Reviewer ’s report  
 
Title: Barriers and facilitators to uptake of cervical cancer screening among women in Uga nda: a 
systematic review  
 
Version: 0 Date: 21 May 2019  
 
Reviewer: Eva Kantelhardt  
 
Reviewer's report:  
 
Black and colleagues present a well written systematic review on barriers and facilitators to 
caervical cancer screening among women in Uganda. The topic is of high relevance considering 
global efforts towards elimination of cervical cancer. Screening is a crucial element and access to 
screening essential. The authors found a considerable number of papers which focus on the topic. 
They have nicely extracted the important factors associated with uptake or non -uptake of 
screening service. I cong ratulate the authors to the thorough work.  
 
 
I may suggest some ideas:  
 
Background  
 
1 The reader may not be familiar with the situation of health service and cancer service in 
Uganda. It would be helpful to minimally describe or outline the health system and N ational 
Cancer Control Plan and where screening is planned to be done in Uganda (which health service 
level?).  
 
 
2 Accessibility is crucial for any uptake of health service. Is there data on how many screening 
Units are active in Uganda? Who offers screening  in public and private? Who is trained? What is 
the National screening strategy?  
 
 
3 The authors repeatedly talk about HPV. Please clarify - are you referring to high risk types?  
 
 
4 Line 68 -70; It is not clear why the poor follow -up and limited recall system  is related to low 
sensitivity of cytology. To me I suppose that cytology screening is impossible due to lack of 
pathologists (since despite low sensitivity it has been successful in high resource countries). Of 
course additionally screening every 2 -3 year s is difficult - but this is true for all screening 
methods therefore a once or twice I a lifetime approach needs to be chosen.  
 
 
5 Line 78 Is there any HPV testing available in Uganda?  
 
Methods  
 
6 Line 163 Why were reasons for non -attendance of HIV pts. excl uded? Of those women 
described as normal population, also a reasonable proportion will be positive and thus this group 
is among the population studied.  
 
 
Results and discussion  
 
7 The proportion of women screened seems very low. Was there any information weat her at all 
the women had a chance to be screened? The authors focus on barriers and facilitators to 
screening much on the side of the women. But this closely links with the problem of service 
availability and efforts needed to use the service. This should be mentioned in limitations.  
 
 
8 table 3 "CCS not considered important" and discussion line 428 - the authors should critically 
discuss that indeed there could be more important issues which women need to consider even if 
they correctly received and understo od health promotion messages on CCS.  
 
 
9 If possible, the authors could indicate weather the studies discussed actually measured reasons 
for a) attending/not attending screening  or if they asked b) about perceived facilitators and 
barriers without assessin g the actual behavior? In the case of a) it should be critically noted that 
possibly women are knowledgeable BECAUSE they went for screening and that it was not the 
reason for screening.  
 
 
 
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 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:  
 
Acceptable  
 
Declaration of competing interests  
Please complete a declaration of competing interests, considering the following questions:  
 
1. Have you in the past five years received reimbursements, fees, fund ing, or salary from an 
organisation that may in any way gain or lose financial ly from the publication of this 
manuscript, either now or in the future?  
 
2. Do you hold any stocks or shares in an organisation t hat may in any way gain or lose 
financially from the publication of this manuscript, either now or in the future?  
 
3. Do you hold or are you currently applying for any patents  relating to the content of the 
manuscript?  
 
4. Have you received reimbursements, fees, funding, or salary from an organization that  
holds or has applied for patents relating to the content of the manuscript?  
 
5. Do you have any other financial competing interests?  
 
6. Do you have any non -financial competing interests in relation to this paper?  
 
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below. If your reply is yes to any, please give details below.  
 
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