Title: From existential uncertainty to a new mindset promoting recovery: Exploring the
development of uncertainty experience in women with vulvar neoplasia – a qualitative
longitudinal study
Version: 2 Date: 24 Nov 2023
Reviewer's report:
Thank you for the opportunity to review this paper. The topic is extremely interesting and  I
commend the authors for examining such experiences.
I know that the authors will likely be disappointed but this paper in its current form is not
publishable, but it could be with substantial work.
The background needs significant work. In its current form its very weak and doesn't build the
conceptual argument. I also think given its qualitative  work that is trying to be person-centred
that the word patient is not used, please use women or participants.
Mishel's work is very outdated, has it been updated / adapted? From danger to an opportunity,
for example, is linear and one directional, very limited and cannot accomodate the complexity
of an illness.  Other summaries of findings not clear in the background.
Ethics - cancelled - cannot cancel participation.
Table 1 not useful. Need to describe why participants died and or didn't participate.
VIN need to be spelt out p. 6
p. 6 year after diagnosis - first diagnosis, or subsequent?
There are several areas where the English expression needs further work throughout. ie. p. 8
participants intended to develop... they did develop, please correct English.
p. 7. Symptoms were stimuli .... study period. Are symptoms the only threat to certainty? study
period? why only study period? This whole paragraph needs unpacking.
There are so few women interviewed that I think there needs to be sone more detail about if one
woman, two women etc described certain experiences. Hard to get a sense when so few women
were interviewed. ie. pg8. If the interviewees were able... how many did this relate to?
p. 9.Participants who were no able to handle their uncertainty... This is a judgement on behalf
of the authors and this should be avoided. Did the women report, speak of struggling to manage
etc...
p. 9 Affected participants - who are you referring to?
Overal find that the fundings are very week. I am not entirely sure if its the analysis or a reflection
of the data. I also get no real sense of the temporality of how women negotiated uncertainty.
I am also not sure that the way that the data is presented best illustrated the issues at hand. I
think having chosen to focus on a few case studies may have drawn the issues out better and
then drawn on the other interviews to help illustrate the point may work better. I also feel the
data remains one dimensional. I do not get a sense of the women; they are not bought to life in
the paper in a way that i would expect and they should. I suggest that the authors find examples
where people have drawn on case studies either for each theme to make an argument clear or
have chosen one or two for the whole paper. Either way can work, it depends on the data and
the experience of the authors.
The discussion, because the framing of the paper, is extremely limited and needs to be entirely
re-worked. In the discussion psychological frameworks appear to be used rather than nursing or
sociological. I think the authors would be best not to ground this in psychology.
A longitudinal study of a year isn't really a limitation. It much longer than most qual studies. I
see it as a strength and suggest that the authors do as well.  I think the length of some interviews
possibly a limitation, as  they do. Again, this judgement if existential threat and repression. I
think the authors are making judgements  and psychologising participants. This isn't appropriate.
There is such a rich body of research on living with uncertainty, ambiguity and liminality that
the authors can draw on from the fields of nursing and sociology and i think the paper would be
strengthened if they could engage with more literature.