Title: Community and Provider Perceptions and Experiences of Cervical Cancer Screening in
Rural Bolivia: A Qualitative Study
Version: 1 Date: 31 Mar 2023
Reviewer's report:
Indeed there is very little in the the literature on  Bolivia's effort at addressing cervical cancer
generally and much less at the level of population groups  in remote and rural areas.  The study
conducted in Monteagudo, Bolivia presents a snapshot of both provider and women and their
partner's perspectives and experience of cervical cancer prevention effort provided by the public
sector. While the authors noted that the size of the study is a limitation and that the results may
not be generalizable across Bolivia,  some of the themes that emerged from this study such as
lack of knowledge around cervical cancer and HPV, prefernece for specialists  have also been
documented in recent HPV studies conducted in Cochahanba, Bolivia;and  even on its own, the
finding can add to the limited body of knowledge.  Given the the LMIC and presence of pockets
of low resource settings in Bolivia, a cytology based screening approach will be a challenge to
bring to widely dispersed population, remote and rural population groups. The WHO Global
Elimination strategy and Guidelines advocates a shift to high precision test such as HPV DNA
assay. In the light of initiatives to introduce self collection and HPV testing, the authors are
encouraged to explore expanding the discussion part on how  the perspectives and experience
of care by women, their partners and the providers could impact access and utilization of HPV
based screening both from the point of view of quality as well as coverage rates.
Additionally, here is a list of queries and comments for consideration and further elaboration
in the manuscript by the authors:
LINE COMMENT/SUGGESTION
74 Since this is an assessment of barriers and challenges in rural Bolivia, I wonder if the overview
can provide some insight into the burden of disease  for these population segmentS?
100-102 Is there a more recent national cancer plan than 2009?
107-110 Would be relevant in the discussion section to reference how the results of this research
can inform Bolivia’s move towards newer screening technologies (HPV) and approaches (self-
collection)
120 Would be relevant to describe the phenomenological approach used in this study?
153-154 I wonder about women in the community who are not in the health registry and their
experience of care?
156 Women’s “intense lived experiences” of having a PAP  test - perhaps additional description
would be helpful to understand this as a sample strategy?
159 Any measure to mitigate a visit by local vis a vis ensuring voluntariness of participation?
340 Unclear what the sentence meant: “they [health personnel] don’t handle it [Pap test samples]
well, we get samples handled poorly  … “
345-346 Some contextualization on how results are shared ? with partners and/or patients?
437 The traditional Healers mentioned in this line maybe a relevant point to include in
the discussion as far as potential role in facilitating community and provider/health system
engagement?
515-517 A note that sample collection for cytology is a skill that does not require specialization
but providing screening services is more than just collecting samples but also requires
knowledge and the decision making skills to interpret and act on the results.
525-527  Would working with traditional healers and community leaders bridge the trust gap?
558-559 Given lack of confidence in health personnel and preference for specialists, I wonder
about how self collection will fare ? What might motivate these women to prefer self collection
over being seen by a specialist?
618 Given the poor knowledge around cervical cancer and HPV among patients and partners
could it have contributed to absence of stigma around cervical cancer. The stigma was always
linked back to the promiscuity perception and association with STI/STDs?