Title: Correlates of cervical cancer screening participation, intention and self-efficacy among
Muslim women in southern Ghana
Version: 1 Date: 22 Mar 2022
Reviewer's report:
This manuscript investigates Muslim women’s intention to screen for cervical cancer using
knowledge, engagement, religion, provider, and TPB construct factors to investigate barriers
and facilitators to screening.  As Muslim women in many regions of the world have lower
screening rates than their non-Muslim counterparts, it is important to determine what barriers
prevent Muslim women from screening.  These data demonstrate that in this Muslim population
in Ghana, women have low levels of education about cervical cancer and women who have
higher education and income are more likely to report interest in attending screening in the
future.
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Abstract
The methods should include more of a description of what was in the questionnaire (i.e., what
were the main exposures and outcomes assessed?)
In the results section, it is a bit confusing to understand the difference between “increased
confidence about seeking screening” and “increased intention to engage in screening”.  It would
help if those primary outcomes were described in the methods.
“Attitude” is also unclear.  This exposure should be described in the methods.
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Introduction
Line 73: I disagree that there is inadequate technology to detect the disease early; afterall, we
have HPV testing, which we know is an incredibly sensitive test (although this technology is
often unavailable in LMICs).  Lack of available screening, treatment, and vaccines seem to be
the main drivers.
Line 78: “disease” should be changed to “virus”.
The discussion on the conceptual framework of the study would fit better in the methods section.
The introduction is lacking a clear study objective.  A sentence describing the purpose of the
study would improve clarity for the reader moving forward.
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Methods
It would be useful to have the main outcomes described at the beginning of the methods section
What is the recommended age to start screening in Ghana?  Are 18-year-olds expected to have
already attended cervix screening?
Line 126: It would be good to list the level of confidence, precision, etc used in the sample size
calculation as well as define what concept is being measured.
How were Muslim households identified (as only 10% of the population is Muslim)?
Was HPV, cervical cancer, and screening education provided between the knowledge and
willingness to screen sections of the questionnaire?  It seems like the majority of women did
not know what cervical cancer was, so then asking them if they’d be willing to screen for it
without giving them information on what that means doesn’t seem like it would give reliable
information.
It would be useful in the “Measures” section to define the primary outcomes of interest
Why did you choose to use point biserial correlation instead of t-tests?
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Results
Did you look to see if knowledge changed by age?  Depending on when women are expected to
start screening, those of screening age might have more knowledge than those who are not.
Where did the knowledge questions about cervical cancer affecting the face and mouth come
from?  These are not knowledge questions I have seen previously asked.
Additionally, I’m not sure what the correct answer is for some of the questions.  For example,
“having multiple sexual partners”: well, you are at higher risk for HPV infection if you have
more partners but also you can get HPV with only one partner.  Similarly, “urine is used for
cervical screening”: it is sometimes, but not often (and probably not in their area?).  I think this
table would benefit  from including more details about the prompt (for example “cervical cancer
affects the face.” instead of “cancer that affects the face” and “you are at higher risk for cervical
cancer if you have multiple sexual partners” instead of “having multiple sexual partners”.  As
well as clearly stating what the correct answer is.
I am still unclear how the outcomes are measured.  To confirm: engagement is previous screen,
intention to engage is “will screen in future”, but I can’t find anywhere where you have defined
what “confidence in screening” means.
Why did you choose to categorize income instead of leaving it as a continuous variable?
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Discussion
Line 302: What does that tell us about their knowledge?  Urine can be used in screening, but is
not the norm and we know that screening can prevent cervical cancer.  So are you saying they
got these answers correct?  Or what are you pointing out with this sentence?
Have consistency of language would provide more clarity to the reader.  You use “confidence in
screening” as well as “self-efficacy” (line 365), and maybe another one as well.  It would help
if this outcome was clearly defined early on and the wording was consistent throughout.
Line 370: Should this say that modesty levels were negatively associated with Pap testing, not
“not associated”?
If possible, it would be useful to include a copy of the survey in the supplementary materials.
Or, if not, a more comprehensive list of the questions used to create the attitudes, behavior, and
subjective norms constructs could be added to the methods.
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Thank you for the opportunity to review your manuscript.  As we move towards the WHO’s
elimination goals it is becoming exceedingly important to not leave certain underscreened
populations behind.  I think with some revisions and clarifying details (how were outcomes
defined, what questions were used to create constructs, etc) this will be a nice addition to the
screening literature.