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: 03 Sep 2019
Reviewer: Mona Saraiya
Reviewer's report:
This manuscript is an analysis of wave 2 of SAGE survey -specifically questions about cervical cancer
screening from 2014/2015 data from Ghana. 
These types of analyses using population-based questions are more relevant than ever given the context
of cervical cancer elimination strategies to improve screening (Increase to screening up to 70-80% once
or twice in a lifetime using a high efficiency test) and vaccination to ultimately "eliminate" cervical
cancer to  rate of 4/100,000.
In that context, some suggestions to improve the manuscript including
1)Referencing the elimination strategy and 
2)2) providing more context about Ghana's cervical or cancer strategy -what are the guidelines it
follows  and  what  are  the  WHO  guidelines  for  cervical  cancer  screening  -that  describes  general
strategies and ages when to start/stop—for example WHO does not recommend to start screening
below  30—(unless  HIV+).  https://www.who.int/reproductivehealth/publications/cancers/cervical-
cancer-guide/en/
Some specific comments:
This  is  the  second  study—please  address  what  the  findings  were  from  the  first  study—did  the
prevalence stay same or not? 
The questions that were asked about pelvic exams in original WHO surveys (like Sage or WHS) were
asked to examine the potential screening that could take place, not taking into account those that could
be done via VIA-but this is an interesting way to explain pelvic exams.—please explain how the
question was originally meant and how its being interpreted ? 
Please use or consider using these references that have used similar questions or examined
Gakidou E, Nordhagen S, Obermeyer Z. Coverage of cervical cancer screening in 57 countries: Low
average levels and large inequalities. PLoS Med 2008; 5:132. 
Akinyemiju T, Ogunsina K, Sakhuja S, Ogbhodo V, Braithwaite D. Life-course socioeconomic status
and breast and cervical cancer screening: analysis of the WHO's Study on Global Ageing and Adult
Health (SAGE). BMJ Open. 2016; 6(11):e012753.
-Please update US reference on cervical cancer screening they are from early 2000 and can be updated.
-Also, the  WHO  toolkit talks  about standardizing  questions  on population based  surveys—please
reference  that  as  well  https://www.who.int/ncds/surveillance/data-toolkit-for-cervical-cancer-
prevention-control/en/
-Given that pelvic exams may be confused with pelvic exams done during childbirth—please add
variable about # of total or livebirths as an explanatory variable
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 recommend additional statistical review
Quality of written English
Please indicate the quality of language in the manuscript:
Needs some language corrections before being published
Declaration of competing interests
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