Title: Barriers and facilitators for breast cancer early diagnosis in an indigenous community in
Mexico: Voices of otomí women
Version: 1 Date: 25 Jul 2023
Reviewer:  Victoria Sánchez Antelo
Reviewer's report:
The study "Barriers and facilitators for breast cancer early diagnosis in an indigenous community
in Mexico: Voices of Otomí women" aimed to identify barriers and facilitators for breast cancer
early diagnosis perceived by women of the Otomí ethnic group in Mexico. Researchers relied
on well-established theories such as the Social Ecological Model, Health Belief Model, and
Healthcare Quality framework. They used qualitative methodology.
Major comments:
1. To better understand the research context, it is recommended to describe the guidelines used
in the Jiquipilco healthcare system for early detection of breast cancer (e.g., mammography
as indicated by the WHO, self-examination, standard of care) and the characteristics of health
resources available for breast cancer prevention (public or private healthcare, costs, availability
of mammography machines).
2. The justification for the theories used would be more precise if:
a. Concepts were presented closer to the research topic (e.g., perceived benefits of
mammography); particularly, the Health Quality framework is presented as goals of healthcare
services, not as theoretical concepts to be explored qualitatively.
b. The use of concepts from multiple theories that overlap as barriers/facilitators is justified (e.g.,
the Health Belief Model contains the notion of "perceived barriers" combined with other aspects
that represent cultural barriers).
c. Table 1 presents concepts from different theoretical frameworks, but their articulation should
be explicit and placed as a result.
d. The analysis presented does not align with the complexity of the proposed theories, with some
frameworks being used marginally (e.g., HQ).
3. The age of participants (18 years and older) should be justified. Are they the target population
for breast cancer preventive policy?
4. The criteria for case selection and formation of focus groups need justification. The authors
refer to intentional sampling: what theoretical-methodological criteria were used to choose
the cases? How was selection bias minimized when contacting cases through an official
organization? Could the refusal to participate affect access to social benefits? Did the participants
have health histories or were they under treatment for breast cancer?
5. The description of participants clarifies that Spanish speakers were included. Were non-
Spanish speakers excluded, or are all Otomi women Spanish speakers? If some don't speak
Spanish, how is the language barrier considered in healthcare access and selection bias? The
process of deductive-inductive data analysis needs justification.
6. RESULTS: The authors propose a complex framework of theories, but in the description
of results and selection of verbatims, these appear unclear. Some results are equivalent (lines
494-501 and 513-515), but they are presented in different dimensions: promotion campaigns for
preventive practices can serve as a "cue to action" from the healthcare system with the potential
to change misconceptions regarding the desired behavior to be promoted and address individual
information needs. The data analysis requires revision.
7. The discussion focuses on literature regarding indigenous belonging as a factor of exclusion,
but this specificity is diluted in the reported results. The authors should emphasize the uniqueness
of Otomi women in their relation to breast cancer and healthcare services.
Minor comments:
1. Clarify the use of the term "adoption" for preventive behavior. The specialized literature uses
"intention to adhere" and reserves "adoption" for new clinical guidelines among health providers.
2. Provide information about the moderator of focus groups, such as their community or
CEDIPIEM affiliation, age, gender, and ethnicity.
3. Clarify the statement regarding data comparison during the coding process (lines 183-185).
4. Specify whether they used focus groups or group discussions. The research purposes and
analysis focus differ between the two.
5. Clarify the nature of the described social program as a barrier. Did it cover healthcare costs
or provide free access?
6. The connection between the COVID pandemic results and the "Social and cultural context
barriers" dimension needs clarification.
7. Some verbatims refer to other conditions, not breast cancer, and should be reanalyzed to
provide clearer data about the explored concepts.