Title: Women’s sexual autonomy as a determinant of cervical cancer screening uptake in Addis
Ababa, Ethiopia: A case-control study
Version: 3 Date: 30 Apr 2022
Reviewer:  Breanne Lott
Reviewer's report:
Study authors,
Thank you for the opportunity to review your manuscript. It is an important area for inquiry with
local and global significance. I enjoyed your clear justification for studying sexual autonomy in
relation to cervical cancer screening uptake. Further clarity regarding the methodology and the
interpretation of your primary finding will strengthen your paper. I hope you find my specific
questions and comments helpful as you revise.
Introduction
1. You accurately report low uptake of preventive screening in Ethiopia. Reference to the WHO
90-70-90 goals outlined in the global strategy for the elimination of cervical cancer as a public
health problem could further illuminate the gap between current screening coverage in Ethiopia
and what is required to meet global screening goals (70% uptake).
2. Lines 67-68, a reference is needed to support the assertion that religious and cultural beliefs
have been associated with screening uptake
3. Clear justification for the study was presented with appropriate literature cited showing the
autonomy and sexual autonomy linked to reproductive health and cervical cancer screening
practices in various settings.
4. It may strengthen your introduction to include specific barriers to screening that women in
Ethiopia face and how greater autonomy may help women to overcome these barriers.
Materials and Methods
5. Inclusion criteria – use of terms cc uptake/receipt vs acceptance/refusal. Since your cases
are women who were aware of cc but had not screened, you may want to clarify the difference
between having received a recommendation to screen and refusing (hesitant) vs. those who
had never been offered screening and that your cases include both. This may be an important
distinction.
6. As an institutional-based study, it would be helpful to describe the institution(s) where the
participants were recruited. If you do not want to name the institutions, you can still describe
the facility in terms of type (primary, secondary, specialty, hospital, community clinic, etc.),
the catchment area/population served, the departments recruited from. You mention “flow of
clients” as a criteria in the sampling procedures section, what was the flow criteria exactly such
as a cut-off of “more than 500 patients screened annually”?
7. I am interested in the data collection measurements you selected and I think readers of your
article would be as well. On line 106 you state that “the standard method was used to assess
sexual autonomy”. Can you elaborate on what that method is and/or cite appropriate literature
for what you consider to be the standard method? Please also justify your selection of the
specific sexual autonomy measurement you used. Is this a reliable and valid measure? Finally,
It would be great to learn more about how this measurement was translated, adapted, and how
its appropriateness was measured for use in Ethiopian populations.
8. In the data collection procedures section, it would be important to include more information
on the administration of the face-to-face interviews – how long on average did the interviews
take, in which languages were they conducted?
9. Information is needed about the response options for the questionnaire items – are these yes/
no questions, are they rated on a Likert scale from 1-5, how are the responses coded and scored?
10. You mention that Principal Component Analysis was used to construct a sexual autonomy
index. You need to further describe the index such as score range and interpretation, PCA output
(eigen values), etc. Some of your description about PCA comes in the results section which
should be relocated to methods. You also state that of the five sexual autonomy questions, “only
two factors passed the PCA” – please state which two factors these were. “Then, using one of
these factors…” the data were categorized into two levels of sexual autonomy: low and high.
Which of the two factors was used and why was that one selected while the other was not?
Results
11. In line 172, you describe “good practice with regard to CC screening” – for clarity, please
describe what qualifies as good practice. Because this is the main finding of your study, I would
also recommend clarifying who the cases/controls are in your interpretation for added clarity.
Importantly, be conscious of how you report the interpretation of your AOR. I understand your
data to be indicating something different than the finding you are reporting. It is possible that I
am misinterpreting your findings so please just double-check your findings as presented in Table
4 and the interpretation here. I understand the findings as presented to mean “The odds of low
sexual autonomy were 3.128 times greater in women who were aware of CC screening but had
not screened before (cases) compared to women who had been screened in the past 3-5 years
(controls)” instead of “respondents with high sexual autonomy were 3.128 times more likely
to have screened”. The way you are reporting the result, screening status is the outcome and
sexual autonomy is the exposure, whereas your study design and the way you have previously
defined cases/controls defines exposure as screened/not screened and sexual autonomy as the
outcome of interest.
12. You use the term “mothers” several times to describe your population. This terminology is
not universally understood outside of Ethiopia as a term to describe all women of a certain age.
Especially because parity is one of the factors you are measuring, some readers may interpret
“mothers” as representative of only women who have given birth and may not understand
“mothers with parity 0” (line 178).
13. It would be interesting to see a table reporting women’s responses to the sexual autonomy
questions. For example, was there a particular statement that most women agreed/disagreed
with? This could inform your discussion. Since only one of the factors was used to create the
sexual autonomy index after PCA, it would be nice to understand which question is being used
to interpret sexual autonomy in your dataset and how the responses were distributed for that
particular question.
Discussion
14. In your conclusion on line 188, you state that “higher sexual autonomy leads to higher odds
for having been screened for CC”. The use of the term “leads” implies causation. Since you are
using a cross-sectional study design, you can only describe the two things as associated, there
is no temporality of one leading to the other one.
15. You posit that higher sexual autonomy could be associated with higher engagement with
preventive health services, such as CC screening (lines 190-194). Since you collected data on
health care utilization (did you visit a health facility in the last 12 months) this is something
you should be able to investigate in your dataset to confirm or refute this idea. If you were to
report the association between SA and the utilization of healthcare, that could strengthen your
discussion.
16. There were some differences in the demographics between the cases and controls of your
study. It could be interested if you reflect on these differences in the discussion section. For
example, the controls were much more likely to be unmarried. I wonder if unmarried women
would have higher perceived sexual autonomy. They may optimistically say that a woman has
the right to refuse sexual intercourse with her husband/partner, but then the actual behavior of
married women might be different than what those who are unmarried imagine or envision.
17. In lines 219-221, you assert that a strength of the study is that you are able to
show a causal association between sexual autonomy and CC screening uptake simply
because the study design is case-control. I respectfully disagree. The way I understand
your study design, a questionnaire was administered at one point in time and there was
not a temporal component to your design so causality cannot be implied. If you disagree
with this, please clarify your methodology. A resource that might be helpful: https://
bmcmedresmethodol.biomedcentral.com/articles/10.1186/s12874-021-01484-7
18. I like that you mention SDGs and the relevance of research on sexual autonomy for
policy changes. This would be an interesting area of discussion to develop further. What
are some interventions or policies that could increase sexual autonomy, either as they have
been demonstrated effective in other countries/settings or how you imagine they might be
implemented in Ethiopia?
Conclusion
19. While I agree with you that increased awareness of cervical cancer and screening services
would be beneficial in Ethiopia, I am not sure that your findings support this conclusion. The
sample you are reporting, including both your cases and your controls, are women who were
aware of cc so you aren’t showing low awareness.
Other
20. “Lifetime CC screening uptake” vs. “screened in the past 3-5 years” – In the methods section,
you describe controls as women who had received and were aware of screening services in the
past 3-5 years” but then other places in the manuscript and in the title you refer to “lifetime
cervical cancer screening”. These terms and definitions seem to be contradicting as currently
written.
Best wishes with revisions!