Title: Barriers to and opportunities for advancing racial equity in cervical cancer screening in
the United States
Version: 0 Date: 19 Dec 2023
Reviewer's report:
To the authors - I enjoyed reading your submission and think that your paper is timely and
important.  Overall, I think the paper is well-written and have made some comments that could
help with clarification of methods, the results, and perhaps the discussion.  I had hoped I could
upload a version of the manuscript with comments but have included them in text form below
(page number, section of manuscript text, reviewer comment). In short, I would love to see some
explanation about why you included the two separate interview analyses together in this paper,
because it doesn't appear that the themes were triangulated between the interview samples. Then
in the Discussion, it would be helpful to consider how your methodological choices influence
the transferability and relevance of the results. It would also be helpful to see some clarity in
what is meant by "clinical decision", particularly in the HCP interviews. What types of decisions
would we expect them to make/how do you envision applying population health disparities
into individual patient encounters? I think that there was a bit of commentary about this in the
Discussion, paritcularly around key informant interviews, but perhaps providers were less clear
in what that would look like?
Here are my page-by-page comments (page number, section of manuscript text, reviewer
comment):
3 We conducted in-depth interviews with health care providers (N=30) and key informants with
expertise in health equity (N=18).  How did you identify? What’s the different bw HCPs and
key informants?
5 BACKGROUND Well written but very long. Should shorten
6 , data indicate that HPV types covered by the HPV vaccine may be less prevalent among
Black women and, conversely, cancer-causing strains not covered by the vaccine may be more
common among Black women relative to white women  What about differential participation
in HPV vaccination? Would mention this, since HPV vaccination is critical in cervical cancer
prevention strategies, and also, needs to be considered for cervical cancer screening, particularly
as HPV testing becomes the new norm.
9 Given health care providers’ central role in cervical cancer screening, it is imperative to
understand how providers implement guidelines among minoritized racialized people
Is there guidance for guideline developers about how to address these factors? (Acknowledging
that equity/= anti-racism)
Shi, Chunhu, et al. "How equity is addressed in clinical practice guidelines: a content analysis."
BMJ open 4.12 (2014): e005660.
Welch, Vivian A., et al. "GRADE equity guidelines 1: considering health equity in GRADE
guideline development: introduction and rationale." Journal of clinical epidemiology 90 (2017):
59-67.
10 We recruited 30 health care providers  How were these numbers determined (i.e. 30 and 18)?
What was the criteria for stopping recruitment?
10 Massachusetts and Rhode Island  I’m assuming there was a bit of convenience sampling,
wondering if/how the results were expected to be influenced by this geographic sample,
especially considering the sample of key informants included national representation.
11 informed by the scientific  What about theoretical frameworks or positioning?
Garvey, Casey M., and Rachel Jones. "Is there a place for theoretical frameworks in qualitative
research?." International Journal of Qualitative Methods 20 (2021): 1609406920987959.
11 clinical decision-making Wondering if it’s worth mentioning at some point what the clinical
decision is. Is the clinical decision to offer opportunistic screening during  clinical encounter?
What about different roles in decision-making – I suspect women who are accessing health care
would view themselves as playing a role in the decision-making as well?
11 Participants were given a $100 gift card for their time Was this communicated in the consent
form? Did particpiants know they were being remunerated this much? $100 might be seen as
coercive?
11 critical realism research paradigm  Was this used in the design of the questions?
11 critical realism research paradigm  Perhaps could add some narrative to explain what critical
realism is, how and why it was used in this work.
12 Code summaries were produced for relevant coded excerpts, which were clustered
into themes and sub-themes using the hierarchical codebooks, memo writing, team-based
discussions, and data analysis matrices—all of which facilitated theme development and
refinement and allowed for subgroup comparisons, including in relation to provider type and
race/ethnicity  After reading the results section, I’m not clear how the two code books were
integrated, or if they were at all? If not integrated, what was the decision to include them/present
them in the same analysis here? Given that there were two distinct samples, who have different
perspectives, and what seems like two independent analyses, I’m wondering if they should be
presented separately, or perhaps considered in an integrated way?
12 Participant Demographic Characteristics Could consider putting this information in a table,
make it more succinct?
12 Nonetheless,  Not necessary
26 First, although key informants were recruited nationally, health care providers were recruited
from Massachusetts and Rhode Island only. Thus, our results based on providers’ accounts
may not be applicable to those practicing in states with different social, economic, and political
contexts.  As I questioned above, perhaps you could explain why you chose this sample, and
perhaps how these contextual factors might influence the transferability of the findings. Was it
important to limit the HCP sample (probably for ease, but also perhaps that’s where you may
have had influence on policy, for example)
26 To facilitate data triangulation, future research should employ multi-method qualitative study
designs as well as mixed-methods research approaches.  I agree – but is it worth explaining
why you presented analyses from two separate samples in the same paper, particularly when the
results didn’t appear to be integrated?
27 Nonetheless, our findings suggest that the development and implementation of cervical
cancer screening guidelines should explicitly recognize and address the impact of racism,
actively involve minoritized racialized communities, and facilitate provider- and institutional-
level practices that foster equity in cervical cancer outcomes. Moreover, in their screening
efforts, health care providers should acknowledge racialized cervical cancer inequities as well
as the role of racism in shaping them (45,59,91). However, it is essential that providers
do not uncritically apply population-level health inequities data to clinical care among
individual minoritized racialized patients, which could lead to stereotyping, making erroneous
assumptions, and screening patients from minoritized racialized groups more frequently than
necessary. Instead, providers should recognize the unique lived experiences of minoritized
racialized individuals and the structural and social factors that shape them (92,93) by using
person-centered, structurally-competent, and trauma-informed practices that acknowledge and
address the impact of racism and emphasize shared decision-making, bodily autonomy, and
agency (96–98). This seems to come more from the interviews of key informants, less from the
interviews of providers?