Title: Correlates of cervical cancer screening participation, intention and self-efficacy among
Muslim women in southern Ghana
Version: 3 Date: 04 May 2022
Reviewer's report:
Thank you for addressing my previous comments.  This is an interesting paper that’s readability
and clarity could benefit from a bit more clarification on some methodological points.  A few
more comments for your consideration:
Methods
• Sample size: While the equation to calculate sample size can be found in the reference, it does
not tell me the numbers you used for your study.  You gave the size of the population, but I do
not have the other information for me to be able calculate sample size for myself to reach your
stated number of 382.  For example, if you used Equation 1 from the Glenn paper, what value
did you use for level of precision and estimated proportion of the attribute that is present in the
population (And, for that matter, what attribute did you use?  Prior screen?  Desire to future
screen?  Something else?).  A few more details would be useful.
• Primary outcomes of interest: In page 6 lines 104-116 you do a good job describing the theory
behind your study, but there is no description of how you operationalized the theoretical topics
(adopted attitudes, subjective norms, and perceived behavior control) into tangible measures.
You additionally mention “intention” further down in the paragraph but not in lines 102-104.
And then you talk about self-efficacy, knowledge, and SES from HBM.  I think a description
of the operational definitions of each of these (six?) theoretical concepts should be added to
the Measurements section.  Knowledge is clearly defined, and then you talk about engagement
(is that relate to intention?).  And how to religion and provider-related factors fit into the
framework?  There is one sentence about the constructs from TPB, but since that is what you
defined as your primary outcomes, I would move this to the beginning of the section.  There is
no mention of how you defined self-efficacy, so it is still unclear how this was operationalized.
I think if you rearranged this section to more clearly align with the theory you mentioned at the
beginning of the methods section it would make it much clearer to the reader what your primary
outcomes are and how they are defined.
Results
• I think the finding that there is no difference in knowledge between those of screening age
and those who are too young to screen is an important and interesting finding.  It means that
women are not being exposed to screening information, even once they are at the recommended
screening age.  I would suggest adding this to your analysis and discussion given that you chose
to interview women both below and at screening age.
• Please cite studies that were used to derive interview questions (“cervical cancer affects the
mouth”, “cervical cancer affects the face”).
• I still don’t understand how the variable “Income” was defined.  The categories are above
average, average, and below average.  How was this calculated?  Were women asked what their
income was and then you calculated an average income?  If so, how did you then group the
women into these three groups?
• Thank you for providing the description about potentially why so many women reported that
urine was used for CCS.  Do you think that many of them knew about urine testing for HPV
given that its not used in-country?  Or do you think perhaps it could be that they’d had urine
tests for other things and thought it was a reasonable assumption that you could test for HPV
in the same way?  I’m wondering whether you think that they answered the question correctly
(because they knew it was used in some places) or incorrectly (because they did not).
Thank you for your clarification on these points.