Reviewer ’s report  
 
Title: Factors affecting cervical cancer screening uptake, vis ual inspection with ace tic acid 
positivity and its predictors among women attending cervical ca ncer screening service in Addis 
Ababa, Ethiopia  
 
Version: 0 Date: 06 Jan 2020  
 
Reviewer: Patricia Vil lain 
 
Reviewer's report:  
 
General comments  
 
The authors have presented the results of an important st udy performed in Addis Ababa, 
Ethiopia. Some of the information will be useful to improve the quality and reach of cervical 
cancer screening in the country.  
 
The major limitation of the study is that the authors have equated VIA positivity to detection of 
CIN. VIA being a screening test has a PPV not exceeding 20% even in a population with high 
prevalence of disease. The authors should replace 'detection of precancerous lesions' with VIA 
positivity in the description of results. The limitation should be clea rly mentioned in the 
description. The title should also reflect this  
 
 
Abstract  
 
* "This study aims to identify factors associated with the cervical cancer screening 
uptake, magnitude of precancerous lesions and its predictors among women attending cervical 
cancer screening service in Addis Ababa, Ethiopia." see general comment .  
 
* Acid (VIA) test was 10.3%. "The magnitude of precancerous lesions of the cervix 
among screened woman in Addis Ababa was found to be moderately high": compared to what? 
Obviously, th e prevalence of CIN is much lower as majority of the VIA positive women do not 
have CIN/cancer  
 
 
Background  
 
Page 3, 18 -22: I suggest:  
 
In Ethiopia, cervical cancer is the second most common female cancer with an age -standardized 
(world) incidence rate esti mated in 2018 of 18.9/100,000 (about 6,294 new cases and 4,884 
deaths estimated annually).  
 
Reference : Bruni L, Albero G, Serrano B, Mena M, Gómez D, Muñoz J, Bosch FX, de Sanjosé 
S. ICO/IARC Information Centre on HPV and Cancer (HPV Information Centre). Human 
Papillomavirus and Related Diseases in Ethiopia. Summary Report 17 June 2019. [Date 
Accessed] (https://www.hpvcentre.net/statistics/reports/ETH.pdf  and GLOBOCAN data 2018 
(https://gco.iarc.fr/today/data/factsheets/populations/231 -ethiopia -fact-sheet s.pdf)  
 
Page 3, 34 -41: "To achieved the 2020 ambitious goals of Ethiopia, cervical cancer screening 
services are being provided for free for all eligible women [6]. But to the contrary, its uptake 
among the community is still very low (7.3% to 23.5%) [9 -14]".  
 
See bruni et al. Summary Report 17 June 2019; It would be important to include in this 
paragraph the following points:  
 
1. Despites guidelines ( Guideline for Cervical Cancer Prevention and Control in Ethiopia 
2015), cervical cancer screening is not im plemented  
 
2. What is the status of the cervical cancer screening in Addis Ababa:  
 
a. is the cervical cancer screening initiative in Addis Ababa a demonstration project?  
 
b. When did it start (quite recent I guess as no previous screened women were reported in 
Table1)  
 
c. Is screening opportunistic i.e. offered to the women attending healthcare facilities?  
 
d. Not clear what happened to women with positive VIA  (please clarify page 4 line 44 -48 
…Of these, only health centers perform VIA test for screening but hospitals were doing Pap 
smear to further investigate referred women with VIA test positive).  Is this recommended in the 
guidelines?  
 
e. Any information ab out VIA performance in Addis Ababa?   
 
3. In addition, it is key for the reader to understand why there is a need for studies 
describing predicting rates of VIA -positivity in Ethiopia:  
 
a. Because they are very limited studies conducted?  
 
b. Screen and trea t approach?  
 
I would like to bring to your attention the following scientific papers ( happy to provide them to 
the authors if needed) that may be interesting to cite:  
 
* Nigussie et al., BMC Women's Health (2019)  
 
* Ethiopian Federal Ministry of Health. Health Sector Development Programme IV 
annual performance report. 2015.  
* Bante et al., BMC Public Health (2019)  
 
* Teame et al., PLoS ONE (2019)  
 
* Gizaw et al.  Cancer Prev Res (Phila). (2019)  
 
* Getachew et al., PLoS ONE (2019)  
 
Page 3, 55 -57: change " Hence, our study aims to identify factors associated with uptake of 
cervical cancer screening and the magnitude of precancerous lesions of the cervix among 
screened women." See general comment.  
 
 
Methods  
 
Participant recruitment  
 
"Recruitment of participan ts continued until saturation is reached, meaning the investigators 
agreed that there was redundancy in the responses": move to data collection (qualitative 
interview) paragraph with replacement of "Recruitment" by "interviews":  
 
 
Data collection procedures  and instruments  
 
1. page 5, 19 -28: instead of "pre -tested, structured data abstraction form"    use "a specifically 
designed form to capture participants characteristics i.e. socio -demographic (age, marital status 
and residence), sexual and reproductive (m enstrual history, pregnancy status and parity, 
contraceptive use history and type of contraceptive used, family history of cervical cancer, HIV 
status and STI history) "  
 
2. Form filled by?  
 
3.On Data Abstraction Form (Supplementary file): please correct/e xplain better the following 
items at the end:  
 
* What was the VIA test result? □ HIV positive  □ HIV negative  □Unknown (I guess 
there is a mistake here)  
 
Part IV: Result of cervical cancer screening  
 
* What is the finding of the cervical cancer screening?  
 
□ Positive                  □ Negative  
 
(VIA findings are normaly classified as :  
 
1: Negative 2: Positive 3: Invasive cancer)  
 
 
Data analysis  
 
* Page 5: "Associations between the outcome variable (status of precancerous lesion of 
the cervix)", see general co mment  
 
* The recoded interviews were transcribed and translated verbatim: remove it as already 
described  
 
 
Results  
 
Some VIA positive women may not have CIN (false positives). So, to avoid confusion, in figures 
and where appropriate please use VIA positive in stead of precancerous lesions of cervix. For 
example I suggest to Change "Predictive factors associated with precancerous lesions of cervix" 
by Predictive factors associated with presence of cervical lesions by visual inspection with acetic 
acid (VIA)" or Predictive factors associated with VIA positivity rate among screened women"  
 
 
Table 1 and 2:   
 
Replace the "frequency" and "percentage" column by one column with the following tittle:  
 
Total (N=844)  
 
n (%)  
 
 
Table 2 Tittle replace "reproductive history" by "Sexual and reproductive history"  
 
Table 3 (mentioned as Table 4 in the manuscript)  
 
 
Results of Qualitative Interview  
 
* "five women were screened for cervical cancer; six approached to be screened but 
refused and four women were among those who never visited health centers for cervical cancer 
screening": this information should be kept only if it brings interesting informat ion to the results. 
At the moment, it is not used so should be removed.  
 
* The 2 first paragraphs "Awareness about cervical cancer" and "Awareness on 
availability of cervical cancer screening program » should not be left as independent paragraphs 
as it is at the moment. They should be included in the "lack of awareness" paragraph ( page 11) 
to prevent duplicated information to be provided;  
* Remove the tittle "Factors affecting cervical cancer screening uptake" because it is not 
necessary and wrong as there  is no comparison performed between women who were screened 
and women who were not.  
 
 
Discussion:  
 
I suggest the following points to be addressed in the discussion:  
 
1. Any data on VIA specificity, sensitivity, PPV i.e. any further data regarding the women 
VIA screened?  
 
2. "Screened woman aged 45 -54 years (AOR= 8.1; 95% CI:1.53 -42.3) and ≥55 years 
(AOR= 8.4; 95% CI: 1.1 -72.3) were more than eight times more likely…": sensitivity of VIA at 
older age (peri - and after -menopausal periods);  
 
3. Higher percentage o f HIV positive women (30%; Table 2: 252/844)) among screened 
women compared to the rate in population (see Adal BMC Public Health (2019) 19:1544; Liu et 
al, AIDS. 2018 March 27; 32(6)). What is the consequence on VIA positive women rate?  
 
4. How could your study influence training of local healthcare providers in the conduct of 
VIA screening? In the conduct of screen and treat approach?  
 
5. Screened women were those attending health facilities who have been asked to 
participate and who agreed to be screened;  
 
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.  
 
No 
 
Are you able to assess any statistics in the manus cript or would you recommend an 
additional statistical review?  
If an additional statistical review is recommended, please speci fy 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:  
 
Needs some language corrections before being published  
 
Declaration of competing interests  
Please complete a declaration of competing in terests, considering the following questions:  
 
1.  Have you in the past five years received reimbursements, f ees, funding, or salary 
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3.  Do you hold or are you currently applying for any patents relating to th e content 
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that holds or has applied for patents relating to the content of the manuscript?  
 
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6.  Do y ou 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' 
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