Response to LTE: Clinical Considerations on HPV Knowledge, Screening, and Vaccination in Brazilian Primary Care

Transparency Statement

The corresponding author (Fábio Ferreira Amorim) affirms that this manuscript provides an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that there were no discrepancies from the original protocol approved by the Institutional Review Board.

We thank the author for the careful and thoughtful reading of our study and for highlighting the clinical relevance of the gaps identified between preventive practices, knowledge, and awareness regarding human papillomavirus (HPV), cervical cancer screening, and HPV vaccination [1]. We particularly appreciate the recognition that, despite substantial knowledge gaps, our findings revealed generally favorable attitudes toward HPV vaccination. The points raised in the Letter to the Editor are constructive and provide an important opportunity to clarify aspects of the study, refine the interpretation of selected findings, and address numerical inconsistencies in the published report.

We agree that the apparent contrast between preventive behavior and understanding deserves careful consideration. In our sample, 69.9% of participants reported having previously undergone a Pap smear, whereas 19.9% were classified as having a screening frequency consistent with the recommended protocol in the original analysis. Likewise, although 72.7% reported that they would “certainly” vaccinate their children against HPV, only 18.5% were aware of the association between HPV infection and cervical cancer [1]. These findings illustrate an important distinction between engaging in, or expressing favorable attitudes toward, preventive practices and having a comprehensive understanding of their rationale. We appreciate the author's emphasis on this issue, which is consistent with one of the central messages of our study.

Concerning cervical cancer screening adherence, we thank the author for this important observation regarding the denominator used to report adherence. In the original analysis, we calculated the screening adherence estimate of 19.9% (60/302) using the entire study sample as the denominator, consistent with the general approach used for the descriptive percentages in the study. We agree, however, that screening adherence is more appropriately and clinically interpreted when specifically examined among women within the age range targeted by the Brazilian cervical cancer screening recommendations [2]. We therefore performed an additional analysis restricted to women aged 25–64 years. Of the 302 participants, 218 (72.2%) were within this target age range. Among these women, 53 (24.3%) reported a Pap smear frequency consistent with the screening protocol. Thus, when the denominator is restricted to women within the recommended screening age range, the estimated adherence increases from 19.9% in the overall sample to 24.3% (53/218). Importantly, although this age‐restricted analysis provides a more clinically appropriate estimate, adherence remained low, with fewer than one in four women in the recommended screening age range reporting a screening frequency consistent with the protocol. This finding reinforces an important gap between prior cervical cancer screening and adherence to the recommended screening schedule. It highlights the need to strengthen longitudinal follow‐up, patient education, and strategies to promote timely screening within primary health care.

Regarding participants' certainty about vaccinating children against HPV, we clarify that this variable was intended to measure stated vaccination intention and, importantly, the degree of certainty regarding that intention, rather than actual parental vaccine uptake. In this context, “I do not know yet” represents a less favorable response in terms of vaccination certainty than “Certainly yes,” because it reflects the absence of a definite intention to vaccinate. We did not collect information on parental or guardian status, number of children, or children's ages in our questionnaire. Therefore, we cannot determine how many participants were mothers or guardians or stratify vaccination intention by parental status. We agree that this aspect may be particularly relevant when interpreting the responses, especially among younger women. The “I do not know yet” response may reflect uncertainty about HPV vaccination itself. However, for some participants, it may also reflect the hypothetical nature of the question among women who did not yet have children. Nevertheless, regardless of parental status, an “I do not know yet” response indicates lower vaccination certainty and a lack of definite intention to vaccinate. It may therefore reflect uncertainty or reduced confidence regarding HPV vaccination and can be considered relevant when identifying opportunities for vaccine education and counseling. However, because parental status, children's ages, and an actual vaccination decision were not assessed, these responses should not, by themselves, be interpreted as definitive evidence of parental vaccine hesitancy. Rather, they indicate a group for whom the importance and benefits of HPV vaccination may not yet be sufficiently established to support a definite positive intention.

Concerning the interpretation of FHS/PHC evaluations among younger women, we agree that “I do not know/do not remember” should not be interpreted as equivalent to an explicitly negative response such as “Certainly no.” However, we believe it is important to distinguish these responses from a favorable assessment of FHS/PHC. Our classification was intended to distinguish a definite positive perception from the absence of such a perception. Accordingly, only responses in which participants were able to affirm the assessed attribute were considered favorable, whereas “I do not know/do not remember” appropriately remained outside the positive category. This distinction is particularly relevant considering the study setting. All participants were registered and receiving care at the participating FHS/PHC unit and therefore had an established relationship with primary health care [1]. In this context, being unable to affirm that professionals understood their questions, provided clear responses, allowed sufficient time to discuss their concerns, or offered specific services cannot be assumed to represent a favorable perception of those attributes. Rather, it indicates that a definite positive perception was not established, whether because of uncertainty, limited knowledge of the service, or lack of confidence regarding the attribute being assessed. We acknowledge that younger women may have had less cumulative exposure to FHS/PHC services than older women, which could have contributed to their greater frequency of “I do not know/do not remember” responses. However, because we did not specifically measure frequency and duration of primary care use, we cannot establish this explanation from our data. Importantly, our interpretation does not equate uncertain responses with negative experiences or imply poorer objective quality of care. Rather, it reflects younger participants' more limited ability to provide a definite positive assessment of several FHS/PHC attributes. We believe this distinction accurately reflects both the operational classification used in the study and the population in which these questions were assessed.

Regarding healthcare professionals as an information source, we agree that reporting healthcare professionals as an information source is conceptually different from receiving a direct and explicit recommendation for HPV vaccination. Our questionnaire assessed the former but did not specifically evaluate whether a healthcare professional had recommended HPV vaccination, the strength of that recommendation, or the content of the recommendation. Therefore, the absence of an independent association between healthcare professionals as an information source and vaccination certainty should not be interpreted as evidence that professional recommendations are ineffective. The evidence the author cites regarding the importance of physician recommendations is consistent with this distinction and provides useful context for interpreting our findings [2].

Concerning television as a source of health information, we agree that the observed association between television and greater certainty about vaccinating children should not be interpreted as a causal effect of television itself. Our cross‐sectional findings demonstrate an association between reporting television as a source of health information and greater vaccination certainty, rather than demonstrating that television inherently increases vaccine confidence. The content, framing, credibility, and context of information conveyed through any communication medium may determine whether that information influences vaccination attitudes favorably or unfavorably. The example the author raised regarding adverse media framing therefore complements rather than contradicts this interpretation [3]. Our findings suggest that television may be an important channel through which health information reaches the population. However, they do not establish that exposure to television per se leads to greater vaccine acceptance. We have therefore interpreted this finding as supporting the potential relevance of mass communication channels for public health communication.

Finally, regarding the numerical discrepancies identified by the author, we thank them for carefully pointing them out. After rechecking the analytical dataset, we confirm that the points raised by the author require clarification. First, the 96.4% reported in the Abstract was inadvertently attributed to awareness of the Pap smear. This percentage corresponds to awareness of the cervical cancer prevention examination (291/302), whereas 226/302 participants (74.8%) specifically reported awareness of the Pap smear. Second, we confirm that the four categories of intention to vaccinate children included 300 valid responses rather than 302: 218 (72.7%) answered “Certainly yes,” 26 (8.7%) “Yes, but only if they wish to,” 47 (15.7%) “I do not know yet,” and 9 (3.0%) “No, in any case.” Two responses were missing for this item in the analytical dataset. We acknowledge that the statement in the Statistical Analysis section indicating that no missing data were identified should have been qualified for this specific item. Third, we also confirm an inconsistency in the presentation of the item assessing whether participants would seek FHS/PHC first for a new health issue. After rechecking the analytical dataset and the original statistical results, the correct distribution was 146 (48.3%) “Certainly yes”, 65 (21.5%) “Probably yes”, 65 (21.5%) “Certainly no”, and 26 (8.6%) “I do not know/do not remember”, totaling 302 participants. Among women aged ≤ 22 years, the corresponding counts were 16 (33.3%), 15 (31.3%), 15 (31.3%), and 2 (4.2%), respectively, whereas among women aged ≥ 23 years, they were 130 (51.2%), 50 (19.7%), 50 (19.7%), and 24 (9.4%), respectively. This corrected distribution is also consistent with the final analytical dataset, in which the “Certainly no” and “I do not know/do not remember” categories had been combined into a single negative/uncertain category: 65 + 26 = 91 participants overall, including 15 + 2 = 17 women aged ≤ 22 years and 50 + 24 = 74 women aged ≥ 23 years. Therefore, the discrepancy was restricted to the presentation of the counts and percentages for the “Certainly no” category and did not affect the statistical comparison between age groups. Finally, the author is correct that 39 of 302 participants correspond to 12.9%, rather than 6.0%. The number of participants was correct, but the percentage was a typographical error.

We sincerely thank the author for the careful, constructive, and clinically oriented appraisal of our study. The issues raised provided an opportunity not only to identify and correct numerical inconsistencies but also to refine the interpretation of screening adherence, vaccination certainty, and younger women's perceptions of primary healthcare services. We believe that these clarifications improve the accuracy, transparency, and clinical interpretation of our findings. Importantly, they also reinforce a central message of the study: favorable preventive behaviors or intentions may coexist with substantial gaps in knowledge and certainty regarding HPV, cervical cancer, and their prevention, underscoring the continuing importance of effective health education and communication strategies within primary health care [1].

Author Contributions

Alessandra Monteiro Ramos: conceptualization, investigation, writing – original draft, methodology, validation, visualization, writing – review and editing, software, formal analysis, project administration, data curation, supervision, resources. Cláudia Vicari Bolignani: investigation, writing – original draft, methodology, writing – review and editing, formal analysis. Leila Bernarda Donato Göttems: investigation, writing – original draft, methodology, writing – review and editing, formal analysis. Ana Maria Costa: investigation, writing – original draft, methodology, writing – review and editing, formal analysis. Heleno Rodrigues Corrêa Filho: investigation, writing – original draft, methodology, writing – review and editing, formal analysis. Wania Maria do Espírito Santo Carvalho: conceptualization, investigation, writing – original draft, methodology, validation, visualization, writing – review and editing, supervision, resources, project administration, formal analysis. Fábio Ferreira Amorim: conceptualization, investigation, writing – original draft, methodology, validation, visualization, writing – review and editing, software, formal analysis, project administration, data curation, supervision, resources.

Ethics Statement

The Institutional Review Board of the Health Sciences Education and Research Foundation in Brazil approved the study.

Consent

Written informed consent was obtained from all the participants.

Conflicts of Interest

The authors declare no conflicts of interest.

Ramos A. M., Bolignani C. V., Göttems L. B. D., et al., “Response to LTE: Clinical Considerations on HPV Knowledge, Screening, and Vaccination in Brazilian Primary Care,” Health Science Reports 9 (2026): e73347. 10.1002/hsr2.73347.

Data Availability Statement

The data that support the findings of this study are available from the corresponding author upon reasonable request.