Reviewer’s report
Title:  Female perspectives on male involvement in a human-papillomavirus-based cervical cancer-
screening program in western Kenya
Version: 1 Date: 22 Apr 2019
Reviewer: Francis Obare
Reviewer's report:
The authors have addressed most of the comments of reviewers. There are, however, some more issues
they need to consider to improve the paper further. These are outlined below.
A.BACKGROUND
1)First  paragraph,  fourth  statement  (page  3,  line  82):  Delete  the  commas  before  and  after
"LMICs".
2)Last paragraph:
a)Third statement (page 4, line 119): The authors deleted "we" but it should be there for the
statement to read well.
b)Third statement (page 4, lines 121-122): Rephrase to read: "identify key themes to inform the
development of a framework for understanding male involvement in cervical cancer prevention".
c)Third statement (page 4, line 123): Replace the semi-colon after "prevention" with a comma.
B.METHODS
1)First paragraph:
a)First statement (pages 4-5, lines 127-130): Rephrase to read: "We used data from … in Western
Kenya to examine perceptions regarding male involvement in cervical cancer prevention."
b)Last statement (page 5, line 134): Change "community health workers" to "community health
volunteers" so that it is consistent with the abbreviated form. 
2)Second paragraph:
a)First  statement  (page  5,  lines  136-137):  The  authors  state  that  they  conducted  in-depth
interviews with a representative sample of CHVs but they do not elaborate how the sample was drawn.
Talking of a representative sample implies that they obtained a list of all CHVs and randomly sampled
those they included in the study. If that was the case, we need to know what the sampling frame was
and how many CHVs were sampled.
b)Third and fourth statements (page 5, lines 139-143): There is still lack of clarity regarding the
subsets of women included in the study, particularly the distinction between 206, 319 and 80. How are
the numbers of women in the fourth statement (i.e. 319 and 80) different from that in the preceding
statement (i.e. 206)? Does it mean that "interviews were sought from" 399 women (319 + 80) as stated
in  the  fourth  statement  and  only  206  interviews  were  completed  as  indicated  in  the  preceding
statement? For clarity, the authors should start by stating the total number of women who were targeted
or included in the study before stating the sub-groups to which they belonged.   
3)Third paragraph:
a)First statement (page 5, line 146): Insert "the role of" between "and" and "male partners".
b)Second statement (page 5, line 148): Change "community" to "communities".
4)Fourth paragraph:
a)Second statement (page 5, lines 151-153): The authors should be sure that the qualitative
interviews were conducted using tablets as stated.
b)Last statement (page 6, lines 156-157): Insert "and" between "researchers" and "then".
5)Fifth paragraph, fifth statement (page 6, line 165): Change "design a framework" to "develop a
framework".
6)Ethical approval (page 6, line 174): Change "boards at" to "boards of".
C.RESULTS
1)First paragraph:
a)First  and  second  statements  (page  6,  lines  179-181):  If  all  in-depth  interviews  that  were
conducted during the parent study were included in the present analysis, what is the utility of the
second statement? In other words, if all the interviews done during the parent study were used in the
analysis for the paper, why should one expect differences in characteristics of participants such that it
warrants mentioning that they did not differ?
b)Fourth statement (pages 6-7, lines 183-187): Rephrase to read: "Whereas most women reported
that the partner's permission … their own, CHVs indicated that despite receiving information …"
c)Last statement (page 7, line 190): Delete "if they" from the statement. 
2)Second paragraph (male partners as perceived barriers):
a)First statement (page 7, lines 193-194): Rephrase to read: "Although most women considered
their own partners as supportive, many were of  the view that male partner opposition was a major
barrier …"
b)Fourth statement (page 7, line 199): Insert "the view" between "expressed" and "that"
3)Third paragraph (partner distrust):
a)Third statement (page 7, lines 205-207): Rephrase to read: "Women who cited distrust as a
barrier to care reported that …"
b)Last statement (page 7, lines 207-210): The two parts of the statement are disconnected. The
first part talks about women seeking services in secret while the second part purports to emphasize that
women reported being unable to seek services or leave their homes. Seeking services secretly and
inability to seek services at all are two different issues and should be argued out as such.
c)Excerpt (page 8, line 212): Change "community sites" to "a community site".
4)Fourth paragraph (partner distrust):
a)Second statement (page 8, line 218): Change "stigmatizations" to "stigmatization".
b)Third statement (page 8, line 219): Insert a hyphen between "HIV" and "related".
c)Excerpt (page 8, line 222): Delete "I" after "then".
5)Sixth  paragraph  (partner  distrust),  second  statement  (page  8,  line  235):  Change
"symptomology" to "symptoms", and "than" to "who".
6)Eighth paragraph (unwillingness to adhere):
a)First statement (page 9, line 252): Insert a hyphen between "post" and "treatment".
b)Last statement (page 9, line 257): Change "in their behalf" to "on their behalf".
7)Eleventh paragraph (male partners as facilitators), second statement (page 10, line 280): Change
"in contrast" to "contrary".
8)Twelfth paragraph (male partners as facilitators), page 10 (line 286): Change "One women" to
"One woman". 
9)Thirteenth paragraph (male partners as facilitators), excerpt (page 11, line 295): Change "There
is" to "There was".
10)Fifteenth paragraph (proposed facilitators):
a)Second statement (page 11, lines 303-304): Rephrase to read: "All participants suggested ways
of increasing male …"
b)Third statement (page 11, line 304): Change "surfaced" to "emerged".
11)Sixteenth paragraph (proposed facilitators), excerpt (page 11, lines 312-315): The excerpt is
from a CHV, yet the preceding statement (lines 310-311) talks about what women said. A quote from a
woman would be appropriate here since it is about the need for continuous education.
12)Seventeenth paragraph (proposed facilitators):
a)First statement (page 11, line 316): Change "Most" to "Much".
b)Last statement (page 11, line 321): Delete the statement as it is redundant since the message is
already in the preceding statement.
c)Excerpts (page 12, lines 322-328): The previous text is largely about the views of women while
the first excerpt is from a CHV. Also, it is not clear what "Outreach and Education IDI" in the second
excerpt stands for. 
13)Nineteenth paragraph (page 12, lines 337-338): The statement is incomplete. Its meaning is
therefore not clear.
14)Last paragraph:
a)First statement (page 12, lines 342-344): Rephrase to read: "Although much of the conversation
around male involvement revolved around partner involvement, participants reported that involvement
of community leaders and village elders could be beneficial for spreading …"
b)Second statement (page 12, line 346): Change "option" to "options".
c)Last  statement  (page  13,  lines  353-355):  For  clarity,  the  statement  could  be  rephrased  to
something like, "However, future research could explore the acceptability, feasibility and effectiveness
of using community leaders to provide cervical cancer information, especially to men."
15)Framework:
a)There is still very limited discussion of how the findings informed the development of the
framework  or  how  the  framework  can  help  us  understand  male  involvement  in  cervical  cancer
prevention programs. One would expect that after presenting the findings, the authors would then
discuss how those findings inform the development of the framework and how the framework helps us
understand male involvement in cervical cancer prevention programs. In particular, what findings
inform which components of the framework and how are the components related to each other? How
does the relationship between the components help us understand male involvement in cervical cancer
prevention  programs?  How  can  the  components  of  the  framework  be  operationalized  so  that  a
researcher who wants to apply it elsewhere will know exactly what kind of information to collect?
These are questions the authors need to answer for their framework to make sense to readers. 
b)Under drivers for facilitating actions (Figure 1), one driver is simply stated as "My life is
important to him". Now, this is vague. In particular, how does one who wants to use the framework
operationalize the phrase? The authors should come up with a concept that best summarizes the phrase,
e.g. "importance men attach to women's lives".
c)Under facilitating actions (Figure 1), the phrase "permission to attend treatment hospital" is
repeated twice. It is not clear whether it is under a different or the same group of drivers given the way
the figure is presented. Also, couldn't the action be simplified to "permission to seek treatment" for
clarity in all places it is used?
d)Under  facilitating  actions,  third  last  bullet  (Figure  1),  change  "suggestions"  to
"recommendations".
e)Under drivers of prohibiting actions (Figure 1), some of the aspects could be phrased better e.g.
"Control  of  partner's  movement"  instead  of  "Does  not  allow  partner  to  leave  home";  "Lack  of
awareness about partner's care-seeking behaviour" instead of "Unaware that partner was treated"; and
"Gender  roles/cultural/community  expectations"  (note  the  forward  slash  between  "cultural"  and
"community"). 
f)Change "attendence" to "attendance" in all places the word is used in the figure.    
D.DISCUSSION
1)First paragraph, fifth statement (page 13, lines 367-368): Rephrase the second part to read: "also
mentioned high levels of knowledge and awareness among their partners".
2)Second paragraph:
a)First statement (page 13, line 371): Change the comma after "support" to a semi-colon.
b)Third statement (page 13, lines 374-375): Change "plethora" to "number", and "motivations for"
to "manifestations of".
3)Third paragraph:
a)Second statement (page 14, lines 381-383): Rephrase to read: "This is consistent with studies
which found that …"
b)Fifth statement (page 14, lines 389-391): Rephrase to read: "Women's views regarding the
relationship between men's lack of knowledge and their inability to provide support for cervical cancer
screening or treatment indicate that … importance of partner education." 
4)Fourth paragraph:
a)First statement (page 14, lines 392-394): Rephrase to read: "Our findings show that lack of
knowledge of cervical cancer prevention among male partners has potential negative influences on
uptake of the services, particularly …"
b)Second  statement  (page  14,  lines  394-396):  Rephrase  to  read:  "This  suggests  a  need  for
identifying strategies to effectively involve male partners in prevention programs."
c)Fifth statement (page 14, lines 399-401): Rephrase to read: "Our findings are consistent with
WHO's recognition of men … as well as its recommendation …"
5)Fifth paragraph, first statement (page 14, lines  402-405): Rephrase to read: "Our findings
regarding … education are also consistent with …"
6)Sixth paragraph:
a)First and second statements (page 15, lines 409-412): Combine the two statements into one to
read: "Importantly, the finding regarding male partners as a barrier to post-treatment care, especially
prevention of complications or HPV re-infection through abstinence from sexual intercourse or condom
use, highlights the need for culturally …"
b)Third statement (page 15, lines 412-415): Change "post treatment care instructions" to "post-
treatment recommendations".
c)Last statement (page 15, lines 415-417): Rephrase the last part to read: "implications for future
research, program and policy decisions…" 
7)Seventh paragraph:
a)First statement (page 15, lines 418-419): It is still not clear what "under-sampled population of
women" actually refers to. Who are these people and what parameters did the authors use to determine
that they are under-sampled? That is what a reader would like to know. Adding a citation alone does not
improve clarity of the statement.
b)Fourth statement (page 15, line 423): Insert a semi-colon between "participants" and "this".
c)Sixth statement (page 15, line 428): Change "in this cluster-randomized study" to "in the parent
study".
d)Seventh statement (page 15, lines 428-429): Delete the statement as it is not informative and
does not add value to the arguments.
e)Last statement (page 15, lines 429-430): Rephrase to read: "The finding regarding women's
emphasis on the importance of male involvement in cervical cancer prevention suggests a need for
future studies to explore…" 
8)Last  paragraph,  first  statement  (page  16,  line  434):  Delete  "this"  between  "of"  and
"understanding".
E.CONCLUSIONS
Last statement (page 16, lines 447-450): Rephrase the second part to read: "…conversations around
male involvement that go beyond vaccination of boys in order to realize the global goal of eliminating
cervical cancer by the year 2030."
F.ABSTRACT
1)Background,  third  statement  (page  2,  line  51):  Insert  "vaginal  swabs  for"  between  "self-
collected" and "human-papillomavirus".
2)Methods, second statement (page 2, line 57): The influence of "family" does not come out in the
main text as alluded to here.
3)Results:
a)First statement (page 2, line 58): This is not a result and should be deleted here. If the authors
conducted 605 in-depth interviews and 595 were included in the analysis, that should be mentioned in
the methods with an explanation of what happened to the 10 interviews that were excluded.
b)Second statement (page 2, lines 58-60): This statement should come as the last one in this
section for flow of argument. It should also be rephrased to something like, "Women reported a general
acceptance of involvement of community leaders in education and screening campaigns in a setting
where such leaders may hold influence over men in the community."
c)Fourth statement (page 2, line 64): Change "own partner" to "own partners". 
G.DECLARATIONS
Author contributions (page 17, line 477): Change "provided manuscript feedback" to "reviewed the
manuscript for substantial intellectual content".
Are the methods appropriate and well described?
If not, please specify what is required in your comments to the authors.
Yes
Does the work include the necessary controls?
If not, please specify which controls are required in your comments to the authors.
Yes
Are the conclusions drawn adequately supported by the data shown?
If not, please explain in your comments to the authors.
Yes
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 editors.
Not relevant to this manuscript
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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3. Do you hold or are you currently applying for any patents relating to the content of the
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4. Have you received reimbursements, fees, funding, or salary from an organization that holds
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