Title: Correlates of intention to screen for cervical cancer among adult women in Kyotera
District, Central Uganda: a community based cross-sectional study.
Version: 1 Date: 21 Feb 2024
Reviewer:  Megan Swanson
Reviewer's report:
The authors should be commended for focusing on an important issue among a vulnerable
population.  The findings (residence, health info source and risk perception associated with
intention to screen) could be leveraged in efforts to improve intention to screen and ideal translate
into greater uptake of screening.  In the discussion section, I would like the authors to be clearer
about the implications of their findings.  The manuscript will have to be revised for consideration
for publication.  See my comments below.
Title: as transwomen don’t have a cervix, I am not sure the need to specify “cisgender”.  If
the authors want to remove gender from the title all together, I think it would be fine to use
“Correlates of intention to screen for cervical cancer in Kyotera District, Central Uganda.”
Presumably the authors are interested in including anyone with a cervix, regardless of gender
expression (though quite taboo in Uganda to express a gender different from sex assigned at
birth).  Presumably, anyone with total hysterectomy would be excluded for lack of cervix? At
the very least, if the authors wish to describe cis/transgender when noting “women,” should be
done consistently throughout the manuscript, not just in the title.
Abstract – needs significant editing, especially results section.
Lines 22-25: It doesn’t make sense to my why each sentence includes 2 different descriptors
(like age and knowledge -related?).  The main finding is 50% intended to screen, so I would
lead with that.  You don’t need to describe age of population in the abstract.
Line 30: “rate” is not exactly correct as implies time.  Authors are talking about prevalence,
rather than “rate.”
Lines 30-32: the conclusion here is more data-driven, but here word “moderate” does not
necessarily seem like the consistent perception of the numbers throughout the paper.  Sometimes
it feels like 50% with intention to screen is too low, sometimes characterized as OK, needs to
be consistent.  The conclusions given in the abstract are different that the conclusions given at
the end of the paper.
Background: Overall, I would try to make more specific to Uganda and specially Central
Uganda.
Lines 40-43: I think the authors are trying to say that cervical cancer is usually attributable to
HPV.  It is not exactly true that “cervical cancer” is the most common HPV-related disease –
for instance, genital warts are an HPV-related disease and prevalence of genital warts is higher
than prevalence of cervical cancer.  It is absolutely true that almost all cervical cancer comes
from HPV, specifically 16 and 18, as authors describe.
Line 48: focus on Uganda, rather than Eswatini
Line 52: I would take out “nonexistent” and just leave as limited.
Lines 51-57: Make clear that East Africa specifically has a dual epidemic: HIV/cervical cancer
so that we can more easily understand the point that lack of resources for prevention/diagnosis
and HIV prevalence have led to the “top killer” situation.
Lines 69-72: Be specific for Uganda
Methods: section is clear, no major suggestions
Results: Please see comments below, presentation of OR not exactly correct.  Authors may also
consider combining Tables 1 and 2 (could add a “total” column with N/% prior to “Intention”
columns).
Lines 181-186: recommend presenting data more-or-less in order of Table 1.  I would conclude
this paragraph by starting the % intending screening, as this is the outcome of interest.
Lines 187-190: not sure why this is a separate paragraph from above?  I think the main outcome
of interest should be in the first paragraph.
Lines 195-207: I don’t understand why this is divided into two paragraphs.  Also, the way the
authors are reporting odds ratios is not exactly correct.  An odds ratio of 1.44 does not mean that
one group is 44% more likely to experience the outcome of interest.  OR 1.44 means the odds of
the event occurring are 1.44 times higher in one group, compared to another.  To calculate the
increase in likelihood, you would need to compare the actual probabilities of the event occurring
in each group, which is not directly captured by odds ratios.  This would be essentially correct for
a risk ratio (relative risk), but odds ratio is different.  Please re-consider how you are presenting
Odds Ratios or consider reporting risk ratios.
Discussion: Needs a significant re-write
Lines 213-220.  Great to compare to data from Masaka, not sure about comparing to Ethiopia
or Indonesia.
Lines 227-228: I would change wording something like, “perhaps improving knowledge about
cervical cancer could improve screening uptake”
Lines 228-234: Seems like these lines about fear should be a different paragraph.  Also, need to
acknowledge that fear was not significant – can still be part of discussion, but should be qualified.
Lines 222-234: instead of starting with the statistically significant findings (residence, health
info source and perception of risk), the authors are staring with knowledge and fear.  I think it
would make more sense to address significant findings first.
Lines 266-268: I don’t understand why this comment about family history is here.  The family
history comment doesn’t seem related to the conclusion of this paragraph.
Lines 271-276: Strengths and Limitations section needs to be significantly expanded.
Line 278: I don’t think the word “although” is correct.  Earlier, the authors portray 50% w
intentions of screening to be too low (which I agree with) – the way this is written makes it seem
like a lot of women want to be screened, but because they don’t think they are at risk, many
might not, which is not what the paper is investigating.  The paper’s outcome is INTENTION,
not actual screening and this is confused in the first sentence of the conclusion.
Lines 279-280: earlier, the authors noted that screening intention was too low because the data
from Masaka reported higher intentions
Lines 283-284: This is the main finding in the paper (residence, health info source and risk
perception associated with intentions for screening), but the rest of the paragraph and certainly
the ending about education does not flow from these data.