Reviewer’s report
Title: 
Title: Knowledge, Attitudes, and Practices of Cervical Cancer Prevention
and Pap Smears in Two Low-Income Communities in Lima, Peru
Version: 
1 
Date: 
01 May 2020
Reviewer's report:
This study assesses the knowledge, attitudes, and practices for cervical cancer
prevention in women from two peri-urban communities in Lima, Peru. The
subject is indeed of great interest, given the high mortality and low adherence to
the pap recommendations of the Peruvian population. However, more detail in
the methods and a clearer presentation of the results are needed in order to give
useful information for decision-making.
Abstract: 
In the results section of the abstract, the number of participants should be
mentioned.
Please mention in the methods of the abstract that open-ended questions were
used
The recommendation of the conclusion of the abstract states that "In these
communities and others like them, measurement instruments and health
education campaigns should be locally tailored to address these underlying
concerns." It seems to be a hasty generalization of this small study. In order to
give more cautious conclusions, it might say "Our results suggest that, in these
communities..."
Introduction:
1st paragraph: authors say that in South America cervical cancer has an "overall
mortality rate of 8.6/100,000 women". Please clarify if it is annually, or by
persons-years.
2nd paragraph: this is a very long paragraph, with several ideas interwoven, that
is not easy to follow. Please select which are the main ideas and order them.
Please summarize the main antecedents (studies that have assessed the
knowledge of cervical cancer and the prevalence of pap smears, in peri-urban
women) and explain which is the gap in the knowledge that your study is trying
to fill (previous studies do not assess peri-urban settings? Or have
methodological flaws? Or is your population somehow special?)
Methods:
Please follow the strobe statements to report the methods section, including:
1.- Study design
2.- Setting (mentioning the demographic and economic characteristics of the
study sites)
3.- Participants (including detailed information, in each site, on how the blocks
were assigned, how the non-probabilistic purposive sampling was carried, and
how sample size was determined).
4.- Variables (detailing how the KAP questionnaire was constructed and
validated, and what were the open-ended questions asked, literally… Also,
explaining why the practice outcome was "Pap smear in the last year" and no in
the last three years as the World Health Organization recommends.)
5.- Procedure (including training of field workers, how field workers introduced
themselves, where the interviews were performed, how were the variables
collected [interview or asking the participant to fill a questionnaire], if there was
an incentive for participating, etc)
6.- Statistical methods (detailing how were the variables selected to be included
in the adjusted logistic regression, and how was the site included in the
regression models: as a cluster? Using random- or fixed-effects models?... Also,
the use of a statistical test for goodness of fit for logistic regression, as the
Hosmer-Lemeshow.)
7.- Ethics (including the IRB where the study was approved, detailing what
personal data has been collected, and how coercion to participate was avoided)
Results:
Mention for each site: how many women were approached, how many rejected
to participate, and how many were excluded for other reasons (in detail).
Please only keep in the text the most important figures of each table, there is no
need to repeat almost all the results of the tables in the text.
Table 1. Please mention what hypothesis tests were used to calculate the p-
values. 
Table 1. Change p-values of "0.000" for "<0.001".
Table 1. Detail what each health insurance categories mean
Table 2: Since no adjusted analysis was performed, the bivariate findings are
very likely to be biased due to confounding variables. I recommend: 1) only
mention descriptively the totals (sort by percentages: from highest to lowest),
and 2) if authors want to assess associated factors, select a variable or collapse
variables into dimensions of "knowledge", "social influences" and "attitudes"
dimensions, in order to perform adjusted regressions and therefore minimize the
risk of confounding (although authors state that correlations are weak, it would
still be an option to collapse variables into dimensions)
Table 3: please include the n and % of those with and without the outcome, in
each category of the exposures. Also, crude ORs should be included. This allows
readers to analyze frequency differences, which may be overestimated because
ORs are used instead of PRs.
Table 3: detail how was the site included in the regression models (since the site
variable is not at person-level but community-level): as a cluster? Using random-
or fixed-effects models?...
Table 3: It would be interesting to include "Per capita income" to the analyses
There is little information regarding the open-ended questions. Please include ad-
hoc paragraphs to mention the most important open-label questions and the
summarize or quotes of their answers.
Discussion:
In the third paragraph, it says "Bivariate analysis also confirm prior reports that
higher levels of educational attainment has been associated with increased
knowledge of cervical cancer and Pap smears(33-35) and that number of
children is highly predictive of receiving a Pap smears". However, as commented
in the results section, the not-adjusted bivariate analyses are very likely to be
biased, so they cannot confirm any hypothesis. At most, it would suggest, but not
confirm.
5th paragraph: It is not clear what do the authors mean by "The possible
introduction of unaccounted for external factors over the course of sampling may
have skewed results"
Are the methods appropriate and well described?
If not, please specify what is required in your comments to the authors.
No
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 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:
Needs some language corrections before being published
Declaration of competing interests
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questions:
1
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salary from an organisation that may in any way gain or lose financially
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or in the future?
3
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Do you hold or are you currently applying for any patents relating to the
content of the manuscript?
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Have you received reimbursements, fees, funding, or salary from an
organization that holds or has applied for patents relating to the content of
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Do you have any other financial competing interests?
6
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Do you have any non-financial competing interests in relation to this
paper?
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interests' below. If your reply is yes to any, please give details below.
I have no competing interests regarding this paper
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