PONE-D-24-13212Spatial distribution and characteristics of women reporting cervical cancer screening in Malawi: An analysis of nationally representative survey dataPLOS ONE

Dear Dr. Twabi,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

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1. revise the title as suggested2. check and revise the biostatistical estimates; significant p-value with overlapping confidence intervals for some variables3. Address the comment on the final multivariate model4. issues about self-reported data 

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Academic Editor

PLOS ONE

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[DL is supported by a National Institute for Health and Care Research (NIHR) Global Health Professorship (NIHR300808), using UK aid from the UK Government to support global health research. The views expressed in this publication are those of the authors and not necessarily those of the NIHR or the UK Government.]

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Partly

Reviewer #2: Yes

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2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: No

Reviewer #2: Yes

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3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: No

Reviewer #2: Yes

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4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

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5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: 1. The title should include the survey type like: (Spatial distribution and characteristics of women reporting cervical cancer screening in Malawi: An analysis of Malawi PHIA). You may improve your title by adding the year of the survey.

2. The paper needs to have line numbers for ease of review since it enables referring to line numbers for feedback or comments.

3. The paper reports that there were variations by regions however the between and intra region variations are not provided. This will strengthen your paper.

4. “Since the study by Msyamboza et al. in 2016,6 there has been no updated countrywide estimate of the cervical cancer screening uptake by the general population in Malawi.” but this paper “https://journals.lww.com/ijnc/fulltext/2023/08010/cervical_cancer_care_cascade_among_women_living.7.aspx” focusses on HIV+ women so may be refine this sentence and perhaps cite this paper.

5. The data collection for PHIA is not done in CSPro. I suggest that the authors refer to the report and recast this section.

6. “Descriptive analyses were also made for age categorisations based on the WHO cervical cancer elimination strategy targets, which included age of less than 35 years, age of 35 to 45 years, and age of 46 years and older” should be moved to data analysis section

7. “These zones include the Southeast, Southwest, Central East, Central West, and the Northern zone” should be categorized as North, Centre and South; and if details are needed then a forest plot by district should be plotted.

8. “A total of 12,815 households and 26,519 participants who were 15 years and older were surveyed during the MPHIA survey. There were 22,662 participants who had undergone HIV testing and had HIV test results” should be taken out or go into the methods section.

9. For Table 1: In order not to scare away readers, can you present the un weighted totals and then the weighted percentages. Your current tables are cumbersome and they may often go unread.

10. The authors should not report unadjusted ORs. The focus should be on adjusted effects.

11. The authors need to check the p-value for marital status since the Cis contain 1 but the p-value is significant. Verify the p-value for occupation as well.

12. The statistic on uptake of HPV vaccine is not a correct one if applied to the entire group of women since it was introduced when most of the women of reproductive age may not have had the opportunity as those below 25 years. Perhaps take that out in order not to mis-inform the readership.

13. The authors need to have around 30 references since 18 is too few.

14. How do your results compare with the Malawi WHO STEPS report? This is a key report on NCD and the authors never cited it? Consider 2009 and 2017 STEPS report.

15. One other limitation is that the paper focusses on just those screened due to the data source. Refer to (https://journals.lww.com/ijnc/fulltext/2023/08010/cervical_cancer_care_cascade_among_women_living.7.aspx) for the care cascade information. This could strengthen your paper but also the PHIA project or similar projects to go further by asking the additional questions to ensure a complete care cascade.

16. Overall: What is the knowledge gap that the paper is bridging? I would put this in the first paragraph under discussion so that the paper is more attractive rather than write the paper just as a narrative essay.

17. Overall: How was the final multivariate model arrived at?

Reviewer #2: Overall Review

Strengths:

The major strengths of the Results and Discussion section include clear and logical presentation, appropriate use of statistical methods, comprehensive interpretation of findings, and a thorough discussion of the implications for public health.

The inclusion of well-designed tables and figures enhances the clarity of the presentation.

Weaknesses:

One potential weakness is the reliance on self-reported data, which may introduce bias. This is acknowledged in the limitations but could be further emphasized.

While the discussion is thorough, more detail on regional disparities and the specific barriers in low-screening areas could provide additional valuable insights.

Recommendations:

Emphasize the limitations of self-reported data more strongly and suggest ways to address this in future research.

Provide a more detailed analysis of regional disparities and the specific barriers to cervical cancer screening in low-screening areas.

Overall Recommendation:

Language review

The manuscript is written in standard English and is generally clear and intelligible. However, there are some areas where improvements could be made to enhance readability and correctness. Here are some specific observations and suggestions:

Abstract:

• The abstract provides a concise summary of the study. Still, it has a minor typographical error: "Malawi has one of the is a country with the highest incidence and mortality rates of cervical cancer in the world." This should be corrected to: "Malawi has one of the highest incidence and mortality rates of cervical cancer in the world."

Main Text

Introduction:

• The introduction is well-written and sets the context for the study. However, some sentences could be rephrased for clarity:

o "Malawi has one of the is a country with the highest incidence and mortality rates of cervical cancer in the world." should be corrected as mentioned above.

o "Despite a national strategic plan to eliminate cervical cancer, as well as a national roll-out of VIA and screen-and-treat services in Malawi, coverage remains far below the national target." This sentence is clear but could be more concise: "Despite a national strategic plan and the roll-out of VIA and screen-and-treat services, cervical cancer screening coverage in Malawi remains far below the national target."

Methods:

• The methods section is detailed and clearly describes the study design, data collection, and statistical analysis. A few minor adjustments for clarity:

o "The survey, carried out between January 2020 and April 2021." This fragment should be completed or integrated into the previous sentence for better flow.

o "We used univariable and multivariable logistics regression approaches to examine associations..." should be "logistic regression" instead of "logistics regression."

Results:

• The results are presented clearly, with appropriate use of tables and figures. Some sentences could be refined for clarity:

o "The overall prevalence of self-reported cervical cancer screening was 16.5% (95% CI 15.5–18.0%). The prevalence of screening was 37.8% (95% CI 34.8–40.9) in women living with HIV and 14.0% (95% CI 13.0–15.0) in HIV negative women." This could be rephrased for better readability: "The overall prevalence of self-reported cervical cancer screening was 16.5% (95% CI 15.5–18.0%). Among women living with HIV, the prevalence was 37.8% (95% CI 34.8–40.9), compared to 14.0% (95% CI 13.0–15.0) in HIV-negative women."

Discussion:

• The discussion appropriately interprets the results and places them in the context of existing literature. Some sentences could be simplified:

o "Screening for cervical cancer was predominant in women living with HIV as compared to the HIV negative population." could be simplified to: "Cervical cancer screening was more common in women living with HIV than in HIV-negative women."

Conclusion:

• The conclusion is clear and summarizes the main findings effectively. Minor grammatical improvements could be made:

o "The uptake of cervical cancer screening remains low in the country and is largely driven by the efforts to address the HIV/AIDS epidemic." This could be rephrased to: "The uptake of cervical cancer screening in Malawi remains low and is primarily driven by efforts to address the HIV/AIDS epidemic."

Specific Typographical and Grammatical Errors

1. Typographical Errors:

o "Malawi has one of the is a country with the highest incidence and mortality rates of cervical cancer in the world." should be corrected to: "Malawi has one of the highest incidence and mortality rates of cervical cancer in the world."

o "logistics regression" should be "logistic regression."

2. Grammatical Errors:

o "The survey, carried out between January 2020 and April 2021." should be integrated into a complete sentence.

o "Screening for cervical cancer was predominant in women living with HIV as compared to the HIV negative population." can be simplified for clarity.

Conclusion

I recommend this manuscript for publication with minor revisions. The suggested revisions include emphasizing the limitations of self-reported data and providing a more detailed analysis of regional disparities in cervical cancer screening rates. These revisions will enhance the clarity and comprehensiveness of the manuscript, making it a valuable contribution to the field of public health.

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Reviewer #1: No

Reviewer #2: Yes: Mansoor Farahani

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Spatial distribution and characteristics of women reporting cervical cancer screening in Malawi: An analysis of the 2020 to 2021 Malawi Population-based HIV Impact Assessment survey data

PONE-D-24-13212R1

Dear Dr. Twabi,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

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Kind regards,

Jonah Musa, MBBS, MSCI,PhD

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

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2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

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3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

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4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

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5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

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6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: The authors have addressed all the comments. The paper can be published. All ethical issues have been addressed. The authors should consider making available the code chunks to enhance replication.

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7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

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