Title: Community and Provider Perceptions and Experiences of Cervical Cancer Screening in
Rural Bolivia: A Qualitative Study
Version: 1 Date: 17 Apr 2023
Reviewer's report:
Line 89: “Ministry of Health” and “systems’ weaknesses”
Lines 84-88: seem more suited to Discussion at the end than the introduction section, lines
89-106 are a bit too detailed. Overall, introduction section can be cut down, it’s a little
meandering and takes a long time to state the paper’s objective.
107: What does it mean the government is redoubling efforts? Because updates to guidelines
are coming soon?
123-140: My first thought was wondering if this much detail was necessary to understand how
did researchers’ identities/roles were expected or actually impacted the research (apart from the
obvious case of being able to speak either Spanish or Guarani). I see this is addressed in lines
600-606 – this makes this section rather unnecessary here.
156: What does “intense lived experience” mean/how it is defined in this context (as opposed
to “lived experience”)?
178-179: would be helpful to briefly explain details of piloting (how many women, where, how
they were selected, were questions adjusted, etc.).
181-183: what was the experience/training of focus group moderators? Were all participants
literate and able to provide written consent?
209-210: unclear how discrepancies were discussed since there was only 1 coder. It would be
more rigorous to have a second person code at least a proportion of the interviews to assess
inter-coder reliability.
213-4: unclear why thematic codes were further refined at the manuscript-drafting stage after
analysis and after consensus had been reached?
258-60: were all women aware of cervical cancer (especially those that had not been screened)?
This seems surprising given data from other low-resource settings where many women have
never heard of it before screening and/or even after screening are not clear on the distinction
between cervical and other types of cancer. I see this addressed in the discussion, but perhaps
a note on sampling is needed here.
-What was the rationale for including husbands/male partners in the focus groups? Is it because
women usually include (or need to include) their husbands to make decisions about their
healthcare?  More context on this would be helpful. There is also evidence that women are often
concerned/afraid of disclosing a positive screening test to male partners due to its perceived
connection to sexual promiscuity, and may not discuss screening with them. Was this addressed
in questions?
-Overall, were there any themes that were different between the indigenous and non-indigenous
focus groups? Since this was a deliberate sampling choice, it should be addressed.
-The use of “some”, “a few”, “frequent” etc. especially in Theme 1, is unnecessarily vague.
It’s informative to add frequencies (of codes, themes, or even instances of what participants
revealed), even if the main approach to analysis is qualitative. It would also be helpful to
have a descriptive/demographic breakdown of participants of the overall samples of community
members and providers, as in X women with screening experience, X women with none, X
married/single, X nurses/doctors.
-Some of the themes are a bit broad and seem to encompass distinct categories: lack of
information/knowledge is different from misconceptions. Men seem to fall into the first and
second, whereas later it is mentioned that women fall into the second (line 490). Lack of
confidence in providers due to perceived lack of skill or knowledge is also conflated with
preference for female providers (or perhaps embarrassment at being seen by male providers).
There is also a mention of preference for traditional healers that is not very thoroughly explored.
-Results and Discussion are repetitive and could be organized more clearly.
On the Results, there are main themes and then sub-themes (?) bolded and in italics. Were these
the codes that emerged more frequently? Sub-themes created by researchers? Why do some of
the 4 themes have these and others do not?
In the Discussion, a whole new category is mentioned (Particular findings) that is a catch-all
category is introduced - sounds like the researchers expecting some of these themes to emerge
and they didn’t. This should be somewhere in the results.
The Discussion section could be a lot more concise. The paragraphs re-stating results are
unnecessary, perhaps the focus should be on recommendations for the future, such as in lines
508-516, 527-532, or 552-560.