.com,reddit.com", services_expanded : "facebook,twitter,www.linkedin.com,www.mendeley.com,reddit.com", services_custom : [ { name: "LinkedIn", url: linkedInUrl, icon:"/img/icon/at_linkedin.svg" }, { name: "Mendeley", url: "http://www.mendeley.com/import/?url=https://f1000research.com/articles/13-630/v2/mendeley", icon:"/img/icon/at_mendeley.svg" }, { name: "Reddit", url: redditUrl, icon:"/img/icon/at_reddit.svg" }, ] }; var addthis_share = { url: "https://f1000research.com/articles/13-630", templates : { twitter : "Demand-side barriers and economic burden in accessing Human Papillomavirus.... Sriram S et al., published by " + "@F1000Research" + ", https://f1000research.com/articles/13-630/v2" } }; if (typeof(addthis) != "undefined"){ addthis.addEventListener('addthis.ready', checkCount); addthis.addEventListener('addthis.menu.share', checkCount); } $(".f1r-shares-twitter").attr("href", "https://twitter.com/intent/tweet?text=" + addthis_share.templates.twitter); $(".f1r-shares-facebook").attr("href", "https://www.facebook.com/sharer/sharer.php?u=" + addthis_share.url); $(".f1r-shares-linkedin").attr("href", addthis_config.services_custom[0].url); $(".f1r-shares-reddit").attr("href", addthis_config.services_custom[2].url); $(".f1r-shares-mendelay").attr("href", addthis_config.services_custom[1].url); function checkCount(){ setTimeout(function(){ $(".addthis_button_expanded").each(function(){ var count = $(this).text(); if (count !== "" && count != "0") $(this).removeClass("is-hidden"); else $(this).addClass("is-hidden"); }); }, 1000); } close How to cite this report {{reportCitation}} Cancel Copy Citation Details $(function(){R.ui.buttonDropdowns('.dropdown-for-downloads');}); $(function(){R.ui.toolbarDropdowns('.toolbar-dropdown-for-downloads');}); $.get("/articles/acj/150361/177813") new F1000.Clipboard(); new F1000.ThesaurusTermsDisplay("articles", "article", "177813"); $(document).ready(function() { $( "#frame1" ).on('load', function() { var mydiv = $(this).contents().find("div"); var h = mydiv.height(); console.log(h) }); var tooltipLivingFigure = jQuery(".interactive-living-figure-label .icon-more-info"), titleLivingFigure = tooltipLivingFigure.attr("title"); tooltipLivingFigure.simpletip({ fixed: true, position: ["-115", "30"], baseClass: 'small-tooltip', content:titleLivingFigure + " " }); tooltipLivingFigure.removeAttr("title"); $("body").on("click", ".cite-living-figure", function(e) { e.preventDefault(); var ref = $(this).attr("data-ref"); $(this).closest(".living-figure-list-container").find("#" + ref).fadeIn(200); }); $("body").on("click", ".close-cite-living-figure", function(e) { e.preventDefault(); $(this).closest(".popup-window-wrapper").fadeOut(200); }); $(document).on("mouseup", function(e) { var metricsContainer = $(".article-metrics-popover-wrapper"); if (!metricsContainer.is(e.target) && metricsContainer.has(e.target).length === 0) { $(".article-metrics-close-button").click(); } }); var articleId = $('#articleId').val(); if($("#main-article-count-box").attachArticleMetrics) { $("#main-article-count-box").attachArticleMetrics(articleId, { articleMetricsView: true }); } }); var figshareWidget = $(".new_figshare_widget"); if (figshareWidget.length > 0) { window.figshare.load("f1000", function(Widget) { // Select a tag/tags defined in your page. In this tag we will place the widget. _.map(figshareWidget, function(el){ var widget = new Widget({ articleId: $(el).attr("figshare_articleId") //height:300 // this is the height of the viewer part. [Default: 550] }); widget.initialize(); // initialize the widget widget.mount(el); // mount it in a tag that's on your page // this will save the widget on the global scope for later use from // your JS scripts. This line is optional. //window.widget = widget; }); }); } close Error Close Add Reset F1000.MICROSERVICES.AFFILIATION = ''; $(document).ready(function () { $('.js-affiliations-form').each((index, form) => { new AffiliationForm({ formId: form.id, institutionErrorSelector: '.comment-enter-institution', departmentErrorSelector: '.comment-enter-department', placeSelector: '.js-add-comment-place', stateSelector: '.js-add-comment-state', zipCodeSelector: '.js-add-comment-zipcode', countrySelector: '.js-add-comment-country', countryErrorSelector: '.comment-enter-country', }); }); }); $(document).ready(function () { var reportIds = { "315524": 0, "315525": 0, "315526": 0, "379661": 0, "312076": 0, "379660": 0, "312077": 0, "379663": 0, "312078": 0, "379662": 0, "312079": 0, "379657": 0, "379656": 6, "379659": 0, "379658": 0, "312075": 0, "312084": 0, "379665": 0, "312080": 0, "379664": 0, "312081": 0, "315537": 0, "312082": 0, "315538": 0, "312083": 0, "385439": 6, "375077": 0, "375076": 0, "375079": 0, "375078": 0, "375073": 0, "385440": 0, "375075": 0, "375074": 0, "375081": 0, "375080": 0, "375082": 0, "367025": 0, "367024": 0, "367026": 0, "377149": 0, "377148": 0, "377151": 0, "377150": 0, "293695": 0, "377145": 0, "377147": 0, "377146": 0, "293700": 0, "293701": 0, "293702": 0, "293703": 0, "377153": 0, "293696": 0, "377152": 0, "293697": 0, "293698": 0, "377154": 0, "293699": 0, "300495": 0, "293704": 0, "347336": 16, "307924": 0, "300500": 0, "307925": 0, "300501": 0, "307926": 0, "300502": 0, "307927": 0, "300503": 0, "300496": 0, "300497": 0, "300498": 0, "307923": 0, "300499": 0, "307932": 0, "307928": 0, "300504": 0, "307929": 0, "307930": 0, "307931": 0, "332789": 0, "332791": 23, "332790": 16, }; $(".referee-response-container,.js-referee-report").each(function(index, el) { var reportId = $(el).attr("data-reportid"), reportCount = reportIds[reportId] || 0; $(el).find(".comments-count-container,.js-referee-report-views").html(reportCount); }); var uuidInput = $("#article_uuid"), oldUUId = uuidInput.val(), newUUId = "4988a8f3-6df3-420e-a561-f6e488f7d558"; uuidInput.val(newUUId); $("a[href*='article_uuid=']").each(function(index, el) { var newHref = $(el).attr("href").replace(oldUUId, newUUId); $(el).attr("href", newHref); }); }); An innovative open access publishing platform offering rapid publication and open peer review, whilst supporting data deposition and sharing. Browse Gateways Collections How it Works Contact For Developers Cookie Notice Privacy Notice RSS Submit Your Research Follow us © 2012-2026 F1000 Research Ltd. ISSN 2046-1402 | Legal | Partner of Research4Life • CrossRef • ORCID • FAIRSharing R.templateTests.simpleTemplate = R.template(' $text $text $text $text $text '); R.templateTests.runTests(); var F1000platform = new F1000.Platform({ name: "f1000research", displayName: "F1000Research", hostName: "f1000research.com", id: "1", editorialEmail: "[email protected]", infoEmail: "[email protected]", usePmcStats: true }); $(function(){R.ui.dropdowns('.dropdown-for-authors, .dropdown-for-about, .dropdown-for-myresearch');}); // $(function(){R.ui.dropdowns('.dropdown-for-referees');}); $(document).ready(function () { if ($(".cookie-warning").is(":visible")) { $(".sticky").css("margin-bottom", "35px"); $(".devices").addClass("devices-and-cookie-warning"); } $(".cookie-warning .close-button").click(function (e) { $(".devices").removeClass("devices-and-cookie-warning"); $(".sticky").css("margin-bottom", "0"); }); $("#tweeter-feed .tweet-message").each(function (i, message) { var self = $(message); self.html(linkify(self.html())); }); $(".partner").on("mouseenter mouseleave", function() { $(this).find(".gray-scale, .colour").toggleClass("is-hidden"); }); }); Sign In Remember me Forgotten your password? Sign In Cancel Email or password not correct. Please try again Please wait... $(function(){ // Note: All the setup needs to run against a name attribute and *not* the id due the clonish // nature of facebox... $("a[id=googleSignInButton]").click(function(event){ event.preventDefault(); $("input[id=oAuthSystem]").val("GOOGLE"); $("form[id=oAuthForm]").submit(); }); $("a[id=facebookSignInButton]").click(function(event){ event.preventDefault(); $("input[id=oAuthSystem]").val("FACEBOOK"); $("form[id=oAuthForm]").submit(); }); $("a[id=orcidSignInButton]").click(function(event){ event.preventDefault(); $("input[id=oAuthSystem]").val("ORCID"); $("form[id=oAuthForm]").submit(); }); }); If you've forgotten your password, please enter your email address below and we'll send you instructions on how to reset your password. The email address should be the one you originally registered with F1000. Email address not valid, please try again You registered with F1000 via Google, so we cannot reset your password. To sign in, please click here . If you still need help with your Google account password, please click here . You registered with F1000 via Facebook, so we cannot reset your password. To sign in, please click here . If you still need help with your Facebook account password, please click here . Code not correct, please try again Reset password Cancel Email us for further assistance. Server error, please try again. If your email address is registered with us, we will email you instructions to reset your password. If you think you should have received this email but it has not arrived, please check your spam filters and/or contact for further assistance. Please wait... Register $(document).ready(function () { signIn.createSignInAsRow($("#sign-in-form-gfb-popup")); $(".target-field").each(function () { var uris = $(this).val().split("/"); if (uris.pop() === "login") { $(this).val(uris.toString().replace(",","/")); } }); });