Reviewer’s report
Title:  Cervical cancer screening practices among women in Ghana: Evidence from Wave 2 of the
WHO Study on Global AGEing and Adult Health
Version: 0 Date: 08 Jul 2019
Reviewer: Paolo Giorgi Rossi
Reviewer's report:
The paper presents a very well conducted and analyzed survey. 
Abstract
In the conclusion, the "lack of national policy…" as  reason for low pap test uptake is  not well
explained and it seems more an assumption than a conclusion deriving from your results. I suggest to
put firstly the other factors and then suggesting that all these are the consequence of a weak health
system and the lack of national policy…
Methods
The design and the rationale are explained very well. In the paragraph about explanatory variables I
suggest to be more precise about the reference literature and, if possible to distinguish the possible
determinants of a pelvic examination and of a pap, given that a pelvic  examination was present.
Statistics. The model building strategy is very well described. Do you really need to set a significance
threshold? Are you going to make formal statistical tests? What does it means: if you find a p of 0.049
you believe that the association is true and if you find a p-value of 0.05 you believe that there is no
association? What does it means in this context to reject the null hypothesis or not? You are not
engaged with a regulatory agency to demonstrate that a drug is  effective or not, so that you need a
predefined threshold. Here you are presenting to  the scientific community several hypotheses, the
multiple testing is evident, it is extremely probable that some "significant" associations will be due to
chance, but also that you do not have power to see as significant many other associations… I suggest to
use p-values and confidence intervals in a continuous way representing the probability that such an
association is due to chance. 
Results
The first paragraph reports data present in the tables.
Why, in the text, perceived health is reported only for Cristian women? The sentence sounds strange.
Table 2 does not report the numbers. One solution could be to report univariate analyses in table 1
(three columns, one with the total, one with those with pelvic, one with those  with pap) and then table
2 and 3 can report only the ORs. The other is to report numbers of women and outcomes by row in
table two, this makes  not useful the unadjusted model and you can report only the adjusted model (thus
it is not easy to appreciate the direction of adjustment).
Discussion
Pag 10 lines 49-54: the sentence is apodictic even if sustained by references. I suggest you have more
information to sustain this point. How the socioeconomic factors, beliefs, relation with health system
and opportunities offered by the health system interact, clearly suggest that there is no penetration of
the pelvic examination (a necessary condition to take a pap smear) ant when there is the opportunity,
very few are taken. It is important to say that the rate in health care involvement can be a cause but also
a consequence of having had a pelvic examination, the same is for the dissatisfaction with health care
and pap test, sampling could be perceived as not useful, needing to come back for an unperceived need.
Are the methods appropriate and well described?
If not, please specify what is required in your comments to the authors.
Yes
Does the work include the necessary controls?
If not, please specify which controls are required in your comments to the authors.
Yes
Are the conclusions drawn adequately supported by the data shown?
If not, please explain in your comments to the authors.
Yes
Are you able to assess any statistics in the manuscript or would you recommend an additional
statistical review?
If  an  additional  statistical  review  is  recommended,  please  specify  what  aspects  require  further
assessment in your comments to the editors.
I am able to assess the statistics
Quality of written English
Please indicate the quality of language in the manuscript:
Acceptable
Declaration of competing interests
Please complete a declaration of competing interests, considering the following questions:
1. Have you in the past five years received reimbursements, fees, funding, or salary from an
organisation that may in any way gain or lose financially from the publication of this
manuscript, either now or in the future?
2. Do you hold any stocks or shares in an organisation that may in any way gain or lose
financially from the publication of this manuscript, either now or in the future?
3. Do you hold or are you currently applying for any patents relating to the content of the
manuscript?
4. Have you received reimbursements, fees, funding, or salary from an organization that holds
or has applied for patents relating to the content of the manuscript?
5. Do you have any other financial competing interests?
6. Do you have any non-financial competing interests in relation to this paper?
If you can answer no to all of the above, write 'I declare that I have no competing interests' below. If
your reply is yes to any, please give details below.
'I declare that I have no competing interests
I agree to the open peer review policy of the journal. I understand that my name will be included on my
report to the authors and, if the manuscript is accepted for publication, my named report including any 
attachments I upload will be posted on the website along with the authors' responses. I agree for my 
report to be made available under an Open Access Creative Commons CC-BY license 
(http://creativecommons.org/licenses/by/4.0/ ). I understand that any comments which I do not wish to 
be included in my named report can be included as confidential comments to the editors, which will not
be published.
I agree to the open peer review policy of the journal