Title: Young women’s perspectives on a user-friendly self-sampling intervention to improve
the diagnosis of sexually transmitted infections in underserved communities in KwaZulu-Natal
South Africa
Version: 4 Date: 19 Sep 2024
Reviewer:  Joanna Busza
Reviewer's report:
General comments: I enjoyed reading this paper and learning a bit more about the process of
conducting a nominal group technique activity. I feel that the value of this paper lies less in
what the findings show about barriers to STI service uptake (which are based on a tiny sample
and in any case reflect evidence already well documented in the literature) and more in the use
of the approach. It seems the authors have planned a participatory cycle that starts with NGT
and then will inform a DCE, which itself will inform the design of local introduction of self-
sampling. Could there be more about how this participatory approach is theorised to lead to
improve uptake of self-sampling and follow-up services? I would like to see the paper framed
more as a methodological piece, with discussion of the challenges and potential benefits of using
this approach. I do not think this should take a lot of work - the Background could include more
literature around participatory research and it applicability to NGT and DCE in particular, the
results on actual barriers and facilitators could be shortened a bit and perhaps replaced with
findings on how participants found the process and their engagement with it, and the Discussion
could emphasise how the NGT will be translated into a DCE and how the DCE will maintain
youth engagement in planning appropriate services, esp self-sampling options.
Specific comments:
Background: I would suggest remvoing the paragraph about distal detrerminents of STI
(uranisation/globalisation) as these broader issues are not addressed by the research. Instead, I
would suggest expanding the paragraph on NGT and DCE as methods, situating them within
the literature on participation and youth engagement.
Methods: You mention that the women were recruited from “under-served” communities, yet
that they were already using family planning and youth clinics. Please could you give a bit
more detail about what you mean by “under-served” and why young women who were already
engaged with SRH services were selected? I would have thought this introduces some bias,
as these are women who have managed to overcome at least some barriers to access. It’s also
not necessary to provide inclusion and exclusion criteria that are mirror images of each other
(obviously if inclusion requires being sexually active, than non sexually active individuals would
be ineligible). Exclusion criteria usually relate to having other reasons for not being allowed to
enrol in a study even if nominally eligible, e.g. mental health issues or cognitive disabilities that
make it difficult to give informed consent (your last point).
I suggest you move the logistical issues around the NGT to the Results section. Not being able
to successfully recruit the first group, and having 1 group successfully completed (with just 8
young women) are findings related to the challenges of implementing a participatory process.
This raises interesting issues around to what extent youth want to engage to service planning
(something there is so much advocacy around). This is a useful finding that could then be
addressed in your Discussion.
Results: I suggest re-focusing the results on the process of the NGT, including your initial
challenges with recruitment and retention. Given your detailed account of the 4 phases of the
NGT, can you describe how participatory each phase was and how actively engaged the young
women were? Do you have any quotes related to how participants viewed the process of the
workshop? I feel that the current presentation of actual barriers to uptake of STI do not offer
new insights into what is a well documented problem in the literature, and difficult to generalise
given the very small sample. Although of course it is heartening that even a small group of
participants validate the key issues that have been raised in the literature. But the ranking process
is interesting and it would be useful to future practitioners if you could describe how this worked,
how easy or difficult it was, whether group dynamics were conducive to the NGT process, etc.
I would be more interested to read this than the quotes relating to difficulties accessing STI
services and the social barriers ie stigma.
Then the generation of strategies to overcome these barriers is again more interesting and unique
to your paper. How were these strategies identified in the smaller groups? Did individuals
dominate the process? How much “leading” did facilitators have to do? How was the numeric
prioritisation organised and implemented? Again, reflections on the approach would have
broader relevance than simply the opinions and experiences of 8 individuals.
Discussion: You cannot really state that your study provides “valuable insights into the priorities
and preferences of young women in the selected communities.” While qualitative methods do,
of course, require smaller samples than surveys etc, 1-group discussion with 8 users of SRH
services is simply too small for any kind of generalisation. However, you did engage 8 young
women proactively in exploring their own perceptions and experiences and thinking about how
to rank and prioritise these; the study can be seen as a useful pilot approach of NGT. The group
did confirm a lot of what is in the literature around why young people do not seek STI diagnosis
and treatment – as such, it was a useful way of actively involving people even when they tell
you what you might have known/predicted in any case. How can this be harnessed for better
service delivery?
I suggest you situate your discussion within the literature on greater community engagement
and the challenges of genuine participation, especially young people. What does it mean that it
was so difficult to organise more than 1 group and recruit more than 8 women? How does this
relate to the large body of advocacy work calling for greater engagement?
It would also be useful to discuss the process of translating the NGT into a DCE. Not all readers
will be familiar with the DCE approach and why / how it is used. And how will the DCE maintain
commitment to participation?