Reviewer ’s report  
 
Title: Individual -level and Community -level Determinants of Cervical Cancer Screening among  
Kenyan Women: A Multilevel Analysis of a Nationwide Survey  
 
Version: 0 Date: 10 May 2017  
 
Reviewer: Johannes Berkhof  
 
Reviewer's report:  
 
General comments.  
 
1. Neither the introduction nor the discussion mentions HPV self -sampling as an alternative 
screening method in low -resource settings. HPV self -sampling may enhance a utonomy (a 
woman can do the test at home), lowers barriers and should be discussed by the authors.  
Furthermore, an HPV DNA test is objective whereas the quality of both VIA and Pap are only 
moderate and variable across laboratories.  
 
 
 
2. What was the rat e of missing data per question/item and how did the authors deal with missing 
data in the multilevel analyses?  
 
 
 
Other comments.  
 
Introduction.  
 
p.6.l .28. "Cervical cancer is easily preventable through HPV vaccination; however, financial 
burden prevents  low-income countries from initiating a comprehensive HPV vaccination 
program [6]".  The reference is outdated (year 2011) and the situation has changed. Nowadays, 
HPV vaccination is not more expensive than HPV screening. Gavi countries have access to 
vaccination at a very low price (about $5 per dose).  
 
 
 
Methods  
 
Where does the abbreviation KDHS stand for?  
 
Results section.  
 
Keep nomenclature uniform throughout the manuscript. For instance, p11.l.17 state "woman had 
low decision -making power at home". p.11. l.26. state "women who had high decision -making 
autonomy". I guess the second statement is the antonym of the first statement, but this is not 
obvious from the description.  
 
 
p.11.l.49. "By contrast, the variable of having undergone the Pap test….."  
 
There is no contrast with the earlier description.  
 
p.12.l.10. "31% of the total variance in the cervical cancer screening behavior was accounted for 
by community differences". This sentence is slightly misleading because it is not clear whether 
these diff erences are really caused by differences between communities or differences among 
women within communities. I prefer a more neutral formulation, .e.g "31% of the total variance 
in the cervical cancer screening behavior was at the community level".  
 
 
p.12.l .43. "older women were 47% (AOR = 1.47; 95% CI = 1.16 -1.85) more likely to undergo 
cervical cancer screening". The odds ratio is incorrectly interpreted as a relative risk, please 
adjust.  
 
 
 
Table 2.  
 
- It is confusing that the same means are presented as in Table 1, but they are slightly 
different (because weighting is now per community rather than per individual).  
 
 
- What is the purpose of this table? These are not community -level characteristics but 
averages of individual -level characteristics. I assume tha t the correlations will be much 
stronger at the individual level than at the community -level. These individual level 
correlations need to be shown in addition to the correlations presented in Table 2.  
 
 
 
Table 3.  
 
- Heading N = 6498. How many are in the cont rol group?  
 
 
- The bivariate associations with community -level characteristics do not add to the 
associations with individual -level characteristics presented before. The community -level 
characteristics are mere averages.  
 
 
 
 
Table 4 and 5.  
 
- Model 3 does not make sense to me because a community -level characteristic can only be 
interpreted after inclusion of individual -level characteristics. This is done in Model 4 
which aims to disentangle community - and individual -level effects.  
 
 
- The between - and within com munity variation  in Model 1 can be described in the text 
but does not deserve a separate empty column in Tables 4 and 5.Therefore present only 
Model 2 and 4.  
 
 
 
 
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:  
 
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, funding, or salary from an 
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3. Do you hold or are you currently applying for any patents relating to the content of the 
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4. Have you received reimbursements, fees, funding, or salary from an organization that 
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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.  
 
Received fees from GSK, Merck, Roche. All fees collected by my employer.  
 
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