Title: Health workers’ perspectives on barriers and facilitators to implementing a new national
cervical cancer screening program in Ethiopia
Version: 3 Date: 13 Dec 2020
Reviewer:  Doug Puricelli Perin
Reviewer's report:
Thank you for the opportunity of reviewing this interesting article about the perspectives of
Ethiopian health workers on the status of cervical cancer screening in their country. The use of
qualitative methods to capture information from an important group of stakeholders about the
reality of their practice vs. what is described in their national cancer control plan is a strength of
your approach. In my experience working with countries to develop their national cancer control
plans, many times there is a stark difference between what the plan contains and the reality on
the ground, due to implementation and sustainability issues.
I have some comments which I hope help strengthen your manuscript even further.
In the Background, p.5, lines 92-94, it would be helpful to include a reference to the provided
information.
In the Methods, p.6, lines 129-130, you mentioned that participants were selected to include
a "variety of perspectives from locations with well-established vs. new screening programs". I
would be helpful to identify these different programs, possibly in the figure, and describe in the
results if there were any differences in the data when comparing the two.
In addition, on pp. 8-9, under the subheader "Interviews", it would be helpful to further describe
the interview guide in the methods, giving a sense of how the questions were developed to assess
the Integrated Behavioral Model constructs. It would also be informative to have a sense of how
the instrument was validated.
In the Results, it is not clear if the subheaders represent the themes that emerged from the
interviews or if they represent pre-defined categories assessed by the authors. Also in this case,
describing how the questions related to the constructs would contribute to clarifying this.
Describing the context from where the responses are coming from (well-established vs. newly
implemented program), and if there concerns/issues are the same or differ would also strengthen
the analysis.
In the Discussion, p.26, lines 537-539, you could explain among the limitations why participants
did not have a chance to review and provide feedback to your findings (which is stated in your
COREQ checklist).
You could further strengthen the Discussion looking into the development of the next national
cancer control plan of Ethiopia for the period beyond 2020 (since the current plan period is
2016-2020). There will be an opportunity to bring in the different stakeholders, including health
care workers, and the international community who supports cancer control activities, such as
the U.N. agencies (WHO, International Agency for Research on Cancer, International Atomic
Energy Agency) and international organizations (Union for International Cancer Control,
International Cancer Control Partnership). Some links for further reference below, which also
contain several resources (guidelines, training, etc.):
https://www.who.int/cancer/nccp/en/
https://screening.iarc.fr/cervical_cancer.php
https://www.iaea.org/sites/default/files/19/10/milestones-document-2019.pdf
https://www.iaea.org/services/key-programmes/programme-of-action-for-cancer-therapy-
pact#content
https://www.uicc.org/national-cancer-control-planning
https://www.iccp-portal.org/
Also, with the official launch of the WHO Global Strategy of Cervical Cancer Elimination, there
could be an opportunity to build the next national cancer control plan in line with the 90-70-90
cervical cancer targets set by this initiative.
https://www.who.int/news-room/events/detail/2020/11/17/default-calendar/launch-of-the-
global-strategy-to-accelerate-the-elimination-of-cervical-cancer
Finally, I understand that the national cancer control plan (NCCP) of Ethiopia recommends VIA
as the screening method. However, you may want to make some considerations regarding HPV
testing as a way to overcome some of the barriers described among your findings, especially
thinking about self-sampling in times of COVID-19, as the ability for the woman to collect the
sample at home becomes even more beneficial.
Again with the ending of the current NCCP period (2016-2020), there is an opportunity for these
stakeholders to gather and discuss what would be feasible for Ethiopia going forward. It would
be good to stress this point in the discussion.
Some suggested literature for implementation of HPV testing in low-resource settings:
https://www.thelancet.com/journals/langlo/article/PIIS2214-109X(19)30048-8/fulltext (rural
Argentina)
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6428151/
https://www.programrose.org/
(Program Rose – community clinics in Malaysia)
https://www.sciencedirect.com/science/article/pii/S0091743519304141
https://obgyn.onlinelibrary.wiley.com/doi/10.1002/ijgo.12773
(implementation of HPV testing in El Salvador)