Reviewer’s report
Title:  Female perspectives on male involvement in a human-papillomavirus-based cervical cancer-
screening program in western Kenya
Version: 0 Date: 26 Feb 2019
Reviewer: Francis Obare
Reviewer's report:
The authors explore male involvement in a human papillomavirus (HPV) screening program in Western
Kenya from the perspectives of women and community health volunteers. They find that women
experienced both support for and opposition to HPV screening from their male partners. I have the
following suggestions for the authors to improve the paper:
GENERAL COMMENTS
1)The authors state that one of their objectives was to develop a framework for male involvement
in cervical cancer prevention programs. One would therefore expect that they show how the key issues
identified from the study inform the framework. In its current form, there is a disconnect between the
key themes emerging from the study and how they informed the development of the framework. What
seems to emerge from the paper is that the framework informed the analysis (e.g. as alluded to on page
6, lines 179-181). This suggests that the framework was already there and they just used it to guide
their analysis rather than developing a new framework based on the study findings. If they in deed used
the findings to develop the framework as indicated in the objective, there should be a clear presentation
of how those findings informed the framework. This also means that the order of objectives as stated in
the last paragraph of the background section will change to start with identifying the key issues and
then developing a framework based on the issues identified. 
2)To  the  extent  that  the  authors  actually  developed  a  framework  for  understanding  male
involvement in cervical cancer prevention programs based on the key findings of the research, then the
utility of having such a framework should be discussed in the background section.
3)The framework itself (Figure 1) shows the flow from screening to results notification, then from
treatment to post-treatment adherence, and from post-treatment adherence to nowhere (i.e. there is no
more core service after post-treatment adherence) while there is no flow from results notification to
treatment (as shown by the downward arrows). Or how is one expected to interpret the downward
arrows? And should one expect some interactions between drivers, facilitating, and prohibiting actions
or they exist independent of each other? In reality, women may have to navigate through a complex
web of drivers, facilitating and prohibiting actions to access services. I am not sure how the authors can
capture such complexity in their framework. And did such complexity emerge from the interviews? The
title  of the  framework is  also  too  long and  can  be shortened  to  something  like  "framework  for
understanding male involvement in cervical cancer prevention programs".
4)The authors have not exhausted the discussion of the limitations of the paper. For instance, since
the views are from women, there is the potential for bias if their views reflect individual prejudices. In
addition, since men were not included in the study, it could be that their perceptions of cervical cancer
prevention programs may be different from what their partners or CHVs think. The extent to which
these limitations may affect the relationships identified in the framework depends on the nature of
variations in participants' and men's perceptions regarding the latter's role in cervical cancer prevention
programs. 
SPECIFIC COMMENTS  
1)Background
a)First paragraph, last statement (page 3, lines 80-82): Rephrase to read: "Effective population-
based screening … lesions therefore remain critical … cancer in the region."
b)Second paragraph, last statement (page 3, lines 89-92): Insert "that" after "suggests".
c)Third paragraph, fifth statement (page 3, lines 98-99): Rephrase to read: "While strategies that
incorporate gender issues are important, …"
d)Last paragraph, last statement (page 4, lines 113-118): Rephrase to read: "Given the gap … in
other SRH issues, we explored the perceptions … cancer prevention study in order to: (1) develop …"  
2)Methods
a)There is confusion regarding the appropriate reference to the nature of in-depth interviews that
were conducted. At some point the authors refer to them as semi-structured (e.g. on page 4, lines 121-
122) and at other times they refer to them as structured (e.g. on page 5, line 128). Which is which?
b)First paragraph, second statement (page 4, lines 124-126): It is not clear what the authors mean
by the phrase "self-collected HPV testing". Also, there is Migori, a town, not a city, and Migori, a
county. The hospital should definitely be located in Migori town.
c)Second paragraph, first statement (page 5, lines 130-131): What is the difference between
"target  communities"  where  the  in-depth  interviews  with  women  were  conducted,  and  "study
communities" where in-depth interviews with community health volunteers were conducted?
d)Second paragraph, fourth statement (page 5, lines 134-135): The authors state that "interviews
were sought from" various groups of women. It is not clear here whether the interviews that were
"sought"  from  the  different  groups  were  actually  conducted  because  "seeking"  is  different  from
successfully conducting the interviews as some women may decline while others may not be available.
How many of the women seeking services and those lost to follow-up were actually interviewed?
e)Third paragraph, last statement (page 5, lines 142-143): The authors state that "They included
questions …" but it is not clear what "they" here actually refers to given the nature of the preceding
statement. Is it the questions or the perceived facilitators and challenges?
f)Fourth paragraph, first statement (page 5, lines 144-145): Delete "and" after "developed" and
change "Dhluo" to "Dholuo".  
3)Results
a)Second paragraph, second statement (page 7, lines 185-186): The authors state that "Participants
and CHVs" but CHVs were also participants in the study such that the distinction between the two is
not clear. Perhaps the authors meant the women and CHVs who participated in the study.
b)Excerpt (page 8, lines 217-218): The excerpt reads more like a general comment on what is
likely to happen rather than actual experiences of stigma by women who sought HPV services as
alluded to in the paragraph preceding the quote.
c)Excerpt (page 9, line 250): It was not clear what the participant meant by the statement, "I can't
allow anybody to abuse my rights" when the quote highlights possibilities for disagreement and the
need for consensus between partners. The statement would have made sense if the participant showed
some agency to seek HPV services even in the face of partner opposition.
d)Eleventh paragraph, second statement (page 9, lines 258-259): Delete "found to be" from the
statement.
e)Thirteenth paragraph and the excerpt below it (page 10, lines 275-280): The authors should
summarize the key message(s) from the excerpt rather than simply narrating what the participant said.
What key message(s) do the authors want the reader to take away from the quote?
f)Sixteenth  paragraph,  first  statement  (page  10,  lines  289-290):  Change  "post  treatment
suggestions" to "post-treatment advice".
g)Seventeenth paragraph, second statement (page 11, lines 297-298): An excerpt from a woman
would have been more appropriate here than one from a CHV given that the preceding statement
alludes to women emphasizing the need for accurate male partner education.
h)Eighteenth paragraph, fourth statement (page 11, line 308): Rephrase the second part to read:
"…may improve their access to services by increasing the chances of getting permission from their
partners."
i)Nineteenth paragraph, third statement (page 11, line 318): Rephrase to read: "Participants also
reported that a better understanding … and cervical cancer prevention …" 
j)Excerpt (page 12, lines 321-323): Rephrase the last part to read: "…post-treatment measures she
is supposed to take are concerned."
k)Excerpt (page 12, lines 326-328): This excerpt is from a CHV, yet the preceding paragraph
alludes to suggestions from women. Also, change "prevention the spread of HPV" to "preventing the
spread of HPV".
l)Last paragraph, second statement (page 12, lines 334-336): The meaning of the statement is not
clear. Why would women's beliefs about the effectiveness of using community members be informed
by the understanding of community elders about the communities and how they function?
m)Last paragraph, last statement (page 12, lines 339-341): It is not clear what the authors meant by
the statement. In particular, it is not clear how "emphasis of community leaders as educators" and the
"desire for male partner education indicate a potentially positive correlation" between using community
leaders as educators and the desire for partner education.
4)Discussion
a)First paragraph, second statement (page 13, lines 349-350): Insert "in" after "part".
b)First paragraph, fourth and fifth statements (page 13, lines 351-354): The authors' assertions
here do not come out clearly from the way the findings are presented i.e. the findings as presented do
not  show  variations  between  male  involvement  in  cervical  cancer  prevention  and  their  level  of
knowledge.  Rather,  participants  expressed  the  view  that  educating  men  on  cervical  cancer  is  an
important step to improving their involvement in prevention programs.
c)Second paragraph, last statement (page 13, lines 362-363): Rephrase to read: "Lack of support
manifests itself through inability to provide financial or logistical support to travel for HPV screening
or treatment."
d)Third paragraph, first statement (page 13, lines 364-366): Delete "an" before "increased". Also,
I am not sure about the appropriateness of presenting quotes from the interviews in the discussion. That
should be stuff for the findings section.
e)Third paragraph, second statement (page 13, lines 366-368): Change "women attempting to
access treatment" to "women accessing treatment."
f)Third paragraph, third statement (page 13, lines 368-369): Rephrase to read: "Majority of
participants reported that targeting male partners during outreach and education activities in the early
phase of prevention programs was the most feasible …"
g)Third paragraph, fourth statement (page 13, lines 369-372): Delete "We found that" from the
statement since it connotes an intervention study that involved educating male partners, yet the finding
is based on what participants felt would be the benefits of involving male partners in HPV programs.
h)Third paragraph, last statement (pages 13-14, lines 372-374): It is not clear what the authors
meant by "standard definition" and how it can exactly "address the importance of education". Or did
the authors mean "standard interventions" given that it is interventions that address specific needs.
i)Fourth paragraph, second statement (page 14, lines 377-378): It is not clear why the authors
singled out researchers here. Shouldn't the information be more relevant for program implementers
who are the ones who develop interventions?
j)Fourth paragraph, third statement (page 14, lines 378-379): Change "larger" to "greater".
k)Fourth  paragraph,  fourth  statement  (page  14,  lines  379-382):  Change  "addresses"  to
"emphasizes".
l)Fourth paragraph, last statement (page 14, lines 382-384): Delete "the" before WHO, and
change "claim" to "recommendation".
m)Fifth  paragraph,  first  statement  (page  14,  lines  385-387):  Rephrase  to  read:  "Our  finding
regarding the potential role of community leaders in conducting male partner education is consistent
with WHO recognition of such leaders playing an "essential role" …" Also, provide page number for
the citation as it is a direct quote.
n)Fifth paragraph, last statement (page 14, lines 387-389): Change "has proved to be" to "is", and
"strategy in improving" to "strategy for improving".
o)Sixth paragraph, first statement (page 14, lines 390-392): It is not clear what the authors meant
by the phrase, "the significant emergence" i.e. there is absolutely no way of determining this from the
information presented.
p)Seventh paragraph, first statement (page 14, lines 398-399): It was not clear what the authors
meant by the phrase, "this study was able to sample a relatively under-sampled population of women".
In particular, how did the authors determine that the population is under-sampled? And it is under-
sampled with respect to what? And how does sampling an under-sampled population make the study
unique?
q)Seventh paragraph, last statement (page 15, lines 406-407): Change "CHV's personal" to "their
personal", and rephrase the second part to read: "…experiences during their interactions with female
clients and their partners throughout …"
r)Last paragraph, first statement (page 15, lines 408-409): Insert "in cervical cancer prevention
programs" at the end of the statement.
s)Last  paragraph,  second  statement  (page  15,  lines  409-411):  Change  "reveals"  to  "shows".
Otherwise as previously noted, the authors do not accomplish what they purport to have accomplished
here i.e. they do not show us how their findings informed the framework.
t)Last paragraph, last statement (page 15, lines 411-414): Again, it is not clear what the authors
meant by "standard definition of male involvement" here. Or did they mean standard interventions to
improve male involvement in such programs? Also, delete reference to Figure 1 here.
5)Conclusion
a)First two statements (page 15, lines 416-419): These statements can be deleted since they are
general in nature and do not highlight key message(s) that a reader can take away from the paper,
which should be the purpose of a conclusion.
b)Third  statement  (page  15,  lines  419-421):  Rephrase  to  read:  "The  findings  of  this  paper
demonstrate … uptake of cervical cancer screening and prevention services."
c)Last statement (page 15, lines 421-423): Rephrase to read: "… these findings highlight the need
for greater … that go beyond …" Also, it is not clear why researchers and policy makers are the only
ones singled out here when program implementers have even a greater role to play in achieving the
goal of eliminating cervical cancer by 2030.
6)Abstract
a)Background, third statement (page 2, lines 50-52): It is not clear what the authors meant by the
phrase "employing self-collected human-papillomavirus (HPV) testing". Perhaps they should explain it
a little bit for the benefit of readers who are conversant with the parent study. Also, rephrase the second
part to read: "… we examined the role of male partners and community leaders … screening services."
b)Methods, first statement (page 3, lines 53-54): Indicate the number of women and CHVs that
participated in the study.
c)Results, second statement (page 2, lines 57-59): The authors state that women participants
acknowledged that most community leaders are male. This, however, is not evident from the findings
presented in the paper. What we have in the paper is the authors' own interpretation of the likely reason
why participants did not discuss the preferred gender of community leaders i.e. "perhaps … because it
is accepted that community leaders are generally men." (see page 12, lines 338-339). But they do not
present any evidence showing that women acknowledged that community leaders are generally men.
d)Results, fourth statement (page 2, lines 59-61): The authors state that opposition from the
partner entailed "perceived negative reactions". What do these reactions entail?
e)Conclusion, last statement (page 2, lines 65-66): This recommendation is not mentioned in the
main text and only appears in the abstract. The abstract should summarize what actually appears in the
main body of the paper. Also, rephrase the statement to read: "Future research should explore the
feasibility and effectiveness of engaging male partners in cervical cancer screening and prevention
programs."
7)Declarations
Availability of data and material (page 16, lines 444-445): Change "on reasonable request" to "upon
reasonable request".
8)References
a)Names of institutions should be spelt out as they are since institutions do not have surnames.
Thus, the World Health Organization should be spelt out as such, not Organization, W.H. The same
applies to the Joint United Nations Programme on HIV/AIDS or UNAIDS.
b)Reference #12 (page 17, lines 488-489): It is not clear why the title for the publication is in
caps. Also, spell out the name of the institution i.e. Population Council.
Are the methods appropriate and well described?
If not, please specify what is required in your comments to the authors.
Yes
Does the work 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 relevant to this manuscript
Quality of written English
Please indicate the quality of language in the manuscript:
Acceptable
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