Sociodemographic Factors Associated With HPV Awareness/Knowledge and Cervical Cancer Screening Behaviors Among Caregivers in the US

Sociodemographic Factors Associated With HPV Awareness/Knowledge and Cervical Cancer Screening Behaviors Among Caregivers in the US | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (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;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Sociodemographic Factors Associated With HPV Awareness/Knowledge and Cervical Cancer Screening Behaviors Among Caregivers in the US Jiyeong Kim, Melanie Dove, Julie HT Dang This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-1120326/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 9 You are reading this latest preprint version Abstract Background . Family caregivers may be at a higher risk for several chronic diseases including cancer. Cervical cancer is one of the most prevalent cancers among U.S. women. Despite family caregivers’ vulnerability, the status of their HPV awareness, knowledge, and preventive health behaviors, including cervical cancer screening, have been understudied. Thus, this study aimed to examine the sociodemographic factors associated with HPV awareness and knowledge, and adherence to the cervical cancer screening guidelines among caregivers in the U.S. Methods . Nationally representative cross-sectional survey data were obtained from the Health Information National Trends Survey (HINTS 5, 2017-2020). Only female caregivers, aged 21-65, were included (N= 834). Weighted multivariate logistic regression was performed to identify factors associated with HPV awareness, knowledge, and adherence to the United States Preventive Service Task Force cervical cancer screening guidelines (by age, race/ethnicity, education, household income, marital status, employment status, and health insurance type). Results. Caregivers who were older (aged 51-65 vs. 21-50), were less educated (high school graduate or less vs. some college or more) showed lower adherence to the cervical cancer screening guidelines (every 3 years) than their counterparts. Caregivers who were older and less educated showed lower HPV awareness (Heard of HPV). Conclusions. There are caregiving populations whose HPV awareness, knowledge and cervical cancer screening adherence are low. To improve their awareness and knowledge of HPV and support their cervical cancer screening behaviors, we need to consider interventions that target those specific populations. Internal Medicine Preventive Medicine Human Papillomavirus (HPV) HPV awareness Cervical cancer screening Caregivers Health disparities sociodemographic Introduction Approximately 53 million individuals were family caregivers in the U.S. in 2020.( 1 ) More than one in five people (21%) provided unpaid healthcare or functional needs for their family members. ( 1 ) This is a 9.5 million increase from 2018 (43.5 million), and the family caregiving population is projected to continue to increase.( 1 ) Caregivers are often described as hidden patients because caregiving is burdensome as it requires physical, emotional, financial sacrifices and is usually a long-term commitment, spanning from several years to over a decade.( 2 ) About a quarter of caregivers (26%) report spending over 20 hours per week providing care.( 3 ) Consequentially, this population is vulnerable to an unhealthy lifestyle and are at high risk for chronic diseases.( 4 – 7 ) Prolonged caregiving causes cumulated stress, including neurohormonal changes and inflammatory responses in the body, weight loss, and sleep deprivation.( 8 , 9 ) According to the caregiver data from the Behavioral Risk Factor Surveillance System (BRFSS), in 2015-17, 14.5% of caregivers experienced an unhealthy mental status for 14 and more days in the past month,( 10 ) 17.6% had an unhealthy physical status for 14 days or more in the past month, and 36.7% reported insufficient sleep (less than 7 hours of sleep).( 10 ) Moreover, 40.7% of caregivers reported multiple chronic medical conditions, including coronary heart disease, stroke, asthma, chronic obstructive pulmonary disease (COPD), arthritis, depressive disorder, kidney disease, diabetes, and cancer.( 10 ) The majority of caregivers are female (61%),( 3 ) and the average age of female caregivers is 50.1 years.( 1 ) Cervical cancer is one of the most prevalent cancers among women in the U.S. and the average age at diagnosis is 50.( 11 ) It is also one of the most common causes of cancer death among U.S. women.( 11 ) For most types of cervical cancer, Human Papilloma Virus (HPV) infection is the primary cause, specifically HPV I6 and 18.( 12 ) Approximately 80 million people in the U.S. are currently infected with HPV.( 13 ) While the majority of HPV infections disappear naturally within 1 to 2 years; ( 12 ) persistent high-risk HPV can cause cancers of the cervix, penis and anus.( 12 ) Papanicolaou cytology (Pap smear) detects changes in cells caused by HPV and allows at-risk women to receive treatment before it becomes invasive carcinoma.( 14 ) As early detection can reduce cervical cancer incidence and mortality significantly, active cervical cancer screening is strongly recommended as an effective prevention strategy. The U.S. Preventive Services Task Force (USPSTF) recommends cervical cytology every 3 years for women aged 21 to 29 years old, and for women aged 30-65 years old, either cervical cytology every 3 years, high-risk Human Papilloma Virus (hrHPV) testing every 5 years, or hrHPV testing in combination with cytology (co-testing) every 5 years.( 15 ) In 2018, 12,733 new cervical cancer cases and 4,138 cervical cancer death were reported despite effective prevention and treatment options.( 16 , 17 ) Despite the threat of cervical cancer, knowledge regarding the cause of cervical cancer and the linkage to HPV infection has been low to moderate among Americans.( 18 – 20 ) Furthermore, HPV knowledge level differs by sociodemographic characteristics (e.g., race/ethnicity, age, income, educational attainment, insurance status, rurality of residence).( 20 – 27 ) HPV knowledge level was lower in racial/ethnic minorities, including Hmong American immigrants, Korean American immigrants, and Hispanics, older populations, and rural residents.( 20 – 27 ) Adherence to the cervical cancer screening guidelines (e.g., pap smear within the past 3 years) has been moderate to high.( 28 , 29 ) Previous analysis of HINTS data (2013-14) revealed that 81.3% of 21-65 years of women reported that they had a Pap smear in the past 3 years.( 30 ) However, stark disparities by sociodemographic factors were observed in cervical cancer screening behavior.( 2 , 3 , 35 , 4 , 8 , 9 , 28 , 31 – 34 ) Similar to the HPV knowledge level, the Pap smear test was less utilized in women who were older and racial/ethnic minorities (African American, Asians, Hispanics).( 3 , 34 , 35 ) Also, low Socioeconomic Status (SES), including low income, low educational attainment, no health insurance, absence of a usual source of healthcare, was significantly associated with low adherence to obtaining cervical cancer screening.( 2 , 4 , 8 , 9 , 31 – 33 ) Reportedly, HPV knowledge level is an essential indicator in cervical cancer screening utilization as these two are positively associated with each other.( 36 , 37 ) Multiple studies have reported this association based on their empirical research or nationally representative survey data analysis.( 36 , 37 ) This relationship is also supported by the Theory of Reasoned Action, a theory explaining how intention and health behaviors are related.( 5 , 6 ) While multiple studies have shown disparities in HPV knowledge and cervical cancer screening behavior in women in the U.S., studies focused on family caregivers’ negative health behaviors due to the caregiving burden and the receipt of preventive clinical services, including cancer screening, are still scant with inconsistent results.( 38 – 47 ) Some studies presented caregivers’ adherence to the Pap smear test being low because of caregiving.( 38 – 41 ) Other studies reported no association between caregiving status and Pap smear utilization.( 39 , 42 , 43 ) Studies have also suggested that the caregivers are more aware of the preventive health services and hence actively participating in cancer screening.( 44 – 47 ) Despite the limited findings, there has been a longstanding concern that caregivers are less likely to perform cancer screenings because the burden of caregiving may hinder them from obtaining care for themselves and their health status is already vulnerable.( 4 – 7 , 38 – 41 ) In addition, the burden of caregiving and the association of chronic medical conditions also differed by sociodemographic characteristics. Family caregivers who are women, racial/ethnic minorities, rural residents, and with low income experienced heavier caregiving burdens,( 7 , 48 – 52 ) and also presented with worse health conditions.( 50 , 53 – 55 ) While we can reasonably assume that subgroups of caregivers are disproportionately low in cervical cancer screening and HPV knowledge, little is known in this area. Given the caregivers’ crucial role in patients’ disease management, treatment compliance, resilience, and mental and spiritual support, and family functioning, and the persisting nature of caregiving, this population needs additional support on the importance of obtaining and adhering to cervical cancer screening recommendations. Therefore, this study aimed to identify sociodemographic factors associated with disparities in HPV knowledge and cervical cancer screening behaviors among caregivers in the U.S. This information will contribute to the development of a targeted intervention to interpose existing inequities in this area. Methods Data source This study used publicly available cross-sectional data, Health Information National Trends Survey (HINTS).( 56 ) HINTS is a self-administered nationally representative survey data collected by the National Cancer Institute. The present study used HINTS 5 Cycle 1,2,3,4 in 2017-2020. HINTS 5 is a random digit-dialed telephone survey and a mailed questionnaire survey in non-institutionalized civilians aged 18 and older in the US. HINTS 5 included data of caregiver population, their health-related behavior, perception, and knowledge of the disease. Geographic addresses were stratified by either area with a high concentration of minority population or low concentration of minority population in HINTS 5 Cycle 2,3,4. HINTS 5 Cycle 1 included one more stratification in geographic address, counties of Central Appalachia. The present study followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guideline.( 57 ) The total number of respondents used in this study was 16,092 (3,285 in Cycle 1, 3,504 in Cycle 2, 5,438 in Cycle 3, 3,865 in Cycle 4). Each response rate was 32.4%, 32.39%, 30.3%, 36.7%, respectively. The response rate was estimated based on Response Rate 2 formula (RR2) from the American Association of Public Opinion Research.( 58 ) In our analysis, we only included female caregivers aged 21-65 (n= 834) because that is the population recommended to obtain a regular cervical cancer screening every 3 years by the USPSTF. Caregiver status Caregiving status was identified by one question; “Are you currently caring for or making health care decisions for someone with a medical, behavioral, disability, or other conditions?” Those who affirmatively responded ‘yes’ were defined as caregivers. Outcome variables HPV Awareness (Heard of HPV) and HPV Knowledge (HPV can cause cervical cancer) To investigate caregivers’ awareness of Human Papillomavirus (HPV), the following survey questions were used; "Have you ever heard of HPV? HPV stands for Human Papilloma Virus. It is not HCV, HIV, or Herpes." Those who answered "yes" were considered to have HPV awareness. Respondents who answered “yes” to the question, “Do you think HPV can cause cervical cancer?” were regarded as having knowledge of the causal effect of HPV on cervical cancer in this study. Cervical cancer screening adherence to the screening guidelines (Had a pap test within 3 years) To distinguish the caregivers who are complaint with the USPSTF cervical cancer screening guidelines, the question, “How long ago did you have your most recent Pap test to check for cervical cancer?” was used. Those who answered, “I have never had a Pap test” were re-coded to “Never.” Caregivers with all other answers were divided into “within guidelines” if they had a pap test within the past 3 years or “outside guidelines” if they had a pap test more than 3 years ago. Covariates Conceptual framework of social determinants of health from the Healthy People 2030 was applied for the choices of sociodemographic predictors in this study( 59 ): Age ( 21 – 50 , 51 – 65 ), birth gender, race/ethnicity (White, Hispanic, African American/Black, Others including Asian, Native Hawaiian/Pacific Islander, American Indian/Alaska Native, Multiple races), household income (less than $ 20,000, $ 20,000 to less than $ 35,000, $ 35,000 to less than $ 50,000, $ 50,000 or more), educational attainment (high school graduate or less, some college or more), marital status (married or living with a romantic partner as a married vs. not married including divorced, widowed, separated, single/never been married), employment status (employed vs. unemployed including homemaker, student, retired, disabled), health insurance type (insured by employment or private insurance, Tricare/VA/Indian Health Services, Medicare, Medicaid.) Statistical Analysis The weighted percent of each outcome was estimated for each demographic characteristic. To examine the association between characteristics and the three outcomes of interest ( 1 ) HPV awareness, 2) HPV knowledge, 3) adherence to the cervical cancer screening guidelines weighted multivariate logistic regression was performed to present odds ratios and 95% confidence intervals (Table 3). The statistical significance was determined at p-value is less than 0.05 and alpha is 0.05. All estimates accounted for the sampling strategy using replicate weights and survey procedures in SAS (SAS Studio, version 9.4, Cary, NC). Results Among female caregivers aged 21-65, 39% were aged 51-65, 64% were non-Hispanic White, 46% reported less than $ 50,000 annual household income, 25% were high school graduate or less education, 60% were employed, 64% were married, 67% were insured by the employment-based or private plan while 33% was insured by the government provided insurance (Medicare, Medicaid, Tricare, VA, Indian Health Services), and approximately 98% was urban (metropolitan, micropolitan, and small town) residents. (Table 1 ). HPV Awareness (Heard of HPV) and HPV knowledge (HPV can cause cervical cancer) Approximately 79% of female caregivers (aged 21-65) heard of HPV and the majority of participants thought that HPV can cause cervical cancer (98%) (Table 2). However, disparities in HPV awareness were found by sociodemographic characteristics (Table 3). Younger female caregivers ( 21 – 50 ) were over 2 times more likely to have heard of HPV compared to older caregivers ( 51 – 65 ) (OR=2.67, 95% CI=1.61, 4.41). Female caregivers whose educational attainment was high school graduate or less were one third times likely to have heard of HPV than individuals with some college or more (OR=3.10, 95% CI=1.16, 5.79 in some college or more group). Adherence to the Cervical Cancer Screening Guidelines (Had a pap test within 3 years) Overall, 83% of female caregivers had a pap test in the past 3 years (Table 2). Sociodemographic disparities were also found (Table 3). Younger caregivers ( 21 – 50 ) were more likely to follow the cervical cancer screening guidelines than older caregivers ( 51 – 65 ) (OR=3.47, 95% CI=2.01, 5.98). Other ethnic groups, including Asian, Native Hawaiian/Pacific Islander, American Indian/Alaska Native, Multiple races were more likely to adhere to the cervical cancer screening guidelines than Hispanic female caregivers (OR=4.63, 95%=1.05, 20.38). Caregivers with some college or more education were nearly 2 times likely to adhere to the cervical cancer screening guidelines than those with high school graduate or less education (OR=2.08, 95% CI=1.16, 3.74). Discussion This study assessed sociodemographic factors associated with HPV awareness (heard of HPV), HPV knowledge (HPV can cause cervical cancer), and adherence to the cervical cancer screening guidelines (had a pap test within 3 years) among female caregivers in the U.S. from 2017-2020. In general, the older age group, Hispanics, those with low education, were less likely to have awareness and knowledge of HPV and adhere to guidelines. Our results were similar to Blake et al.( 60 ) who reported lower levels of HPV awareness among women who were older, less educated, had lower-income, had no health insurance, and were of a racial/ethnic minority (Hispanics). One plausible explanation could be that HPV awareness and HPV vaccination campaigns target younger age groups. Healthcare professionals also focus more on younger age groups to promote HPV vaccine uptake and HPV awareness. Thus, older generations, aged 51-65, are less likely to be exposed to these HPV campaigns and educational efforts. Previous literature reported differences in HPV knowledge level by race/ethnicity, specifically lower knowledge among U.S. racial/ethnic minorities including Hmong American immigrants, Korean American immigrants, and Hispanic women.( 23 , 24 , 26 , 27 , 61 ) Although other ethnic groups, including Asian female caregivers, were less likely to know about HPV than non-Hispanic Whites, African American/Blacks, and Hispanics in this study, it was not significant. Prior studies that examined HPV knowledge among the general population revealed that age,( 21 , 23 ) as well as socioeconomic status (income and educational attainment, rurality of residence)( 20 – 22 , 24 ) was also associated. However, socioeconomic factors, including household income, educational status, were not associated with HPV knowledge in this population. Presumably, individuals with higher education and higher income are more likely to have higher health literacy and greater access to health resources which can possibly increase their knowledge and awareness of HPV. However, this hypothetical relationship was not observed in this study. One explanation could be that only participants who answered that they have had heard of HPV, were asked subsequently, “Do you think HPV can cause cervical cancer?”. In other words, people who are already aware of HPV are more likely to know the causation of cervical cancer which may make it more challenging to associate additional socioeconomic disparities in HPV knowledge among this population. Additionally, this made the sample size of those with HPV knowledge even smaller, which may have resulted in non-significant differences in some of the socioeconomic factors. This can be the limitation of HINTS 5 data to precisely analyze variables related to HPV knowledge. Further comprehensive analysis to examine the association of socioeconomic characteristics and HPV knowledge among female caregivers with a larger sample will be necessary. Prior studies reported that older age,( 62 – 64 ) low income,( 2 , 8 ) low educational attainment,( 2 , 4 , 8 , 33 ) lack of health insurance,( 2 , 8 , 33 ) marital status,( 2 , 4 , 33 ) was associated with low cervical cancer screening rates (within 3 years) among US women. Johnson et al( 63 ) reported younger age groups had higher odds of having a pap test within 5 years than older age groups in general US women. Similar associations were observed in the present study. Although most (93% or higher) female caregivers reported ever having a Pap smear in the past, many subgroups did not adhere to the cervical cancer screening guidelines of every 3 years. Healthy People 2030 aimed to reach 84.3% of adherence to the cervical cancer screening guidelines among U.S. women.( 65 ) In our analysis, the younger age group (aged 21-50) showed satisfied status to reaching the goal (91%) while the older age group (aged 51-65) was far behind the target (75%). Considering the average diagnosed age of cervical cancer in the U.S. is 50, the older age group is the one who needs our attention to improve and maintain their adherence to the USPSTF guidelines. Education was significantly associated with the adherence to the cervical cancer screening guidelines in both general women and caregivers. Women with low educational attainment (high school graduate or less education) showed lower odds of cervical cancer screening behaviors than those with higher educational attainment (4-year college and more education) in general women ( 63 ), and this trend was the same in the caregiver population in this study. However, low household income was not significantly associated with the adherence of cervical cancer screening guidelines among caregivers in this study, although low-income earners (annual household income < $ 30,000) showed lower odds in obtaining cervical cancer screening within 5 years among U.S. women in previous studies ( 63 , 66 ). The association of age and the adherence to the cervical cancer screening guidelines could be explained by the relationship that low HPV awareness and knowledge is closely related to the low HPV screening behavior.( 36 , 37 ) Thus, older caregivers who have low HPV awareness are less likely to obtain cervical cancer screening guidelines. Moreover, it is possible that the caregivers who have low financial resources and educational attainment may be less likely to have heard of HPV and may also be less knowledgeable of HPV. As a result, they may be less likely to acknowledge the importance of HPV screening and have fewer resources, including financial, physical, emotional, to adhere to the recommended cervical cancer screening guidelines. Small sample size could be one potential reason for the no significant association between household income and the adherence to the cervical cancer screening among caregivers. Hence, further comprehensive examination will be necessary with the larger sample population to see whether household income is associated with the adherence to the cervical cancer screening behaviors among caregivers. In previous research, women with public health insurance had higher odds in obtaining a cervical cancer screening within 5 years than those with private insurance.( 63 ) As the coverage of the public insurance has increased since 2016, a study reported that government provided insurance holder’s preventive health services utilization rate were also higher than that of non-government insurance holders. However, in this study, significant differences between the health insurance types were not observed in HPV awareness and knowledge, and adherence to the cervical cancer screening guidelines among caregivers. Further research will be necessary to examine the role of health insurance types in adherence to cervical cancer screening behaviors among caregivers. It will help to identify vulnerable subpopulations to improve adherence among caregivers. Prior studies reported that African-Americans and Hispanics women had lower adherence to cervical cancer screening guidelines than non-Hispanic Whites.( 63 , 64 ) However, in this study, rather the White caregivers had lower odds in pap test guideline adherence than the Black caregiver’s odds when compared to Hispanics, but it was not significant. Other ethnic groups’ odds of adherence to the cervical cancer screening guidelines were higher than Hispanics’ odds. Further research is recommended to investigate the association of ethnic minorities and adherence to the cervical cancer screening guidelines among caregivers. Limitation The current study has several limitations. First, HINTS is a cross-sectional survey at one point of the year. Hence, it cannot guarantee temporality and causal inference in the outcomes of interests in this study. Second, a low response rate (overall 32%) is concerning because those responding to the survey may be different than those who don’t and so the survey may not be representative of the target population. Third, the small sample size may be related to some of the non-significant results. Although full sample weights were applied to account for non-response rate and other biases, concerns in representativeness in race/ethnicity may still exist. Lastly, the definition of caregiver may not be precise enough to distinguish the 'ongoing basis multiple-duty medical need-based caretakers' from 'mild (light hours) life aid-based caretakers.' Therefore, the intensity of their caregiving duty was not accounted for in this study. Moreover, this study did not include the rurality of residence as a sociodemographic factor despite the potential association with the disparities in HPV awareness and knowledge as well as adherence to the guidelines of cervical cancer screening. Because nearly 98% of caregivers were urban residents, we did not think we could have meaningful results out of this population distribution. However, further investigation is needed to better understand how rurality of residence affects caregivers' cervical cancer screening behaviors, including the caregiving burden among rural residents. Although the incidence of invasive cervical cancer was higher in the rural area at every stage ( 60 , 67 , 68 ) individuals living in resource-limited or rural areas showed lower rates of cervical cancer screening compared to the general population in the U.S.( 69 ) Female caregivers who are residing in rural areas are experiencing a heavier caregiving burden and presenting with worse health conditions.( 50 ) Previous studies reported the potential barriers to receive cancer screening among rural residents could be a lack of access to care, health insurance coverage, mistrust of healthcare. Along with these potential reasons, periodic cervical cancer screening may be less recommended by the healthcare professionals in rural caregivers.( 70 , 71 ) This could be partially due to the lack of healthcare services resources, including the shortage of healthcare professionals in rural areas. If a limited number of healthcare professionals are required to cover a large group of rural residents, non-urgent health issues, including preventive services, could be often less prioritized. However, the relationship between rurality and low adherence to the cervical cancer screening guidelines is still unclear.( 71 , 72 ) Conclusion It is important to acknowledge the association between HPV and cervical cancer screening behaviors as higher HPV awareness and knowledge are closely related to higher adherence to cervical cancer screening behaviors.( 73 , 74 ) Furthermore, adhering to the recommended cervical cancer screening is crucial for detecting cervical cancer early and reducing mortality significantly.( 75 , 76 ) Therefore, targeted intervention to improve HPV awareness and cervical cancer screening adherence will be effective and urgently required among female caregivers as this populations’ health condition is at risk. We found that sociodemographic factors, particularly age, race/ethnicity, educational attainments, were associated with disparities in HPV awareness and adherence to the cervical cancer screening guidelines among female caregivers in the U.S. The value of this study is the suggestion that targeted interventions should focus on women caregivers who are aged 51-65, have low educational attainment (high school graduate or less). Efforts to improve HPV awareness and knowledge as well as adherence to the cervical cancer screening guidelines in this vulnerable subpopulation is needed. Abbreviations HINTS: Health Information National Trends Survey HPV: Human Papillomavirus BRFSS: Behavioral Risk Factor Surveillance System Pap Smear: Papanicolaou cytology USPSTF: U.S. Preventive Services Task Force Declarations Ethics approval and consent to participate Ethics approval and participant consent was not necessary as this study involved the use of a previously-published de-identified database. The data used in the study were publicly available. All the methods performed in the study followed the relevant guidelines and regulations. Consent for publication Not applicable. Availability of data and materials The datasets generated and/or analyzed during the current study are available in the Health Information National Trends Survey, https://hints.cancer.gov/data/default.aspx Competing interests We declare no competing interests regarding the research, authorship, and/or publication of this article. Funding There was no funding source for this study. Authors’ contributions JK conceived the study. JK designed the study protocol and conducted literature search under the supervision of JHTD. JK and MD analyzed and interpreted the data. JK wrote the manuscript and JHTD and MD substantially contributed to the manuscript revision. Acknowledgement Not applicable. References Caregiving in the US 2020 | The National Alliance for Caregiving [Internet]. [cited 2021 Aug 21]. 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Available from: https://pubmed.ncbi.nlm.nih.gov/28613745/ Tables Table 1 Demographic characteristics of female caregiving population 2017-2020 Frequency, n Percentage, % (95% CI) age (years) 21-50 432 61.18 (56.10, 66.25) 51-65 402 38.82 (33.75, 43.90) 834 100.00 Race/ethnicity Non-Hispanic White 461 63.55 (58.83, 68.27) Black/African American 139 13.94 (11.20, 16.67) Hispanic 126 13.13 (10.11, 16.16) Others 72 9.38 (5.62, 13.14) 798 100.00 Household income Less than $20,000 151 20.45 (15.13, 25.77) $20,000-less than $35,000 96 11.87 (9.17, 14.57) $35,000-less than $50,000 104 13.73 (10.71, 16.75) $50,000 or more 435 53.95 (49.15, 58.76) 786 100.00 Years of education High school or less Some college or more 164 664 25.06 (20.57, 29.55) 74.94 (70.45, 79.43) 828 100.00 Area: Rurality Urban 813 97.75 (96.60, 98.91) Rural 21 2.25 (1.09, 3.40) 834 100.00 Employment Employed 501 59.54 (54.29, 64.78) Unemployed 308 40.46 (35.22, 45.71) 809 0.00 Marital Status Married 499 64. 02 (58.89, 69.14) Not Married 330 35.98 (30.86, 41. 11) 829 100.00 Health Insurance By employment or private 484 67.34 (62.00, 72.68) Tricare, VA, Indian Health Services 36 3.98 (1.95, 6.11) Medicare 41 3.39 (2.04, 4.74) Medicaid 151 25.29 (20.19, 30.40) 712 100.00 Table 2 Caregiver's HPV Awareness/knowledge and Cervical Cancer Screening Behaviors, Frequency (n) and weighted percent (%) HPV Awareness HPV Knowledge Pap Test in 3 Years N / row total Weighted percent (95% CI) N /row total Weighted percent (95% CI) N/ row total Weighted percent (95% CI) Total 661/834 79% 547/560 98% 671/805 83% age (years) 21-50 369/432 84% (79%, 89%) 318/324 98% (96%, 100%) 381/416 91% (88%, 94%) 51-65 292/402 66% (58%, 75%) 229/236 98% (96%, 100%) 290/389 75% (69%, 81%) Race/ ethnicity White 400/460 84% (79%, 89%) 340/345 99% (97%, 100%) 373/451 83% (79%, 87%) Black/African American 100/139 69% (57%, 80%) 79/81 99% (96%, 100%) 114/132 88% (80%, 96%) Hispanic 94/126 77% (67%, 87%) 74/75 98% (95%, 100%) 96/119 77% (68%, 87%) Others 17/34 53% (31%, 76%) 15/15 93% (81%, 100%) 30/32 94% (88%, 100%) Household income Less than $20,000 104/150 70% (56%, 84%) 76/82 98% (95%, 100%) 113/143 80% (71%, 89%) $20,000 to <$35,000 64/96 69% (57%, 82%) 48/50 95% (85%, 100%) 65/91 86% (79%, 94%) $35,000 to <$50,000 78/104 78% (66%, 90%) 58/60 95% (88%, 100%) 82/101 80% (70%, 89%) $50,000 or more 383/435 82% (75%, 89%) 338/341 99% (98%, 100%) 374/425 87% (82%, 91%) Years of education High school or less Some college or more 98/164 559/663 61% (49%, 73%) 83% (78%, 88%) 61/68 482/488 96% (93%, 100%) 98% (97%, 100%) 115/153 553/648 76% (67%, 85%) 87% (84%, 90%) Employment Employed 407/501 78% (71%, 86%) 348/354 98% (96%, 100%) 410/484 85% (81%, 90%) Unemployed 234/307 74% (67%, 82%) 185/192 98% (96%, 100%) 241/298 83% (77%, 88%) Marital Status Married 413/499 81% (75%, 86%) 354/360 98% (96%, 100%) 417/487 85% (81%, 89%) Not Married 245/329 72% (63%, 80%) 191/198 99% (98%, 100%) 249/313 83% (78%, 89%) Health Insurance Employment/ private 418/484 83% (75%, 90%) 365/368 99% (98%, 100%) 412/472 88% (84%, 92%) Tricare/VA/Indian Health 28/36 81% (64%, 98%) 24/25 99% (96%, 100%) 29/35 91% (81%, 100% Medicare 32/40 76% (56%, 96%) 23/24 88% (62%, 100%) 30/38 86% (73%, 100%) Medicaid 109/151 73% (62%, 84%) 82/87 96% (92%, 100%) 124/147 83% (75%, 91%) Table 3 HPV Awareness and Knowledge and Cervical Cancer Screening Behaviors Among Caregivers (Odds Ratio and 95% CI) HPV awareness (HeardHPV) Odds Ratio (95% CI) HPV knowledge (HPV can cause Cervical Cancer) Odds Ratio (95% CI) Within guidelines (Pap test in 3 years) Odds Ratio (95% CI) age (years) 21-50 2.67 (1.61, 4.41) 1.11 (0.18, 6.68) 3.47 (2.01, 5.98) 51-65 Reference Reference Reference Race/ethnicity White 1.63 (0.90, 2.94) 1.15 (0.26, 5.02) 1.46 (0.77, 2.79) Black/African American 0.67 (0.30, 1.50) 1.12 (0.06, 22.25) 2.20 (0.73, 6.58) Hispanic Reference Reference Reference Others 0.35 (0.12, 1.02) 0.21 (0.01, 9.87) 4.63 (1.05, 20.38) Less than $20,000 Reference Reference Reference Household $20,000-less than $35,000 0.96(0.37, 2.51) 0.44 (0.01, 24.96) 1.02 (0.45, 2.30) income $35,000-less than $50,000 1.48 (0.63, 3.48) 0.53 (0.04, 7.02) 1.62 (0.66, 3.97) $50,000 or more 1.96 (0.87, 4.40) 3.39 (0.28, 40.71) 1.62 (0.75, 3.50) Years of education High school or less Some college or more Reference 3.10 (1.16, 5.79) Reference 2.36 (0.50, 11.10) Reference 2.08 (1.16, 3.74) Employment Employed 1.26 (0.68, 2.34) 1.08 (0.20, 5.93) 1.23 (0.67, 2.23) Unemployed Reference Reference Reference Marital Status Married 1.62 (0.95, 2.77) 0.68 (0.18, 2.57) 1.17 (0.68, 1.99) Not Married Reference Reference Reference Health By employment or private 1.74 (0.77, 3.93) 4.97 (0.36, 21.63) 1.52 (0.75, 3.07) insurance Tricare, VA, Indian Health 1.57 (0.46, 5.37) 2.79 (0.36, 21.63) 2.05 (0.51, 8.28) Medicare 1.18 (0.34, 4.08) 0.27 (0.04, 2.02) 1.27 (0.32, 5.00) Medicaid Reference Reference Reference *Bold-coded is statistically significant, P-value < 0.05. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Major revision 10 Mar, 2022 Reviews received at journal 09 Mar, 2022 Reviews received at journal 28 Jan, 2022 Reviewers agreed at journal 18 Jan, 2022 Reviewers invited by journal 17 Dec, 2021 Editor assigned by journal 17 Dec, 2021 Editor invited by journal 17 Dec, 2021 Submission checks completed at journal 17 Dec, 2021 First submitted to journal 27 Nov, 2021 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-1120326","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":70889259,"identity":"dd5a000d-eabc-49db-a1f8-798f2c029f33","order_by":0,"name":"Jiyeong Kim","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAz0lEQVRIiWNgGAWjYBACxmYGZoYEBhsgMwGMGBgOEKcljQQtQMAMxIcZoOqJ0MLczmNs8DDnfGJ/e/IziQd/GOT4biTg18LYzGOckLjtduKMM8/MJBLbGIwlidFyAKRlg0SCsUFiA0PiBiK1nANqSf9skPCHoZ4oLUCHHQBqyTF8kMDGkGBAWAtbsUHitmTjGWfeFD5IbJMwnHnmAX4thv2HN0v+3GYn29+evuHgjz828nzHCdhi2MBhgMyXwK8cBOQZ2Am4YxSMglEwCkYBAIZ9SfaaA9kPAAAAAElFTkSuQmCC","orcid":"","institution":"University of California, Davis","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Jiyeong","middleName":"","lastName":"Kim","suffix":""},{"id":70889260,"identity":"6e8d740e-8c91-4d5e-a475-4139c9132576","order_by":1,"name":"Melanie Dove","email":"","orcid":"","institution":"University of California, Davis","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Melanie","middleName":"","lastName":"Dove","suffix":""},{"id":70889261,"identity":"f7e5c8e5-2288-4d77-a18b-ca1261b1ce6f","order_by":2,"name":"Julie HT Dang","email":"","orcid":"","institution":"University of California, Davis","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Julie","middleName":"HT","lastName":"Dang","suffix":""}],"badges":[],"createdAt":"2021-11-28 00:59:02","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-1120326/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-1120326/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":16623749,"identity":"e5c4ccf5-7bd2-42a5-a2d1-7853f3ae10de","added_by":"auto","created_at":"2021-12-20 17:35:55","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":385821,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-1120326/v1/8e09aff3-c851-482a-a877-ca73585dad6f.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eSociodemographic Factors Associated With HPV Awareness/Knowledge and Cervical Cancer Screening Behaviors Among Caregivers in the US\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eApproximately 53 million individuals were family caregivers in the U.S. in 2020.(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) More than one in five people (21%) provided unpaid healthcare or functional needs for their family members. (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) This is a 9.5 million increase from 2018 (43.5 million), and the family caregiving population is projected to continue to increase.(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) Caregivers are often described as hidden patients because caregiving is burdensome as it requires physical, emotional, financial sacrifices and is usually a long-term commitment, spanning from several years to over a decade.(\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) About a quarter of caregivers (26%) report spending over 20 hours per week providing care.(\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) Consequentially, this population is vulnerable to an unhealthy lifestyle and are at high risk for chronic diseases.(\u003cspan additionalcitationids=\"CR5 CR6\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e) Prolonged caregiving causes cumulated stress, including neurohormonal changes and inflammatory responses in the body, weight loss, and sleep deprivation.(\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e) According to the caregiver data from the Behavioral Risk Factor Surveillance System (BRFSS), in 2015-17, 14.5% of caregivers experienced an unhealthy mental status for 14 and more days in the past month,(\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e) 17.6% had an unhealthy physical status for 14 days or more in the past month, and 36.7% reported insufficient sleep (less than 7 hours of sleep).(\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e) Moreover, 40.7% of caregivers reported multiple chronic medical conditions, including coronary heart disease, stroke, asthma, chronic obstructive pulmonary disease (COPD), arthritis, depressive disorder, kidney disease, diabetes, and cancer.(\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eThe majority of caregivers are female (61%),(\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) and the average age of female caregivers is 50.1 years.(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) Cervical cancer is one of the most prevalent cancers among women in the U.S. and the average age at diagnosis is 50.(\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e) It is also one of the most common causes of cancer death among U.S. women.(\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e) For most types of cervical cancer, Human Papilloma Virus (HPV) infection is the primary cause, specifically HPV I6 and 18.(\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e) Approximately 80 million people in the U.S. are currently infected with HPV.(\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e) While the majority of HPV infections disappear naturally within 1 to 2 years; (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e) persistent high-risk HPV can cause cancers of the cervix, penis and anus.(\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e) Papanicolaou cytology (Pap smear) detects changes in cells caused by HPV and allows at-risk women to receive treatment before it becomes invasive carcinoma.(\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e) As early detection can reduce cervical cancer incidence and mortality significantly, active cervical cancer screening is strongly recommended as an effective prevention strategy. The U.S. Preventive Services Task Force (USPSTF) recommends cervical cytology every 3 years for women aged 21 to 29 years old, and for women aged 30-65 years old, either cervical cytology every 3 years, high-risk Human Papilloma Virus (hrHPV) testing every 5 years, or hrHPV testing in combination with cytology (co-testing) every 5 years.(\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e) In 2018, 12,733 new cervical cancer cases and 4,138 cervical cancer death were reported despite effective prevention and treatment options.(\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eDespite the threat of cervical cancer, knowledge regarding the cause of cervical cancer and the linkage to HPV infection has been low to moderate among Americans.(\u003cspan additionalcitationids=\"CR19\" citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e) Furthermore, HPV knowledge level differs by sociodemographic characteristics (e.g., race/ethnicity, age, income, educational attainment, insurance status, rurality of residence).(\u003cspan additionalcitationids=\"CR21 CR22 CR23 CR24 CR25 CR26\" citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e) HPV knowledge level was lower in racial/ethnic minorities, including Hmong American immigrants, Korean American immigrants, and Hispanics, older populations, and rural residents.(\u003cspan additionalcitationids=\"CR21 CR22 CR23 CR24 CR25 CR26\" citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eAdherence to the cervical cancer screening guidelines (e.g., pap smear within the past 3 years) has been moderate to high.(\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e) Previous analysis of HINTS data (2013-14) revealed that 81.3% of 21-65 years of women reported that they had a Pap smear in the past 3 years.(\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e) However, stark disparities by sociodemographic factors were observed in cervical cancer screening behavior.(\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan additionalcitationids=\"CR32 CR33\" citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e) Similar to the HPV knowledge level, the Pap smear test was less utilized in women who were older and racial/ethnic minorities (African American, Asians, Hispanics).(\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e) Also, low Socioeconomic Status (SES), including low income, low educational attainment, no health insurance, absence of a usual source of healthcare, was significantly associated with low adherence to obtaining cervical cancer screening.(\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan additionalcitationids=\"CR32\" citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eReportedly, HPV knowledge level is an essential indicator in cervical cancer screening utilization as these two are positively associated with each other.(\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e) Multiple studies have reported this association based on their empirical research or nationally representative survey data analysis.(\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e) This relationship is also supported by the Theory of Reasoned Action, a theory explaining how intention and health behaviors are related.(\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eWhile multiple studies have shown disparities in HPV knowledge and cervical cancer screening behavior in women in the U.S., studies focused on family caregivers\u0026rsquo; negative health behaviors due to the caregiving burden and the receipt of preventive clinical services, including cancer screening, are still scant with inconsistent results.(\u003cspan additionalcitationids=\"CR39 CR40 CR41 CR42 CR43 CR44 CR45 CR46\" citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e) Some studies presented caregivers\u0026rsquo; adherence to the Pap smear test being low because of caregiving.(\u003cspan additionalcitationids=\"CR39 CR40\" citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e) Other studies reported no association between caregiving status and Pap smear utilization.(\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e) Studies have also suggested that the caregivers are more aware of the preventive health services and hence actively participating in cancer screening.(\u003cspan additionalcitationids=\"CR45 CR46\" citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eDespite the limited findings, there has been a longstanding concern that caregivers are less likely to perform cancer screenings because the burden of caregiving may hinder them from obtaining care for themselves and their health status is already vulnerable.(\u003cspan additionalcitationids=\"CR5 CR6\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan additionalcitationids=\"CR39 CR40\" citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e) In addition, the burden of caregiving and the association of chronic medical conditions also differed by sociodemographic characteristics. Family caregivers who are women, racial/ethnic minorities, rural residents, and with low income experienced heavier caregiving burdens,(\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan additionalcitationids=\"CR49 CR50 CR51\" citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e) and also presented with worse health conditions.(\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e, \u003cspan additionalcitationids=\"CR54\" citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e) While we can reasonably assume that subgroups of caregivers are disproportionately low in cervical cancer screening and HPV knowledge, little is known in this area. Given the caregivers\u0026rsquo; crucial role in patients\u0026rsquo; disease management, treatment compliance, resilience, and mental and spiritual support, and family functioning, and the persisting nature of caregiving, this population needs additional support on the importance of obtaining and adhering to cervical cancer screening recommendations. Therefore, this study aimed to identify sociodemographic factors associated with disparities in HPV knowledge and cervical cancer screening behaviors among caregivers in the U.S. This information will contribute to the development of a targeted intervention to interpose existing inequities in this area.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eData source\u003c/h2\u003e \u003cp\u003eThis study used publicly available cross-sectional data, Health Information National Trends Survey (HINTS).(\u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e) HINTS is a self-administered nationally representative survey data collected by the National Cancer Institute. The present study used HINTS 5 Cycle 1,2,3,4 in 2017-2020. HINTS 5 is a random digit-dialed telephone survey and a mailed questionnaire survey in non-institutionalized civilians aged 18 and older in the US. HINTS 5 included data of caregiver population, their health-related behavior, perception, and knowledge of the disease. Geographic addresses were stratified by either area with a high concentration of minority population or low concentration of minority population in HINTS 5 Cycle 2,3,4. HINTS 5 Cycle 1 included one more stratification in geographic address, counties of Central Appalachia. The present study followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guideline.(\u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eThe total number of respondents used in this study was 16,092 (3,285 in Cycle 1, 3,504 in Cycle 2, 5,438 in Cycle 3, 3,865 in Cycle 4). Each response rate was 32.4%, 32.39%, 30.3%, 36.7%, respectively. The response rate was estimated based on Response Rate 2 formula (RR2) from the American Association of Public Opinion Research.(\u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e) In our analysis, we only included female caregivers aged 21-65 (n= 834) because that is the population recommended to obtain a regular cervical cancer screening every 3 years by the USPSTF.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eCaregiver status\u003c/h2\u003e \u003cp\u003eCaregiving status was identified by one question; \u0026ldquo;Are you currently caring for or making health care decisions for someone with a medical, behavioral, disability, or other conditions?\u0026rdquo; Those who affirmatively responded \u0026lsquo;yes\u0026rsquo; were defined as caregivers.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eOutcome variables\u003c/h2\u003e \u003cdiv id=\"Sec6\" class=\"Section3\"\u003e \u003ch2\u003eHPV Awareness (Heard of HPV) and HPV Knowledge (HPV can cause cervical cancer)\u003c/h2\u003e \u003cp\u003eTo investigate caregivers\u0026rsquo; awareness of Human Papillomavirus (HPV), the following survey questions were used; \"Have you ever heard of HPV? HPV stands for Human Papilloma Virus. It is not HCV, HIV, or Herpes.\" Those who answered \"yes\" were considered to have HPV awareness. Respondents who answered \u0026ldquo;yes\u0026rdquo; to the question, \u0026ldquo;Do you think HPV can cause cervical cancer?\u0026rdquo; were regarded as having knowledge of the causal effect of HPV on cervical cancer in this study.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section3\"\u003e \u003ch2\u003eCervical cancer screening adherence to the screening guidelines (Had a pap test within 3 years)\u003c/h2\u003e \u003cp\u003eTo distinguish the caregivers who are complaint with the USPSTF cervical cancer screening guidelines, the question, \u0026ldquo;How long ago did you have your most recent Pap test to check for cervical cancer?\u0026rdquo; was used. Those who answered, \u0026ldquo;I have never had a Pap test\u0026rdquo; were re-coded to \u0026ldquo;Never.\u0026rdquo; Caregivers with all other answers were divided into \u0026ldquo;within guidelines\u0026rdquo; if they had a pap test within the past 3 years or \u0026ldquo;outside guidelines\u0026rdquo; if they had a pap test more than 3 years ago.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eCovariates\u003c/h2\u003e \u003cp\u003eConceptual framework of social determinants of health from the Healthy People 2030 was applied for the choices of sociodemographic predictors in this study(\u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e): Age (\u003cspan additionalcitationids=\"CR22 CR23 CR24 CR25 CR26 CR27 CR28 CR29 CR30 CR31 CR32 CR33 CR34 CR35 CR36 CR37 CR38 CR39 CR40 CR41 CR42 CR43 CR44 CR45 CR46 CR47 CR48 CR49\" citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e, \u003cspan additionalcitationids=\"CR52 CR53 CR54 CR55 CR56 CR57 CR58 CR59 CR60 CR61 CR62 CR63 CR64\" citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e65\u003c/span\u003e), birth gender, race/ethnicity (White, Hispanic, African American/Black, Others including Asian, Native Hawaiian/Pacific Islander, American Indian/Alaska Native, Multiple races), household income (less than \u003cspan\u003e$\u003c/span\u003e20,000, \u003cspan\u003e$\u003c/span\u003e20,000 to less than \u003cspan\u003e$\u003c/span\u003e35,000, \u003cspan\u003e$\u003c/span\u003e35,000 to less than \u003cspan\u003e$\u003c/span\u003e50,000, \u003cspan\u003e$\u003c/span\u003e50,000 or more), educational attainment (high school graduate or less, some college or more), marital status (married or living with a romantic partner as a married vs. not married including divorced, widowed, separated, single/never been married), employment status (employed vs. unemployed including homemaker, student, retired, disabled), health insurance type (insured by employment or private insurance, Tricare/VA/Indian Health Services, Medicare, Medicaid.)\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis\u003c/h2\u003e \u003cp\u003eThe weighted percent of each outcome was estimated for each demographic characteristic. To examine the association between characteristics and the three outcomes of interest (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) HPV awareness, 2) HPV knowledge, 3) adherence to the cervical cancer screening guidelines weighted multivariate logistic regression was performed to present odds ratios and 95% confidence intervals (Table 3). The statistical significance was determined at p-value is less than 0.05 and alpha is 0.05. All estimates accounted for the sampling strategy using replicate weights and survey procedures in SAS (SAS Studio, version 9.4, Cary, NC).\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eAmong female caregivers aged 21-65, 39% were aged 51-65, 64% were non-Hispanic White, 46% reported less than \u003cspan\u003e$\u003c/span\u003e50,000 annual household income, 25% were high school graduate or less education, 60% were employed, 64% were married, 67% were insured by the employment-based or private plan while 33% was insured by the government provided insurance (Medicare, Medicaid, Tricare, VA, Indian Health Services), and approximately 98% was urban (metropolitan, micropolitan, and small town) residents. (Table \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eHPV Awareness (Heard of HPV) and HPV knowledge (HPV can cause cervical cancer)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eApproximately 79% of female caregivers (aged 21-65) heard of HPV and the majority of participants thought that HPV can cause cervical cancer (98%) (Table 2). However, disparities in HPV awareness were found by sociodemographic characteristics (Table 3). Younger female caregivers (\u003cspan class=\"CitationRef\"\u003e21\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e50\u003c/span\u003e) were over 2 times more likely to have heard of HPV compared to older caregivers (\u003cspan class=\"CitationRef\"\u003e51\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e65\u003c/span\u003e) (OR=2.67, 95% CI=1.61, 4.41). Female caregivers whose educational attainment was high school graduate or less were one third times likely to have heard of HPV than individuals with some college or more (OR=3.10, 95% CI=1.16, 5.79 in some college or more group).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAdherence to the Cervical Cancer Screening Guidelines (Had a pap test within 3 years)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eOverall, 83% of female caregivers had a pap test in the past 3 years (Table 2). Sociodemographic disparities were also found (Table 3). Younger caregivers (\u003cspan class=\"CitationRef\"\u003e21\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e50\u003c/span\u003e) were more likely to follow the cervical cancer screening guidelines than older caregivers (\u003cspan class=\"CitationRef\"\u003e51\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e65\u003c/span\u003e) (OR=3.47, 95% CI=2.01, 5.98). Other ethnic groups, including Asian, Native Hawaiian/Pacific Islander, American Indian/Alaska Native, Multiple races were more likely to adhere to the cervical cancer screening guidelines than Hispanic female caregivers (OR=4.63, 95%=1.05, 20.38). Caregivers with some college or more education were nearly 2 times likely to adhere to the cervical cancer screening guidelines than those with high school graduate or less education (OR=2.08, 95% CI=1.16, 3.74).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study assessed sociodemographic factors associated with HPV awareness (heard of HPV), HPV knowledge (HPV can cause cervical cancer), and adherence to the cervical cancer screening guidelines (had a pap test within 3 years) among female caregivers in the U.S. from 2017-2020. In general, the older age group, Hispanics, those with low education, were less likely to have awareness and knowledge of HPV and adhere to guidelines.\u003c/p\u003e \u003cp\u003eOur results were similar to Blake et al.(\u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e) who reported lower levels of HPV awareness among women who were older, less educated, had lower-income, had no health insurance, and were of a racial/ethnic minority (Hispanics). One plausible explanation could be that HPV awareness and HPV vaccination campaigns target younger age groups. Healthcare professionals also focus more on younger age groups to promote HPV vaccine uptake and HPV awareness. Thus, older generations, aged 51-65, are less likely to be exposed to these HPV campaigns and educational efforts.\u003c/p\u003e \u003cp\u003ePrevious literature reported differences in HPV knowledge level by race/ethnicity, specifically lower knowledge among U.S. racial/ethnic minorities including Hmong American immigrants, Korean American immigrants, and Hispanic women.(\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e61\u003c/span\u003e) Although other ethnic groups, including Asian female caregivers, were less likely to know about HPV than non-Hispanic Whites, African American/Blacks, and Hispanics in this study, it was not significant. Prior studies that examined HPV knowledge among the general population revealed that age,(\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e) as well as socioeconomic status (income and educational attainment, rurality of residence)(\u003cspan additionalcitationids=\"CR21\" citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e) was also associated. However, socioeconomic factors, including household income, educational status, were not associated with HPV knowledge in this population. Presumably, individuals with higher education and higher income are more likely to have higher health literacy and greater access to health resources which can possibly increase their knowledge and awareness of HPV. However, this hypothetical relationship was not observed in this study. One explanation could be that only participants who answered that they have had heard of HPV, were asked subsequently, \u0026ldquo;Do you think HPV can cause cervical cancer?\u0026rdquo;. In other words, people who are already aware of HPV are more likely to know the causation of cervical cancer which may make it more challenging to associate additional socioeconomic disparities in HPV knowledge among this population. Additionally, this made the sample size of those with HPV knowledge even smaller, which may have resulted in non-significant differences in some of the socioeconomic factors. This can be the limitation of HINTS 5 data to precisely analyze variables related to HPV knowledge. Further comprehensive analysis to examine the association of socioeconomic characteristics and HPV knowledge among female caregivers with a larger sample will be necessary.\u003c/p\u003e \u003cp\u003ePrior studies reported that older age,(\u003cspan additionalcitationids=\"CR63\" citationid=\"CR62\" class=\"CitationRef\"\u003e62\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e) low income,(\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e) low educational attainment,(\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e) lack of health insurance,(\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e) marital status,(\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e) was associated with low cervical cancer screening rates (within 3 years) among US women. Johnson et al(\u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e) reported younger age groups had higher odds of having a pap test within 5 years than older age groups in general US women. Similar associations were observed in the present study. Although most (93% or higher) female caregivers reported ever having a Pap smear in the past, many subgroups did not adhere to the cervical cancer screening guidelines of every 3 years. Healthy People 2030 aimed to reach 84.3% of adherence to the cervical cancer screening guidelines among U.S. women.(\u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e65\u003c/span\u003e) In our analysis, the younger age group (aged 21-50) showed satisfied status to reaching the goal (91%) while the older age group (aged 51-65) was far behind the target (75%). Considering the average diagnosed age of cervical cancer in the U.S. is 50, the older age group is the one who needs our attention to improve and maintain their adherence to the USPSTF guidelines. Education was significantly associated with the adherence to the cervical cancer screening guidelines in both general women and caregivers. Women with low educational attainment (high school graduate or less education) showed lower odds of cervical cancer screening behaviors than those with higher educational attainment (4-year college and more education) in general women (\u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e), and this trend was the same in the caregiver population in this study. However, low household income was not significantly associated with the adherence of cervical cancer screening guidelines among caregivers in this study, although low-income earners (annual household income \u0026lt;\u003cspan\u003e$\u003c/span\u003e30,000) showed lower odds in obtaining cervical cancer screening within 5 years among U.S. women in previous studies (\u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e, \u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e66\u003c/span\u003e). The association of age and the adherence to the cervical cancer screening guidelines could be explained by the relationship that low HPV awareness and knowledge is closely related to the low HPV screening behavior.(\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e) Thus, older caregivers who have low HPV awareness are less likely to obtain cervical cancer screening guidelines. Moreover, it is possible that the caregivers who have low financial resources and educational attainment may be less likely to have heard of HPV and may also be less knowledgeable of HPV. As a result, they may be less likely to acknowledge the importance of HPV screening and have fewer resources, including financial, physical, emotional, to adhere to the recommended cervical cancer screening guidelines. Small sample size could be one potential reason for the no significant association between household income and the adherence to the cervical cancer screening among caregivers. Hence, further comprehensive examination will be necessary with the larger sample population to see whether household income is associated with the adherence to the cervical cancer screening behaviors among caregivers.\u003c/p\u003e \u003cp\u003eIn previous research, women with public health insurance had higher odds in obtaining a cervical cancer screening within 5 years than those with private insurance.(\u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eAs the coverage of the public insurance has increased since 2016, a study reported that government provided insurance holder\u0026rsquo;s preventive health services utilization rate were also higher than that of non-government insurance holders. However, in this study, significant differences between the health insurance types were not observed in HPV awareness and knowledge, and adherence to the cervical cancer screening guidelines among caregivers. Further research will be necessary to examine the role of health insurance types in adherence to cervical cancer screening behaviors among caregivers. It will help to identify vulnerable subpopulations to improve adherence among caregivers.\u003c/p\u003e \u003cp\u003ePrior studies reported that African-Americans and Hispanics women had lower adherence to cervical cancer screening guidelines than non-Hispanic Whites.(\u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e, \u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e) However, in this study, rather the White caregivers had lower odds in pap test guideline adherence than the Black caregiver\u0026rsquo;s odds when compared to Hispanics, but it was not significant. Other ethnic groups\u0026rsquo; odds of adherence to the cervical cancer screening guidelines were higher than Hispanics\u0026rsquo; odds. Further research is recommended to investigate the association of ethnic minorities and adherence to the cervical cancer screening guidelines among caregivers.\u003c/p\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eLimitation\u003c/h2\u003e \u003cp\u003eThe current study has several limitations. First, HINTS is a cross-sectional survey at one point of the year. Hence, it cannot guarantee temporality and causal inference in the outcomes of interests in this study. Second, a low response rate (overall 32%) is concerning because those responding to the survey may be different than those who don\u0026rsquo;t and so the survey may not be representative of the target population. Third, the small sample size may be related to some of the non-significant results. Although full sample weights were applied to account for non-response rate and other biases, concerns in representativeness in race/ethnicity may still exist. Lastly, the definition of caregiver may not be precise enough to distinguish the 'ongoing basis multiple-duty medical need-based caretakers' from 'mild (light hours) life aid-based caretakers.' Therefore, the intensity of their caregiving duty was not accounted for in this study. Moreover, this study did not include the rurality of residence as a sociodemographic factor despite the potential association with the disparities in HPV awareness and knowledge as well as adherence to the guidelines of cervical cancer screening. Because nearly 98% of caregivers were urban residents, we did not think we could have meaningful results out of this population distribution. However, further investigation is needed to better understand how rurality of residence affects caregivers' cervical cancer screening behaviors, including the caregiving burden among rural residents. Although the incidence of invasive cervical cancer was higher in the rural area at every stage (\u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e, \u003cspan citationid=\"CR67\" class=\"CitationRef\"\u003e67\u003c/span\u003e, \u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e68\u003c/span\u003e) individuals living in resource-limited or rural areas showed lower rates of cervical cancer screening compared to the general population in the U.S.(\u003cspan citationid=\"CR69\" class=\"CitationRef\"\u003e69\u003c/span\u003e) Female caregivers who are residing in rural areas are experiencing a heavier caregiving burden and presenting with worse health conditions.(\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e) Previous studies reported the potential barriers to receive cancer screening among rural residents could be a lack of access to care, health insurance coverage, mistrust of healthcare. Along with these potential reasons, periodic cervical cancer screening may be less recommended by the healthcare professionals in rural caregivers.(\u003cspan citationid=\"CR70\" class=\"CitationRef\"\u003e70\u003c/span\u003e, \u003cspan citationid=\"CR71\" class=\"CitationRef\"\u003e71\u003c/span\u003e) This could be partially due to the lack of healthcare services resources, including the shortage of healthcare professionals in rural areas. If a limited number of healthcare professionals are required to cover a large group of rural residents, non-urgent health issues, including preventive services, could be often less prioritized. However, the relationship between rurality and low adherence to the cervical cancer screening guidelines is still unclear.(\u003cspan citationid=\"CR71\" class=\"CitationRef\"\u003e71\u003c/span\u003e, \u003cspan citationid=\"CR72\" class=\"CitationRef\"\u003e72\u003c/span\u003e)\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIt is important to acknowledge the association between HPV and cervical cancer screening behaviors as higher HPV awareness and knowledge are closely related to higher adherence to cervical cancer screening behaviors.(\u003cspan class=\"CitationRef\"\u003e73\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e74\u003c/span\u003e) Furthermore, adhering to the recommended cervical cancer screening is crucial for detecting cervical cancer early and reducing mortality significantly.(\u003cspan class=\"CitationRef\"\u003e75\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e76\u003c/span\u003e) Therefore, targeted intervention to improve HPV awareness and cervical cancer screening adherence will be effective and urgently required among female caregivers as this populations\u0026rsquo; health condition is at risk.\u003c/p\u003e\n\u003cp\u003eWe found that sociodemographic factors, particularly age, race/ethnicity, educational attainments, were associated with disparities in HPV awareness and adherence to the cervical cancer screening guidelines among female caregivers in the U.S. The value of this study is the suggestion that targeted interventions should focus on women caregivers who are aged 51-65, have low educational attainment (high school graduate or less). Efforts to improve HPV awareness and knowledge as well as adherence to the cervical cancer screening guidelines in this vulnerable subpopulation is needed.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cul\u003e\n\u003cli\u003e\n\u003cp\u003eHINTS: Health Information National Trends Survey\u003c/p\u003e\n\u003c/li\u003e\n\u003cli\u003e\n\u003cp\u003eHPV: Human Papillomavirus\u003c/p\u003e\n\u003c/li\u003e\n\u003cli\u003e\n\u003cp\u003eBRFSS: Behavioral Risk Factor Surveillance System\u003c/p\u003e\n\u003c/li\u003e\n\u003cli\u003e\n\u003cp\u003ePap Smear: Papanicolaou cytology\u003c/p\u003e\n\u003c/li\u003e\n\u003cli\u003e\n\u003cp\u003eUSPSTF: U.S. Preventive Services Task Force\u003c/p\u003e\n\u003c/li\u003e\n\u003c/ul\u003e"},{"header":"Declarations","content":"\u003cul\u003e\n \u003cli\u003e\n \u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n \u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eEthics approval and participant consent was not necessary as this study involved the use of a previously-published de-identified database. The data used in the study were publicly available.\u003c/p\u003e\n\u003cp\u003eAll the methods performed in the study followed the relevant guidelines and regulations.\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003e\n \u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n \u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003e\n \u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n \u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eThe datasets generated and/or analyzed during the current study are available in the Health Information National Trends Survey, \u003ca href=\"https://hints.cancer.gov/data/default.aspx\"\u003ehttps://hints.cancer.gov/data/default.aspx\u003c/a\u003e\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003e\n \u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n \u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eWe declare no competing interests regarding the research, authorship, and/or publication of this article.\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003e\n \u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n \u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eThere was no funding source for this study.\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003e\n \u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u003c/p\u003e\n \u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eJK conceived the study. JK designed the study protocol and conducted literature search under the supervision of JHTD. JK and MD analyzed and interpreted the data. JK wrote the manuscript and JHTD and MD substantially contributed to the manuscript revision.\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003e\n \u003cp\u003e\u003cstrong\u003eAcknowledgement\u003c/strong\u003e\u003c/p\u003e\n \u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eCaregiving in the US 2020 | The National Alliance for Caregiving [Internet]. [cited 2021 Aug 21]. Available from: https://www.caregiving.org/caregiving-in-the-us-2020/\u003c/li\u003e\n \u003cli\u003eM H, SS D, N B. Cervical cancer screening among U.S. women: analyses of the 2000 National Health Interview Survey. Prev Med (Baltim) [Internet]. 2004 [cited 2021 Aug 19];39(2):270\u0026ndash;8. 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Available from: https://pubmed.ncbi.nlm.nih.gov/28613745/\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cdiv class=\"gridtable\"\u003e\n\u003ctable id=\"Tab1\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003eDemographic characteristics of female caregiving population 2017-2020\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n\u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eFrequency, n\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003ePercentage, % (95% CI)\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eage (years)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e21-50\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e432\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e61.18 (56.10, 66.25)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e51-65\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e402\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e38.82 (33.75, 43.90)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e834\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e100.00\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eRace/ethnicity\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eNon-Hispanic White\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e461\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e63.55 (58.83, 68.27)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eBlack/African American\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e139\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e13.94 (11.20, 16.67)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eHispanic\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e126\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e13.13 (10.11, 16.16)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eOthers\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e72\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e9.38 (5.62, 13.14)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e798\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e100.00\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eHousehold income\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eLess than $20,000\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e151\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e20.45 (15.13, 25.77)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e$20,000-less than $35,000\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e96\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e11.87 (9.17, 14.57)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e$35,000-less than $50,000\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e104\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e13.73 (10.71, 16.75)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e$50,000 or more\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e435\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e53.95 (49.15, 58.76)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e786\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e100.00\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eYears of education\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eHigh school or less\u003c/p\u003e\n\u003cp\u003eSome college or more\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e164\u003c/p\u003e\n\u003cp\u003e664\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e25.06 (20.57, 29.55)\u003c/p\u003e\n\u003cp\u003e74.94 (70.45, 79.43)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e828\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e100.00\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eArea: Rurality\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eUrban\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e813\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e97.75 (96.60, 98.91)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eRural\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e21\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e2.25 (1.09, 3.40)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e834\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e100.00\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eEmployment\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eEmployed\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e501\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e59.54 (54.29, 64.78)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eUnemployed\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e308\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e40.46 (35.22, 45.71)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e809\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.00\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMarital Status\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMarried\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e499\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e64. 02 (58.89, 69.14)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eNot Married\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e330\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e35.98 (30.86, 41. 11)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e829\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e100.00\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eHealth Insurance\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eBy employment or private\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e484\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e67.34 (62.00, 72.68)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eTricare, VA, Indian Health Services\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e36\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e3.98 (1.95, 6.11)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMedicare\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e41\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e3.39 (2.04, 4.74)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMedicaid\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e151\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e25.29 (20.19, 30.40)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e712\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e100.00\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003ctable id=\"Taba\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cp\u003eTable 2\u003c/p\u003e\n\u003cp\u003eCaregiver's HPV Awareness/knowledge and Cervical Cancer Screening Behaviors, Frequency (n) and weighted percent (%)\u003c/p\u003e\n\u003c/caption\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd colspan=\"3\" align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd colspan=\"4\" align=\"left\"\u003e\n\u003cp\u003eHPV Awareness\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"4\" align=\"left\"\u003e\n\u003cp\u003eHPV Knowledge\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"5\" align=\"left\"\u003e\n\u003cp\u003ePap Test in 3 Years\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd colspan=\"3\" align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eN\u003c/p\u003e\n\u003cp\u003e/ row total\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eWeighted percent\u003c/p\u003e\n\u003cp\u003e(95% CI)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eN\u003c/p\u003e\n\u003cp\u003e/row total\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eWeighted percent\u003c/p\u003e\n\u003cp\u003e(95% CI)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eN/\u003c/p\u003e\n\u003cp\u003erow total\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"3\" align=\"left\"\u003e\n\u003cp\u003eWeighted percent\u003c/p\u003e\n\u003cp\u003e(95% CI)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd colspan=\"3\" align=\"left\"\u003e\n\u003cp\u003eTotal\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e661/834\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e79%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e547/560\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e98%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e671/805\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"3\" align=\"left\"\u003e\n\u003cp\u003e83%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eage (years)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"3\" align=\"left\"\u003e\n\u003cp\u003e21-50\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e369/432\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e84%\u003c/p\u003e\n\u003cp\u003e(79%, 89%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e318/324\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e98%\u003c/p\u003e\n\u003cp\u003e(96%, 100%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e381/416\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"3\" align=\"left\"\u003e\n\u003cp\u003e91%\u003c/p\u003e\n\u003cp\u003e(88%, 94%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd colspan=\"3\" align=\"left\"\u003e\n\u003cp\u003e51-65\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e292/402\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e66%\u003c/p\u003e\n\u003cp\u003e(58%, 75%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e229/236\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e98%\u003c/p\u003e\n\u003cp\u003e(96%, 100%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e290/389\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"3\" align=\"left\"\u003e\n\u003cp\u003e75%\u003c/p\u003e\n\u003cp\u003e(69%, 81%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eRace/\u003c/p\u003e\n\u003cp\u003eethnicity\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"3\" align=\"left\"\u003e\n\u003cp\u003eWhite\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e400/460\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e84%\u003c/p\u003e\n\u003cp\u003e(79%, 89%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e340/345\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e99%\u003c/p\u003e\n\u003cp\u003e(97%, 100%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e373/451\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"3\" align=\"left\"\u003e\n\u003cp\u003e83%\u003c/p\u003e\n\u003cp\u003e(79%, 87%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd colspan=\"3\" align=\"left\"\u003e\n\u003cp\u003eBlack/African American\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e100/139\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e69%\u003c/p\u003e\n\u003cp\u003e(57%, 80%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e79/81\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e99%\u003c/p\u003e\n\u003cp\u003e(96%, 100%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e114/132\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"3\" align=\"left\"\u003e\n\u003cp\u003e88%\u003c/p\u003e\n\u003cp\u003e(80%, 96%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd colspan=\"3\" align=\"left\"\u003e\n\u003cp\u003eHispanic\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e94/126\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e77%\u003c/p\u003e\n\u003cp\u003e(67%, 87%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e74/75\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e98%\u003c/p\u003e\n\u003cp\u003e(95%, 100%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e96/119\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"3\" align=\"left\"\u003e\n\u003cp\u003e77%\u003c/p\u003e\n\u003cp\u003e(68%, 87%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd colspan=\"3\" align=\"left\"\u003e\n\u003cp\u003eOthers\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e17/34\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e53%\u003c/p\u003e\n\u003cp\u003e(31%, 76%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e15/15\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e93%\u003c/p\u003e\n\u003cp\u003e(81%, 100%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e30/32\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"3\" align=\"left\"\u003e\n\u003cp\u003e94%\u003c/p\u003e\n\u003cp\u003e(88%, 100%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eHousehold income\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"3\" align=\"left\"\u003e\n\u003cp\u003eLess than $20,000\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e104/150\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e70%\u003c/p\u003e\n\u003cp\u003e(56%, 84%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e76/82\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e98%\u003c/p\u003e\n\u003cp\u003e(95%, 100%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e113/143\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"3\" align=\"left\"\u003e\n\u003cp\u003e80%\u003c/p\u003e\n\u003cp\u003e(71%, 89%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd colspan=\"3\" align=\"left\"\u003e\n\u003cp\u003e$20,000 to \u0026lt;$35,000\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e64/96\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e69%\u003c/p\u003e\n\u003cp\u003e(57%, 82%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e48/50\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e95%\u003c/p\u003e\n\u003cp\u003e(85%, 100%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e65/91\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"3\" align=\"left\"\u003e\n\u003cp\u003e86%\u003c/p\u003e\n\u003cp\u003e(79%, 94%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd colspan=\"3\" align=\"left\"\u003e\n\u003cp\u003e$35,000 to \u0026lt;$50,000\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e78/104\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e78%\u003c/p\u003e\n\u003cp\u003e(66%, 90%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e58/60\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e95%\u003c/p\u003e\n\u003cp\u003e(88%, 100%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e82/101\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"3\" align=\"left\"\u003e\n\u003cp\u003e80%\u003c/p\u003e\n\u003cp\u003e(70%, 89%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd colspan=\"3\" align=\"left\"\u003e\n\u003cp\u003e$50,000 or more\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e383/435\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e82%\u003c/p\u003e\n\u003cp\u003e(75%, 89%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e338/341\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e99%\u003c/p\u003e\n\u003cp\u003e(98%, 100%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e374/425\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"3\" align=\"left\"\u003e\n\u003cp\u003e87%\u003c/p\u003e\n\u003cp\u003e(82%, 91%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eYears of education\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"3\" align=\"left\"\u003e\n\u003cp\u003eHigh school or less\u003c/p\u003e\n\u003cp\u003eSome college or more\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e98/164\u003c/p\u003e\n\u003cp\u003e559/663\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e61%\u003c/p\u003e\n\u003cp\u003e(49%, 73%)\u003c/p\u003e\n\u003cp\u003e83%\u003c/p\u003e\n\u003cp\u003e(78%, 88%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e61/68\u003c/p\u003e\n\u003cp\u003e482/488\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e96%\u003c/p\u003e\n\u003cp\u003e(93%, 100%)\u003c/p\u003e\n\u003cp\u003e98%\u003c/p\u003e\n\u003cp\u003e(97%, 100%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e115/153\u003c/p\u003e\n\u003cp\u003e553/648\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"3\" align=\"left\"\u003e\n\u003cp\u003e76%\u003c/p\u003e\n\u003cp\u003e(67%, 85%)\u003c/p\u003e\n\u003cp\u003e87%\u003c/p\u003e\n\u003cp\u003e(84%, 90%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eEmployment\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"3\" align=\"left\"\u003e\n\u003cp\u003eEmployed\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e407/501\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e78%\u003c/p\u003e\n\u003cp\u003e(71%, 86%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e348/354\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e98%\u003c/p\u003e\n\u003cp\u003e(96%, 100%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e410/484\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"3\" align=\"left\"\u003e\n\u003cp\u003e85%\u003c/p\u003e\n\u003cp\u003e(81%, 90%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd colspan=\"3\" align=\"left\"\u003e\n\u003cp\u003eUnemployed\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e234/307\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e74%\u003c/p\u003e\n\u003cp\u003e(67%, 82%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e185/192\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e98%\u003c/p\u003e\n\u003cp\u003e(96%, 100%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e241/298\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"3\" align=\"left\"\u003e\n\u003cp\u003e83%\u003c/p\u003e\n\u003cp\u003e(77%, 88%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eMarital Status\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"3\" align=\"left\"\u003e\n\u003cp\u003eMarried\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e413/499\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e81%\u003c/p\u003e\n\u003cp\u003e(75%, 86%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e354/360\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e98%\u003c/p\u003e\n\u003cp\u003e(96%, 100%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e417/487\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"3\" align=\"left\"\u003e\n\u003cp\u003e85%\u003c/p\u003e\n\u003cp\u003e(81%, 89%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd colspan=\"3\" align=\"left\"\u003e\n\u003cp\u003eNot Married\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e245/329\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e72%\u003c/p\u003e\n\u003cp\u003e(63%, 80%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e191/198\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e99%\u003c/p\u003e\n\u003cp\u003e(98%, 100%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e249/313\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"3\" align=\"left\"\u003e\n\u003cp\u003e83%\u003c/p\u003e\n\u003cp\u003e(78%, 89%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eHealth Insurance\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"3\" align=\"left\"\u003e\n\u003cp\u003eEmployment/ private\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e418/484\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e83%\u003c/p\u003e\n\u003cp\u003e(75%, 90%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e365/368\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e99%\u003c/p\u003e\n\u003cp\u003e(98%, 100%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e412/472\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"3\" align=\"left\"\u003e\n\u003cp\u003e88%\u003c/p\u003e\n\u003cp\u003e(84%, 92%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd colspan=\"3\" align=\"left\"\u003e\n\u003cp\u003eTricare/VA/Indian Health\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e28/36\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e81%\u003c/p\u003e\n\u003cp\u003e(64%, 98%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e24/25\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e99%\u003c/p\u003e\n\u003cp\u003e(96%, 100%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e29/35\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"3\" align=\"left\"\u003e\n\u003cp\u003e91%\u003c/p\u003e\n\u003cp\u003e(81%, 100%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd colspan=\"3\" align=\"left\"\u003e\n\u003cp\u003eMedicare\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e32/40\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e76%\u003c/p\u003e\n\u003cp\u003e(56%, 96%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e23/24\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e88%\u003c/p\u003e\n\u003cp\u003e(62%, 100%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e30/38\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"3\" align=\"left\"\u003e\n\u003cp\u003e86%\u003c/p\u003e\n\u003cp\u003e(73%, 100%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd colspan=\"3\" align=\"left\"\u003e\n\u003cp\u003eMedicaid\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e109/151\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e73%\u003c/p\u003e\n\u003cp\u003e(62%, 84%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e82/87\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e96%\u003c/p\u003e\n\u003cp\u003e(92%, 100%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e124/147\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"3\" align=\"left\"\u003e\n\u003cp\u003e83%\u003c/p\u003e\n\u003cp\u003e(75%, 91%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" width=\"0\"\u003e\u003ccaption\u003e\n\u003cp\u003eTable 3\u003c/p\u003e\n\u003cp\u003eHPV Awareness and Knowledge and Cervical Cancer Screening Behaviors Among Caregivers (Odds Ratio and 95% CI)\u003c/p\u003e\n\u003c/caption\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd width=\"107\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"171\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"142\"\u003e\n\u003cp\u003e\u003cstrong\u003eHPV awareness\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e(HeardHPV)\u003c/p\u003e\n\u003cp\u003eOdds Ratio (95% CI)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"149\"\u003e\n\u003cp\u003e\u003cstrong\u003eHPV knowledge\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e(HPV can cause\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Cervical Cancer)\u003c/p\u003e\n\u003cp\u003eOdds Ratio (95% CI)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"180\"\u003e\n\u003cp\u003e\u003cstrong\u003eWithin guidelines\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e(Pap test in 3 years)\u003c/p\u003e\n\u003cp\u003eOdds Ratio (95% CI)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"107\"\u003e\n\u003cp\u003eage (years)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"171\"\u003e\n\u003cp\u003e21-50\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"142\"\u003e\n\u003cp\u003e\u003cstrong\u003e2.67 (1.61, 4.41)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"149\"\u003e\n\u003cp\u003e1.11 (0.18, 6.68)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"180\"\u003e\n\u003cp\u003e\u003cstrong\u003e3.47 (2.01, 5.98)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"107\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"171\"\u003e\n\u003cp\u003e51-65\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"142\"\u003e\n\u003cp\u003eReference\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"149\"\u003e\n\u003cp\u003eReference\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"180\"\u003e\n\u003cp\u003eReference\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"107\"\u003e\n\u003cp\u003eRace/ethnicity\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"171\"\u003e\n\u003cp\u003eWhite\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"142\"\u003e\n\u003cp\u003e1.63 (0.90, 2.94)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"149\"\u003e\n\u003cp\u003e1.15 (0.26, 5.02)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"180\"\u003e\n\u003cp\u003e1.46 (0.77, 2.79)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"107\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"171\"\u003e\n\u003cp\u003eBlack/African American\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"142\"\u003e\n\u003cp\u003e0.67 (0.30, 1.50)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"149\"\u003e\n\u003cp\u003e1.12 (0.06, 22.25)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"180\"\u003e\n\u003cp\u003e2.20 (0.73, 6.58)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"107\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"171\"\u003e\n\u003cp\u003eHispanic\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"142\"\u003e\n\u003cp\u003eReference\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"149\"\u003e\n\u003cp\u003eReference\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"180\"\u003e\n\u003cp\u003eReference\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"107\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"171\"\u003e\n\u003cp\u003eOthers\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"142\"\u003e\n\u003cp\u003e0.35 (0.12, 1.02)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"149\"\u003e\n\u003cp\u003e0.21 (0.01, 9.87)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"180\"\u003e\n\u003cp\u003e\u003cstrong\u003e4.63 (1.05, 20.38)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"107\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"171\"\u003e\n\u003cp\u003eLess than $20,000\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"142\"\u003e\n\u003cp\u003eReference\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"149\"\u003e\n\u003cp\u003eReference\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"180\"\u003e\n\u003cp\u003eReference\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"107\"\u003e\n\u003cp\u003eHousehold\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"171\"\u003e\n\u003cp\u003e$20,000-less than $35,000\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"142\"\u003e\n\u003cp\u003e0.96(0.37, 2.51)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"149\"\u003e\n\u003cp\u003e0.44 (0.01, 24.96)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"180\"\u003e\n\u003cp\u003e1.02 (0.45, 2.30)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"107\"\u003e\n\u003cp\u003eincome\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"171\"\u003e\n\u003cp\u003e$35,000-less than $50,000\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"142\"\u003e\n\u003cp\u003e1.48 (0.63, 3.48)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"149\"\u003e\n\u003cp\u003e0.53 (0.04, 7.02)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"180\"\u003e\n\u003cp\u003e1.62 (0.66, 3.97)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"107\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"171\"\u003e\n\u003cp\u003e$50,000 or more\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"142\"\u003e\n\u003cp\u003e1.96 (0.87, 4.40)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"149\"\u003e\n\u003cp\u003e3.39 (0.28, 40.71)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"180\"\u003e\n\u003cp\u003e1.62 (0.75, 3.50)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"107\"\u003e\n\u003cp\u003eYears of education\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"171\"\u003e\n\u003cp\u003eHigh school or less\u003c/p\u003e\n\u003cp\u003eSome college or more\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"142\"\u003e\n\u003cp\u003e\u003cstrong\u003eReference\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.10 (1.16, 5.79)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"149\"\u003e\n\u003cp\u003eReference\u003c/p\u003e\n\u003cp\u003e2.36 (0.50, 11.10)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"180\"\u003e\n\u003cp\u003e\u003cstrong\u003eReference\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.08 (1.16, 3.74)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"107\"\u003e\n\u003cp\u003eEmployment\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"171\"\u003e\n\u003cp\u003eEmployed\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"142\"\u003e\n\u003cp\u003e1.26 (0.68, 2.34)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"149\"\u003e\n\u003cp\u003e1.08 (0.20, 5.93)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"180\"\u003e\n\u003cp\u003e1.23 (0.67, 2.23)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"107\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"171\"\u003e\n\u003cp\u003eUnemployed\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"142\"\u003e\n\u003cp\u003eReference\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"149\"\u003e\n\u003cp\u003eReference\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"180\"\u003e\n\u003cp\u003eReference\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"107\"\u003e\n\u003cp\u003eMarital Status\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"171\"\u003e\n\u003cp\u003eMarried\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"142\"\u003e\n\u003cp\u003e1.62 (0.95, 2.77)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"149\"\u003e\n\u003cp\u003e0.68 (0.18, 2.57)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"180\"\u003e\n\u003cp\u003e1.17 (0.68, 1.99)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"107\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"171\"\u003e\n\u003cp\u003eNot Married\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"142\"\u003e\n\u003cp\u003eReference\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"149\"\u003e\n\u003cp\u003eReference\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"180\"\u003e\n\u003cp\u003eReference\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"107\"\u003e\n\u003cp\u003eHealth\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"171\"\u003e\n\u003cp\u003eBy employment or private\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"142\"\u003e\n\u003cp\u003e1.74 (0.77, 3.93)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"149\"\u003e\n\u003cp\u003e4.97 (0.36, 21.63)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"180\"\u003e\n\u003cp\u003e1.52 (0.75, 3.07)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"107\"\u003e\n\u003cp\u003einsurance\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"171\"\u003e\n\u003cp\u003eTricare, VA, Indian Health\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"142\"\u003e\n\u003cp\u003e1.57 (0.46, 5.37)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"149\"\u003e\n\u003cp\u003e2.79 (0.36, 21.63)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"180\"\u003e\n\u003cp\u003e2.05 (0.51, 8.28)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"107\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"171\"\u003e\n\u003cp\u003eMedicare\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"142\"\u003e\n\u003cp\u003e1.18 (0.34, 4.08)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"149\"\u003e\n\u003cp\u003e0.27 (0.04, 2.02)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"180\"\u003e\n\u003cp\u003e1.27 (0.32, 5.00)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"107\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"171\"\u003e\n\u003cp\u003eMedicaid\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"142\"\u003e\n\u003cp\u003eReference\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"149\"\u003e\n\u003cp\u003eReference\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"180\"\u003e\n\u003cp\u003eReference\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003e*Bold-coded\u003c/strong\u003e is statistically significant, P-value \u0026lt; 0.05.\u003c/p\u003e\n\u003c/div\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-womens-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmwh","sideBox":"Learn more about [BMC Women's Health](http://bmcwomenshealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bmwh/default.aspx","title":"BMC Women's Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Human Papillomavirus (HPV), HPV awareness, Cervical cancer screening, Caregivers, Health disparities, sociodemographic","lastPublishedDoi":"10.21203/rs.3.rs-1120326/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-1120326/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003e\u003cem\u003eBackground\u003c/em\u003e\u003c/strong\u003e\u003cem\u003e.\u003c/em\u003e\u0026nbsp;Family caregivers may be at a higher risk for several chronic diseases including cancer. Cervical cancer is one of the most prevalent cancers among U.S. women. Despite family caregivers’ vulnerability, the status of their HPV awareness, knowledge, and preventive health behaviors, including cervical cancer screening, have been understudied. Thus, this study aimed to examine the sociodemographic factors associated with HPV awareness and knowledge, and adherence to the cervical cancer screening guidelines among caregivers in the U.S. \u003c/p\u003e\u003cp\u003e\u003cstrong\u003e\u003cem\u003eMethods\u003c/em\u003e\u003c/strong\u003e\u003cem\u003e.\u003c/em\u003e\u0026nbsp;Nationally representative cross-sectional survey data were obtained from the Health Information National Trends Survey (HINTS 5, 2017-2020). Only female caregivers, aged 21-65, were included (N= 834). Weighted multivariate logistic regression was performed to identify factors associated with HPV awareness, knowledge, and adherence to the United States Preventive Service Task Force cervical cancer screening guidelines (by age, race/ethnicity, education, household income, marital status, employment status, and health insurance type).\u0026nbsp;\u003c/p\u003e\u003cp\u003e\u003cstrong\u003e\u003cem\u003eResults.\u003c/em\u003e\u003c/strong\u003e Caregivers who were older (aged 51-65 vs. 21-50), were less educated (high school graduate or less vs. some college or more) showed lower adherence to the cervical cancer screening guidelines (every 3 years) than their counterparts.\u0026nbsp;Caregivers who were older and less educated showed lower HPV awareness (Heard of HPV).\u003c/p\u003e\u003cp\u003e\u003cstrong\u003e\u003cem\u003eConclusions.\u003c/em\u003e\u003c/strong\u003e\u0026nbsp;There are caregiving populations whose HPV awareness, knowledge and cervical cancer screening adherence are low. To improve their awareness and knowledge of HPV and support their cervical cancer screening behaviors, we need to consider interventions that target those specific populations.\u0026nbsp;\u003c/p\u003e","manuscriptTitle":"Sociodemographic Factors Associated With HPV Awareness/Knowledge and Cervical Cancer Screening Behaviors Among Caregivers in the US","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2021-12-20 17:35:51","doi":"10.21203/rs.3.rs-1120326/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Major revision","date":"2022-03-10T06:39:08+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2022-03-09T22:38:00+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2022-01-28T11:26:07+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"37bed51f-9992-4746-8e5c-6bed45d18418","date":"2022-01-19T01:40:53+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2021-12-17T15:42:25+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2021-12-17T15:41:01+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2021-12-17T14:28:03+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2021-12-17T14:26:19+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Women's Health","date":"2021-11-28T00:45:37+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-womens-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmwh","sideBox":"Learn more about [BMC Women's Health](http://bmcwomenshealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bmwh/default.aspx","title":"BMC Women's Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"caaa8351-b08e-425a-b1da-3937b5c501ce","owner":[],"postedDate":"December 20th, 2021","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[{"id":9278399,"name":"Internal Medicine"},{"id":9278400,"name":"Preventive Medicine"}],"tags":[],"updatedAt":"2022-08-03T04:59:21+00:00","versionOfRecord":[],"versionCreatedAt":"2021-12-20 17:35:51","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-1120326","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-1120326","identity":"rs-1120326","version":["v1"]},"buildId":"GqpaHPwrfC8PjnIFayRh5","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}