Reviewer’s report
Title:  Socio-Demographic  Characteristics  and  Associated  Factors  Influencing  Cervical  Cancer
Screening among Women Attending in St. Paul ’s Teaching and Referral Hospital, Ethiopia
Version: 0 Date: 27 Apr 2019
Reviewer: Björn Strander
Reviewer's report:
Abebe Belete Woldetsadik and co-authors have made a cross sectional study to evaluate socioeconomic
factors  and  knowledge  and  attitudes  among  women  in  Ethiopia  that  are  related  to  self-reported
participation in cervical screening. The study is important as it highlights the lack of protection the
majority of women in low income countries have against cervical cancer, a common and basically
preventable disease.
Conslusions are supported by the data presented. But I had a difficult time understanding the results of
this study. I find it impossible to publish without revisions. I guess the authors have the material, and it
is a matter of re-writing.
Results are presented in the text. There are also 4 tables. Table 1 supposedly compares the association
between screening participation and different socioeconomic variables. The associations are given as
COR (Crude odds ratios? Should be spelled out) and AOR (Adjusted OR? Adjusted for what? All other
variables?). Raw data is presented only for screened. The data for unscreened women is missing. P-
values are unnecessary as confidence intervals are The headline should be changed to something like
Socioeconomic characteristics and participation in cervical screening last 3 years - logistic regression
model
Table 2 is more clear-cut and the data is from the entire population. But why are not participating
women compared with non-participating women concerning these risk factors?
Table 3 has the same draw back as Table 1. Where is the data for the non-participants? And also, what
is adjusted for? Differences in the answers in all other questions about knowledge and perception? The
headline has to be re-written.
Table 4. Same problems as table 1 and 3.
I don´t think the language has to be perfect, but there are too many unclear wordings and language
ambiguity that impair readability and obscure messages. Try to find somebody, not necessarily a
researcher, who can revise the English in the manuscript. There are also key words here and there in the
manuscript that are surprisingly omitted.
If it is in line with the journal's policy I want to know the professions of the authors and there academic
titles. Furthermore I want to know what their individual contribution is in the project. I also want to
know the role of the funding organization (National Natural Science Foundation of China). 
The power calculation is not comprehensible to me. For example - what does "a proportion of 50% "
mean in this context. 
The references that are not validated but are accessible on the internet should be provided with interned
addresses. 
Why were women ≥ 49 years of age excluded?
The clinic had 1500 visits each month. According to the abstract (not stated in main manuscript) it took
three months to recruit 425 participants. Still the response rate was "100%". This has to be explained
and a non-response analysis is wanted.
The aim is stated as "the purpose of this study is to determine the influence of socio-demographic
characteristics and related factors on cervical screening." 
I think the aim should be restricted to cover the geographical area. Or possibly "in an African setting".
The result cannot be valid for all populations.
As an international reader I am curious about what possibilities women have to get a smear. It is stated
that smear-taking is "freely available" but also that it is most accessible in urban hospital. It would be
an important part of the background to describe the availability and the practical obstacles for cervical
screening in Ethiopia - both in rural and urban areas. I also would like to know what analyses are made
(cytology? HPV?) and the availability of laboratory resources and colposcopy and treatment of women
with abnormal findings.
In the Data collection section it should be mentioned that information on screening was self-reported. 
What variables were discarded after Chi-square analysis and what were the outcomes of these analysis?
That could be described in a supplement. 
Readers might not be familiar with the value of Ethiopian Birr. Please give a translation also into Euros
or US dollars.
The data are based on women seeking care in an urban hospital. I would like a more extensive
discussion about the external validity and selection bias in regard of the general Ethiopian female
population.  
Some of the questions, like age of first intercourse and number of partners, can probably be regarded as
sensitive in the cultural context. In a face to face-interview, how could this influence the honesty in the
answers?
With referral to table 1 religion was not associated with screening uptake. But data on religion is not
reported in table 1.
What is the purpose of asking about history of irregular menstruation, diabetes mellitus, infertility and
hypertension - lumped together?
The study has used the questionnaires developed by the authors in reference 19. This is a good study
also performed in Ethiopia, but with differences in results. It would be interesting and reasonable if the
differences and similarities were discussed. Among other differences Bayu et al found a need for a
sample size of 1286, three times as high as in the present work.
Some data are reported with 3 decimals. This is not necessary and affects readability in a negative way.
Details:
L 46 Cervical cancer is the most important public health priority issue throughout the world. Is it?
Reference?
L 47-48 How can something that is reported need to be estimated?
L 61 Is this the original source? What about Gakidou E, Nordhagen S, Obermeyer Z. Coverage of
cervical cancer screening in 57 countries: low average levels and large inequalities. PLoS Med. 2008;
5. Are there new data since 2008?
L 209 "Our study found that nulliparous women were less likely screened compared with multiparous
women. In fact underuse of screening among single women is not a significant public health concern
while they are less  likely chance to develop the disease compared to multiparous  women." This
statement is difficult to understand. Is to be nulliparous equal to not being exposed to HPV in Ethiopia?
Is nulliparous equal to be single?
Björn Strander
Associate professor
Regional Cancer Center West
Sweden
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.
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 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
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