Title: Implementation of HPV-based screening in Burkina Faso: lessons learned from the
PARACAO hybrid-effectiveness study.
Version: 1 Date: 14 Feb 2021
Reviewer's report:
I thank the authors for giving me the opportunity to review this interesting study on the
implementation of HPV -based screening project in Burkina Faso. I congratulate you on the
underlying work. I believe some rewriting at different levels of the paper will contribute to
making it stronger.
I have structured my review per section.
Abstract
You may have to revise it a bit after integration of reviewers’ comments including some of mine.
Background
I suggest that the authors dedicate a section, preferably in the methods, to describe the
PARACAO intervention. Thus, they can include the theoretical framework of the PARACAO
(Line 115-121) there.
Methods
[General comment] I think for better clarity, the methods section needs to be restructured.
The authors could do it as follows:  i) Study settings or context ii) Description of PARACAO
intervention iii) Study design. Then after the study design, I suggest that for each of the
quantitative and the qualitative component the authors describe iv) Study sampling v) Data
sources and data collection and outcomes vi) Analytical approach. They could close the methods
section with vii) Ethics considerations.
Line 133: Regarding the choice of hybrid effectiveness type III design, I suggest that the authors
give more details on this design and explain why they have chosen it. Also, I recommend that
the authors give the reader more details on the mixed methods design. Will quantitative and
qualitative methods be used sequentially or concurrently? Will these methods be given relatively
equal weight, or will one methodology be dominant?
Line 134-136: As I stated earlier this paragraph should be at the ethical consideration section,
not at the study design.
Line 137: Regarding the context, I recommend that the authors describe the Burkina Faso health
system as some readers may not be familiar with it. This could be helpful to understand and
interpret the results.
Line 151: There seems to be confusion in this section. The participants you described here are
only eligible women for the HPV-based screening. I recommend that the authors describe all
their study participants who are women, midwives, and laboratory staff if I understood well.
Lines 175-211: All this information should be in the section describing the PARACAO
intervention.
Line 213: What this title “Methods. evaluation” means?
Before describing outcomes and covariates, I suggest that the authors give more details on their
data sources and their data collection process.
Line 220: Regarding satisfaction, why the authors did not assess health workers’ satisfaction?
Measuring their satisfaction in this study could have helped to anticipate issues when scaling-
up the intervention. In rural areas, where there are a shortage of healthcare professionals and a
lack of infrastructure, this approach could be difficult to implement.
Lines 234-236: this paragraph should be in the ethical consideration section.
Line 274: I think that more details should be provided on how direct observations data were
collected. Also, direct observation could enable changes in health providers’ tasks (Hawthorne
effect) that need to be discussed as a limitation in the discussion section.
Line 280-286. More details on the type of interviews and how they were conducted are necessary
to inform the reader. (Structure interviews? In-depth interviews? Are they recorded? In which
language? When were these interviews conducted? Immediately after the visit, or the following
days after it.  Also, were these interviews conducted at the beginning, or the end of the project,
or throughout the implementation of the project. I believe this kind of information is important
because it can induce potential biases (e.g., recall bias) that might be discussed.
Line 326: The description of the qualitative analysis seems superficial. I strongly recommend
that the authors describe better this section.
Results
[General comment] Results are mostly dominated by quantitative results and small qualitative
results. We noticed very few quotes that could have enriched the findings. In addition, one of
the objectives of this study was to explore the acceptability of the project by women, but I do
not perceive any results related to it.
Lines 392-404:  I believe more quotes from patients’ interviews and more information
particularly on the level of education of patients (when you quoted) would have helped the reader
to better understand how patient experience, motivation, and knowledge of the project would
have affected screening completeness and their satisfaction.
Line 411: In the results section, value judgment must be avoided (curiously, surprisingly, etc.)
Lines 413-415: This paragraph trying to explain the positive association between the amount of
money spent on travel and patient satisfaction is an unnecessary comment in the result section.
It fits better in the discussion section.
Discussion
[General comment] My main comment is that the authors need to give more insights into
the policy implications of the interesting findings. As the authors recognized this project was
conducted in the ideal conditions in an urban area where people have access to healthcare and
information. Based on the findings I recommend that the authors try to discuss the challenges
that the implementers of this strategy will face when they scale up it, especially in rural areas
where most of the Burkinabe population live. I glimpse some challenges in terms of lack of
infrastructure (laboratory) staffing and training, and acceptability issues, particularly in villages
where women often need permission from their husbands to get access to healthcare. Once the
authors identify and discuss these challenges, they could formulate some recommendations to
policymakers.