Reviewer ’s report  
 
Title: Effects of peer health education on perception and practic e of screening for cervical cancer  
among urban residential women in south -east Nigeria: a before and after study  
 
Version: 0 Date: 27 Dec 2016  
 
Reviewer: Malcolm Steinberg  
 
Reviewer's report:  
 
My major concern with this paper is that the major conclusion is not supported by the data 
collected. Specifically, it is mentioned that 'the positive effects of peer health education on 
practice of screening should be enhanced by subsidizing the cost of s creening in order to ensure 
that the poor are not excluded'. Unfortnately, the data collected in this study do not provide the 
basis for this conclusion. I suggest that this paper is reqritten to focus on knowledge and 
perceptions of cancer of the cervix b efore and after a peer education intervention and that an 
attempt to demonstrate that this intervention will result in changed practices is reconsidered 
given the financial barriers that are finally provided at the end of the paper.  
 
 
 
Further comments provi ded to the editor follow:  
 
Suggest the authors refer to other screening technologies besides Pap in the background.  
 
 
Authors mention that 'the level of uptake of cervical cancer screening in Nigerian women is 
abysmally low and unrelated to levels of awarenes s' but provide two references that refer to 
health care workers only making a generalization from these sources problematic.  
 
 
Authors mention that peer education draws on the Diffusion of Innovation Behavioral Theory. 
Suggest authors note that peer educati on draws on several well -known behavioural theories, 
including Social Learning Theory, Theory of Reasoned Action and Diffusion of Innovation 
Theory. It is also not clear how the authors drew on this theory in the construction of their 
questionnaire. No fur ther reference is given to this theory in the analysis and discussion.  
 
 
Suggest that authors consider the potential biases of selecting wives of clergy men in the 
dioceses as the peer health educators. I suspect this may have set up a power imbalance and if  so, 
may have put extra pressure on women in the peer education sessions to comply with 
recommendations to access screening. As such, educators are not real peers of the women in the 
dioceses that do not have clergy partners. Also, we are told that these w omen were recruited. 
How was this done? Did the women volunteer or were they simply asked to participate? Did they 
receive any honorarium or token of appreciation? It seems as if the time commitment for 
everything the peer educators did was quite significa nt. How was the peer educators' training 
manual from Zambia adapted? Was it translated?  
 
 
It is not clear what sampling frame/list was used from which women were consecutively 
recruited from each of the five parishes at the final stage. Not clear why a diffe rence of 13% was 
chosen for the sample size determination.  
 
 
It is mentioned that the peer health educators provided repeated sessions of health education on 
cervical cancer and its prevention to women in their parishes during monthly meetings for at 
least 3  consecutive months. Suggest authors provide some data on the range of sessions attended.  
 
 
We are told that two of the four urban dioceses were selected by simple random sampling at the 
first stage. This appears to assume that these urban centres are simil ar. Suggest some justification 
is given for this with respect to income and education differentials, culture, religion, etc that 
might impact on ca cervix prevention knowledge and practice. We are told in the discussion at 
the end of the paper that 'equal allocation was used at the final stage of selection of participants' 
but this is not mentioned in the section on sampling.  
 
 
Who administered the questionnaires? Was it a self administered questionnaire? Did the women 
complete the questionnaire in groups? D id the participants sign a consent form? There is no 
mention in this paper about ethical clearance for this study.  
 
 
Was any identifying information collected from the participants? Was the data anonymized 
before analysis?  
 
 
We are told nothing about the peer  health education intervention itself. I assume it was one 
session only. How long was it? How was it conducted? How were the women invited to/recruited 
into the session(s)? What were they told it would cover (that may have biased their perceptions 
about in dividual risk for cancer of the cervix and benefits of screening prior to completing the 
base line questionnaire?  
 
 
What 'appropriate summary statistics and tests of statistical significance of observed differences 
and associations were applied'?  
 
 
15 question naires were discarded before analysis because they were inappropriately completed. 
What was the basis for this decision?  
 
 
Suggest that the authors round off average age of participants.  
 
 
We are told that the 'highest proportions of respondents had completed  tertiary education'.  
 
 
Suggest that the authors provide a proportion as has been done for other demographic variables.  
 
 
It would have been good to learn about health care utilization p ractices from the participants, 
notably for reproductive health needs. In  the discussion, we are informed about the frequent 
contacts women make with health services but not about use of reproductive health services.  
 
 
Results data are not presented consistently. Numbers and percentages are given for the 
proportion of participant s who screened for cervical cancer but only percentages for other 
parameters.  
 
 
In the discussion, a reason for low screening practices given is a delay in receiving test results. 
No information about actual delays is given. There are also many more reasons  for poor 
screening practices cited in the literature that are not mentioned, such as access problems, lack of 
privacy in the clinics, partner barriers, costs.  
 
 
We are told that the probable reason for why those that screened used the Pap test is that this  is 
the commonest method used. What other methods are used in these services? It would seem 
unlikely that liquid -based cytology, HPV DNA testing and visual inspection with acetic acid 
methods are provided in the services offered to these women.  
 
 
The author s suggest that 'although the observed change in practice was slight, a sustained 
increase could be expected over time if the peer health educators continue to educate the women 
repeatedly'. I suggest that the authors are not considering other barriers to s creening mentioned 
above. In addition, it is assumed that this ongoing education could be provided by peer educators 
but there is no discussion about the challenges of retaining peer educators for this work.  
 
 
In the second last paragraph, we eventually lear n about additional barriers to screening other than 
knowledge of and perceptions about cancer of the cervix and screening for cancer of the cervix. 
Notably, we are told that women must pay an average of $150 (presumably USD) to be screened 
for cervical can cer, and that it is estimated that 70% of Nigerians live on less than US$1/day. 
This suggests that peer education initiatives alone are highly unlikely to have impact on 
screening practices. As mentioned above, it would have been useful for the authors to have 
included questions about financial status in the questionnaire. These economic barriers could 
also have been reviewed in the introduction as critical issues to explore. Thus, while the authors 
conclude the paper by saying that 'However, the positive e ffects of peer health education on 
practice of screening should be enhanced by subsidizing the cost of screening in order to ensure 
that the poor are not excluded', the data collected in this study do not provide the basis for this 
conclusion.  
 
 
 
 
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.  
 
Unable to a ssess  
 
Are the conclusions drawn adequately supported by the data shown?  
If not, please explain in your comments to the auth ors. 
 
No 
 
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 edi tors. 
 
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  
 
 
 
 
 
 
 
 
 
 
 
 
Declaration of competing interests  
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