Reviewer ’s report  
 
Title: Exploring Iranian Women's Per ceptions and Experiences Regarding Cervical Cancer -
Preventive Behaviors  
 
Version: 0 Date: 03 Oct 2017  
 
Reviewer: Richard Fielding  
 
Reviewer's report:  
 
BMWH -D-17-00314 Exploring Iranian Women's Perceptions and Experiences Regarding 
Cervical Cancer - Preventive Behaviors  
This paper addresses an important area of cancer prevention.  Cervical cancer (CC) remains a 
major preventable cancer among women, and in some parts of Asia remains a very serious health 
threat to women.  The paper has a number of features that raise conce rns and need to be 
addressed, and needs to be extensively copy edited for correct grammar.  
 
Major points:  
Abstract:  
1. Results: There isn't really much information in the Results section of the Abstract.  Could a 
little more information be introduced? For  example what are the main barriers and 
"considerable challenges" these Iranian women face?  
 
Introduction:  
2. The authors list a number of "risk factors" for cervical cancer; what is the strength of 
evidence that these are of significance? A more critical approach could be taken.  Given the 
emphasis on HPV in current prevention efforts this seems underemphasized, almost an "also 
ran" item when it is arguably among the most important risks and probably easily 
preventable.  
 
3. P3 - opening sentence "All women  aged 35 -54 are at risk of getting cervical cancer."  CC risk 
is not confined to this age range, and it is important that it is recognized that CC risk 
continues to increase throughout life, and can in theory occur in women in their 20s.  Amend 
accordingly .  
 
4. P3 para 1 - how does the low response rate for Pap smear uptake in Iran compare to other 
jurisdictions where it is done on a voluntary recall basis?  
 
Methods:  
5. Para 1 last sentence: "a team of experts…" Please briefly explain their role(s). What were 
they commenting on? The design? The topic? The methods?  
 
6. Interviews: Where were the focus groups performed? I am a bit confused about the 
methodology used.  If 27 women were involved, and 19 were interviewed individually, does 
that mean only 8 had focus groups, and would they be of 2 -3 women each? It doesn't really 
meet the requirements for a focus group.  Alternatively, if all women were included in 3 
groups of 9 women each, why was a double interview approach used? More details are 
needed of the m ethods.  "Content analysis" is like saying "statistical analysis".  It doesn't tell 
us much about the analytic approach and the means used to ensure quality control and avoid 
"cherry picking" favourable results that match what the investigators might want to find.  
 
Results:  
7. The Results section would be improved by better organization. Perhaps begin by reporting 
women's understanding of CC and its causes, before looking at prevention.  As it stands I'm 
left wondering what if anything these women understa nd about CC as many seem to confuse 
CC with other gynaecological problems. This would improve the flow of the results along a 
more logical line making it easier to follow.  For example when talking about pros and cons 
of prevention, it isn't clear which qu otes are being used to support which position.  
 
8. The Results and quotes by the women interviewed are of considerable interest as they make 
available insights into how Iranian women view this issue, for example "hesadat" and 
concerns around speculum hygie ne.  However, the poor organization of the Results tends to 
make it a bit chaotic.  This section needs to be better structured, using sub -headings, and 
some indication as to how these different elements of the interviews relate to one another.   
Another wa y this causes problems is in duplication - in two separate places, concerns about 
loss of femininity and threats to marital stability are expressed independently.  These should 
be combined.  This suggests that the data analysis would benefit from a more st ructured 
approach.  
The self -care section is a good example.  Here, though the results flow better, the structure 
provided by sub headings (healthy lifestyle, stress management, medical check -ups)would help 
to assist the authors in assembling their argume nts more coherently.  Actually In this section it is 
much more consistent, but in the previous section (2) it is hard to follow where the authors are in 
their arguments.  
In section 4 the change from talking about family roles to support from family member s is an 
example of where a sub -head would help the reader.  
Section 6 - if about risk perception, then this needs to be mentioned in the sub -head.  How is this 
different from the section that mentions cultural beliefs about cause (Hesadat)?  
P32 - last para - What is the evidence that stress "causes" cancer?  To claim stress management 
improves preventive behaviours without evidence to support this claim is inappropriate.  
 
Minor points:  
The article overall needs editing for English standard a s there are many small grammatical and 
phrasing errors that need correcting.  
 
In addition:  
Introduction  
P1 - opening phrase: "Based on the report…" Delete this as it is redundant.  
P1, second sentence: "…low source countries"  - amend to either "…low reso urce…" or "low 
income" countries.  
P1 para 1, 5th sentence - "…lately diagnosed…" amend to read "…late diagnosis of…"  
P1 para 1, 6th sentence "…no certain statistics…"  amend to read "…no reliable statistics…"  
P1 para 2, sentence 1: "…and are numerous…" - delete  
P2 para 1, sentence 3: "…and quiet smoking…" amend to "and quitting smoking" and end of that 
sentence amend to read "…may help to decrease risk and prevent cervical cancer."  
P2 line 37 -38 - delete "…while…" (in the USA…)  
 
Results:  
When reporting quo tes from respondents, please include the women's ages.  
The use of the term "challenges" ("overall the women had challenges in their concept of 
prevention") is misleading in this context.  I think the authors mean "difficulties" - I would 
reserve "challen ges" for external circumstances that limit women's access, but difficulties for 
internal issues, such as low knowledge.  Alternatively, be more specific "challenges in 
understanding". Etc.  
P14 - the quote from participant 17 should use "she" not "he".  
Are the methods appropriate and well described?  
If not, please specify what is required in your comments to the authors.  
 
No 
 
Does the wo rk 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 releva nt to this manuscript  
 
Quality of written English  
Please indicate the quality of language in the manuscript:  
 
Not suitable for publication unless extensively edited  
 
Declaration of competing interests  
Please complete a declaration of competing interests, considering the following questions:  
 
1. Have you in the past five years received reimbursements, fees, funding, or salary from an  
organisation that may in any way gain or lose financially from the publi cation of this  
manuscript, either now or in the future?  
 
2. Do you hold any stocks or shares in an organisation that may in any way gain or lose  
financially from the publication of this manuscript, either now or in the future?  
 
3. Do you hold or are you curr ently applying for any patents relating to the content of the  
manuscript?  
 
4. Have you received reimbursements, fees, funding, or salary from an organization that 
holds  or has applied for patents relating to the content of the manuscript?  
 
5. Do you have any  other financial competing interests?  
 
6. Do you have any non -financial competing interests in relation to this paper?  
 
If you can answer no to all of the above, write 'I declare that I have no competing interests' 
below.  If your reply is yes to any, please give details below.  
 
I declare that I have no competing interests.  
 
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