Title: HIV status and knowledge of cervical cancer among women in Ghana
Version: 0 Date: 29 Sep 2023
Reviewer's report:
Title: Predictors of comprehensive knowledge of cervical cancer among women with and
without HIV in Ghana
Journal: BMC Women’s Health
REVIEW COMMENTS
The study sought to determine the predictors of comprehensive knowledge of HPV and cervical
cancer among WLHIV and those with negative or unknown HIV status. The study is without
doubt an important one focussing on a pertinent health issue. I have suggested a few requirements
to draw attention of authors to a number of contentious issues with the view to help improve the
report further and strengthen the findings.
Comments:
1. I recommend that authors consider using the line numbering feature in word to make content
navigation easier. Text that show location of deficiencies have been placed in double quote
marks.
2. Title: “Comprehensive” Consider dropping this adjective throughout the report as it is
neither objectively meaningful nor supported by the statistical definition provided. See parallel
comment under Data Management and Analysis below.
3. Abstract/Methods: “Binary logistic…” This is not fully accurate. What about multivariate
analysis? Revise based on further details provided under Methods section
4. Abstract/ Results: Check punctuation. There are multiple stops in the wrong places
5. Page 5/Paragraph 1: “among h WLHIV” Check typo errors
6. Methods/Study Design: It is unclear whether a cross-sectional design best captures the study
protocol: while the cross-sectional design suits distinct, uniquely-defined populations, women
from ART and gynae clinics have very different population demographics. A true cross-sectional
study should allow prevalence estimates to be computed for a single population under study:
for instance, it is not feasible to calculate prevalence of HIV from this sample. Systematically
recruiting from these dissimilar populations may introduce significant bias to a cross-sectional
design and confound the interpretations. Authors are invited to comment on this, acknowledge
the limitation, or clarify  how the study design allows these biases to be overcome.
7. Methods/Study Design: Authors should clarify how differences in access to screening for the
two groups do not affect the findings of the study: for eg. if women at the gynae clinic have
greater access to screening, that could explain higher knowledge levels, couldn’t it?
8. Methods/Study Population and sampling: “excluded from this study” What about women with
prior cervical screening exposure? Were they also excluded? Authors rightly noted in Discussion
that exposure to screening could confound findings
9.  Methods/Study Population and sampling: “fron” Check spelling, placement of reference and
punctuation. References should be placed inside and not outside stop marks
10. Methods/Study Population and sampling: “with these parameters” The authors need to
reconsider the justification for sample size. The formula for estimating required sample size
depends on the objective for the study. Here, that link is missing making the justification for
sample size arbitrary. The authors should note that the formula quoted here provides a suitable
sample to estimate the prevalence of HR HPV, nothing more. It does not guarantee enough
power for the stratification/sub-group analysis used to investigate risk factors.
It would be useful to revise this with a biostatistician and to also consider how the calculation
accounts for stratification of categorical variables
11. Methods/Data collection instrument (page 7): “validated questionnaire” Provide reference
if results of validation are published elsewhere. Otherwise provide details on how questionnaire
was evaluated for reliability and validity. This is important because the report is based on the
quality of the instrument used to measure women’s health knowledge. Also provide instrument
as supplementary file
12. Include question marks for questions to conform to standard punctuation style
13.  Methods/Data collection procedure (page 7): From the procedure outlined, there is no
mention of blinding. Authors should justify why this was not feasible to perform
14. Methods/Data collection procedure (page 7): “four nurses were trained…” Delete redundant
statement
15. Methods/Data management and analysis (page 8): What is defined here is “sufficient
knowledge” and not “comprehensive knowledge” as indicated in the Title and elsewhere. Are
these terms used interchangeably? This must be clarified. If yes, authors should reconsider the
appropriateness of the use of “comprehensive” to qualify women’s knowledge based on the
statistical approach used (greater than median score) to classify patients.
16. Methods/Data management and analysis (page 8):  “internal reliability…Cronbach alpha”
Provide a reference to show how this was estimated. Otherwise provide methods and data to
show how this was measured
17. Methods/Data management and analysis (page 8):  “0.793” Report 2 decimal places for
consistency
18. Methods/Data management and analysis (page 8): “while controlling for other variables”
This statement is vague and does not show exactly what variables were controlled for in
multivariate analysis. Authors should provide greater details on which variables were included
in model 2 and model 3 and which were dropped. Also provide details on how conclusions were
made to drop variables in different models.
19. Results/ Characteristics (page 9): “HIV-status” Authors should provide information on how
HIV status was verified.
20.  Results/ Characteristics (page 9): “46.6% were single” It is not clear from the information
presented here whether these distributions are significantly different between HIV and non-HIV
individuals. Chi squared analysis can clarify this question. Significant and systematic differences
will confirm that the sample is drawn from distinct populations and may explain findings or
indicate sampling bias
21. Table 1: Check notation. The mathematical symbol for a square is required here, not a 2
22. Table 2: “Ever use of hormonal contraceptive” Correct grammar
23. Discussion (page 16) “there is a need for a more comprehensive strategies “ Correct grammar
24. Authors should add a section on Limitations after Conclusions