Title: Iranian Women's Psychological Responses to positive HPV test result: A Qualitative
Study
Version: 1 Date: 14 Dec 2020
Reviewer:  Christine Campbell
Reviewer's report:
Thanks for the opportunity to review this interesting manuscript that reports on findings of
qualitative interviews with women diagnosed with a positive HPV test as part of cervical cancer
screening in Iran. The authors report important psychological and emotional reactions to the
positive HPV test result that should be used to inform local policy and practice, and will be
of wider resonance as many countries are in the process of adopting HPV testing for cervical
screening.
In the view of this reviewer, HPV is not itself a diagnosis: the title and throughout the manuscript
it would be better to use wording such as ‘after a positive HPV test result’
Additional comments on each section below:
Background
The rationale for the study is described clearly – although a number of studies have reported
on women’s views and experiences following a positive HPV test, few are from countries with
the relatively low HPV positivity rates (approx. 7.4% as reported by the authors in Iran), nor
from countries with the specific cultural and religious contexts that will likely shape women’s
reactions and responses.
It would be useful to know the rate of cervical cancer incidence, and the % of women
participating in cervical cancer screening, in Iran. Is there a national screening programme –
co-testing is available but not covered by (government?) insurance, so do most women have
screening but pay for it by private insurance?Also as valuable context, what proportion of women
with a positive test for a hrHPV go on to be diagnosed with pre-invasive or invasive cervical
disease in Iran. Has an HPV vaccination programme been introduced?
The religious, social, and cultural norms that shape women’s lives in modern Iran should be
briefly elaborated on for an international journal – otherwise it is too easy for international
readers to make assumptions.
- lines 3-8 – ‘Testing positive for hrHPV does not necessarily mean women are not infected
with low-risk HPV strains too. This point must be taken into account that a number of the
women detected in the screening are infected with both genotypes which must not be overlooked.
Women with genital warts (GWs) often excluded from the previous studies while these women
may have different psychological responses since their partners or themselves may deal with
GWs, too’ not sure what these sentences add to the argument as they are not critical to the later
development to the paper
Methods
A bit more detail is needed. Does the hospital clinic see women from a diverse backgrounds?
Or women with private insurance?
“Women in this context were provided HPV-related information, neither with leaflets nor with
the integrated HPV education program.” – I think ‘neither’ and ‘nor’ should be ‘either’ and ‘or’
here, completely changing the meaning of the sentence. It needs to be clearer when women were
provided with this information – by post at the time of their referral, or only when they reached
the clinic?
- page 4, line 27 ‘Between interviews usually lasted about a week to 10 days.’ Not sure of the
value of this sentence.
- page 4 ‘Data saturation was achieved over fifteen months, from September 2018 to December
2019’  - should reflect in the Discussion if any difference in responses from women in earlier
interviews compared to later interviews – perhaps there wasn’t’ but this is a fairly long time, so
need to be sure there wasn’t different information materials provided, or coverage in the media
etc that might have shaped women’s attitudes
- page 4 ‘Some interviews were conducted in two sessions’ – why? What difference might this
have made to the information provided by the woman compared to the interviews in one session?
Qualitative analysis is robust and well-described.
Results
These are important results, clearly demonstrating that receipt of a positive HPV test result is the
cause of considerable emotional and psychological distress to women, with responses situated
within their own individual relationship status, and wider cultural stigma.
- page 6, line 25 – why the word ‘Unexpectedly’? – the internet is one of the main sources of
health information for people in many countries  - if this not the case in Iran?
- page 7, line 24 ‘indulging’ not an appropriate word, better ‘women reporting participation in
oro-genital practices’
- page 9, the choice of quote on lines 6& 7 seems to contradict the sentence above. Maybe a
sentence is missing.
- page 11, line 22 – ‘HPV has the potential to improve health outcomes’ this is awkward
wording, needs a modifier such as ‘despite a positive HPV result being distressing news for
many women,  the HPV test result also has the potential to improve health outcomes’ Authors
should consider elaborating on this issue in the Discussion, e.g. through discussing the concept
of the ‘teachable moment’ in the Iranian context (Senore C, Giordano L, Bellisario C, Di Stefano
F, Segnan N. Population based cancer screening programmes as a teachable moment for primary
prevention interventions. A review of the literature. Front Oncol. 2012;2:45. Published 2012
May 8. doi:10.3389/fonc.2012.00045).
Discussion
The authors should consider the need for review of the information materials provided to women
– these need to be factual, but to what extent is wording drawing on US or CDC wording (where
social, cultural and religious norms are different) rather than wording that is still factual but
situated in the lived experience of women in Iran? these may be contributing to the distress, and
review is also an opportunity to address the core concerns identified in this study
The authors might also consider adding to the Discussion a comment on the place of health
literacy and especially education about women’s reproductive health in Iranian education and
health contexts.