Reviewer ’s report  
 
Title: Individual -level and Community -level Determinants of Cervical Cancer Screening among  
Kenyan Women: A Multilevel Analysis of a Nationwide Survey  
 
Vers ion: 0 Date: 26 Apr 2017  
 
Reviewer: Paolo Giorgi Rossi  
 
Reviewer's report:  
 
The paper uses well collected data to afford an interesting issue. The anlyses are clever and 
original.  
 
 
 
Abstract  
 
Background  
 
I suggest to drop the sentence about the relevance in the World, if you want to put something in 
the abstract please refer to a more contextualized epidemiology (Kenya, West Africa…)  
 
 
There are many studies about community level factors (GPs' attitudes, soc io economic status of 
the area, etc.) I think the statement should be "mostly studied individual…"  
 
 
 
Methods  
 
Please report the age range.  
 
Results  
 
Please report also the proportion of women who knew about cervical cancer on the total 
interviewed (the total is  in the methods, but it is difficult for the readers to be sure that 9014 is 
the right denominator).  
 
 
The OR for "older women" is not understandable for the reader: who are the reference (age 
bracket) and the comparison?  
 
 
For me (a non -English speaker reader ) the concept of "sexual autonomy" is not clear. May be is 
only my fault.  
The OR 1.15 is not a 15% increase in probability to be screened. The outcome is too common to 
directly use OR to estimate prevalence ratio.  
 
 
 
Background  
 
Among the  screening methods t hat have been proposed for low income countries, the authors 
should mention the HPV test. That is much more effective than VIA and even once in a life can 
reduce mortality.  
 
 
Pag 5, second paragraph: the epidemiology has been reported at the beginning of the  
background, I suggest to put this part of the description of the burden of disease in Kenya just 
after the description of the burden in Africa and to mention only screening coverage here.  
 
 
Pag 6: some parts of the introduction are presented as conclusions.  
 
 
Pag 6 last paragraph: I suggest to avoid to say "only studied individual"…  
 
 
Please explicit the objective of the study.  
 
 
 
Methods  
 
Some of the "individual" variables are actually community level variables: the distance from the 
health service is almost equal   for an entire village; the socioeconomic level is an area based 
indicator if I correctly understood.  
 
 
Statistical analyses: the authors used complex models using a logit link, in this case the OR is not 
a good approximation of the prevalence ratio. I sugg est to use log binomial link or to transform 
the OR according to prevalence in Prevalence Ratios in order to discuss them properly.      
 
 
 
Results  
 
Pag 11, 2nd par. Last lines. It does not make any sense to say that are negatively (or positively) 
associated with other characteristics, because these characteristics does not have a clear direction 
in their classification.  
Pag 13, last paragraph: the interpretation of OR is not correct, with a relatively common outcome 
OR 1.47 is far from representing 47% more c overage.  
 
 
 
Discussion  
 
I may agree that a national insurance would increase Pap test coverage, but this point should be 
sustained in a better way, including your data and other evidences from other low income 
countries.  
 
 
I also suggest to comment about the effect of logistical barriers, that you partially observed in 
your study with the variable distance to health facility, but that could also be part of the 
community level un -explained variance. The subjective variable in  this case could misclassify 
the real barriers since women living in very deprived Areas may have low expectations and cha 
judge a minor problem what a women living in a city could judge a big issue. The inclusion of an 
objective variable could help.  
 
 
The issue of logistical barriers is also mentioned in the implication for policies, but now it is not 
treated in the discussion.  
 
 
In the text there are some typos.  
 
 
 
 
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 additio nal 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  
Please complete a declaration of competing interests, considering the following questions:  
 
1. Have you in the  past five years received reimbursements, fees, funding, or salary from an 
organisation that may in any way gain or lose financially from the publication of this 
manuscript, either now or in the future?  
 
2. Do you hold any stocks or shares in an organisation that 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 inter ests in relation to this paper?  
 
 
If you can answer no to all of the above, write 'I declare that I have no competing interests' 
below. If your reply is yes to any, please give details below.  
 
'I declare that I have no co mpeting interests  
 
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