Reviewer's report
Title:Symptomatic presentation with cervical cancer in Uganda: a qualitative
study assessing the pathways to diagnosis in a low-income country
Version:3Date:4 November 2014
Reviewer: Laura Marlow
Reviewer's report:
This is a well written article that presents data collected from women with cervical
cancer in Uganda. As the authors point out, the research literature from LMICs is
lacking and their contribution to the literature should therefore be welcomed. In
general, I think the study appears sound and the methods are well described
(although some more detail needed – see below). Interpretation of the findings is
adequate and well described in the context of theory and previous research. The
authors have completed other studies that were not cited here. Please see some
specific comments below.
Major Compulsory Revisions
Introduction:
- Para 2: The authors should acknowledge the contextual differences between
the UK and Uganda, i.e. health system set-up
- Para 2, last line: the authors state that “In Uganda… there are few data from
qualitative studies assessing help seeking process for cancers” could the authors
describe the studies that there are. If there are no studies to discuss here the
authors should widen their criteria and describe other studies exploring attitudes
to cervical cancer more generally in Uganda or other African countries. For
example, they should describe these two studies which seem to be their own
work:
Mwaka et al. Understanding cervical cancer: an exploration of lay perceptions,
beliefs and knowledge about cervical cancer among the Acholi in northern
Uganda. BMC Womens Health. 2014 Jul 15;14:84.
Mwaka et al.Barriers to biomedical care and use of traditional medicines for
treatment of cervical cancer: an exploratory qualitative study in northern Uganda.
Eur J Cancer Care (Engl). 2014 Jun 13.
- Para 3: Could the authors add a few sentences describing the Andersen
model/Model of Pathways to treatment – some readers may not be familiar with
these.
Methods:
- How were patients approach about the survey and who by? E.g. approached by
a researcher or doctor? Approached before or after a regular appointment?
Approached in the waiting room of the hospital?
- Were all patients at the hospital recruited to the survey? How many were
approached? An idea of response rate to the survey would be useful.
- “… we purposively sampled patients who were not too unwell to participate”
how was this determined/decided? e.g. by their doctor?
- Were these public/private hospitals – please clarify
- Did the authors plan to recruit in two phases?
- Perhaps add the interview guide as supplementary data.
- “…with the help of two trained research assistants” Trained in what? Please
clarify.
- Lines 176-180, regarding the landmark events, where participants asked to use
landmark events to recall symptoms/timings etc? Or perhaps this just seemed to
happen naturally. Please re-phase or move to the results section if it is a finding
rather than something participants were asked to do.
- Where were the interviews based? E.g. In the hospital/At the participant home?
- Line 248/249: Please clarify what is meant by “modest amount of money”. This
last sentence seems strange, surely “participants were given an incentive of xx to
participate” would be more appropriate.
Results
- Please rephrase line 378/379 “The few respondents who had been screened for
cervical cancer and understood their negative result believed they were no longer
at risk” – the fact that they believed they were no longer at risk means they did
not fully understand the meaning of their screening result.
- Given that this is qualitative, I do not think the authors should use the term
‘respondent’ to refer to women who were interviewed.
Discussion
- The authors should acknowledge participation bias i.e. the more socially
motivated women may have been the ones who agreed to participate.
Table 2
- I think the authors should remove the horizontal line that represents the
arbitrary boundary or justify why they have included this.
Minor Essential Revisions:
- I think the reflexivity section should be part of the limitations. Using a male
interviewer is certainly a limitation.
- I think the authors should delete the last sentence of the first paragraph in the
discussion - I feel this plays down the recall bias which is a limitation to the study.
- Table 2: The term TTI is used inn the title and TTD is used in the third column –
please clarify.
- Table 2: The headings for columns two and three need to be swapped around.
Level of interest: An article whose findings are important to those with closely
related research interests
Quality of written English: Acceptable
Statistical review: No, the manuscript does not need to be seen by a statistician.
Declaration of competing interests:
I declare that I have no competing interests