Title: Developing a Culturally Tailored Short Message Service (SMS) intervention for
Improving the Uptake of Cervical Cancer Screening among Ghanaian Women in Urban
Communities
Version: 1 Date: 20 Jan 2022
Reviewer's report:
Thank you for the opportunity to review this manuscript. Cervical cancer is such a huge problem
in Africa and each and every attempt to improve screening uptake is so valuable. I enjoyed
reading the manuscript.
The introduction is well written and introduces cervical cancer as worldwide and Ghanaian
problem. What I find missing in the description of the policy, is whether the policy makes
provision for free screening or whether Ghanaian women have to pay out of pocket for these
services. Please add as, when describing the common barriers, financial restraints are mentioned
as worldwide problem and it is one of the major problems identified by the women.
On page 5 (starting at line 90) it is said that culturally tailored, evidence-based mobile health
(mHealth) based interventions should be developed – but what for is not mentioned. Please
clarify.
The design and methods are not clear. If I understand correctly, mixed methods were used to
enable the researchers to develop and pre-test mobile text messages. To collect the data, focus
groups and a survey were conducted. The results were used to develop “the questions” – but
what questions are referred to? Did the SMS intervention consist of questions? Then the study
setting is described – and the reader is lost as it seems as if only one part of the study – the
pretesting of the intervention is reported. However, the outcomes assessed by means of the pre-
test and the how it was assessed are not described. It seems as if the outcomes of the intervention
were opinions on the messages received and I am not sure how the data were collect.
This brings me back to the design and I wonder whether this was not a multimethod study and
not a mixed method study as there were 3 parts – qualitative, quantitative  that did not inform
each other and then an intervention design using a one group posttest approach as the messages
were send and opinions were assessed. afterwards.
I think stating clear objectives, before the addressing the design and participants, would assist
to clarify how the parts or phases of the study would be reported.
Qualitative data collection refers. Please mention the number of focus groups that were
conducted, the number of women that participated and when the data were collected. I assume
the participants were purposively selected? Did any inclusion criteria apply? The interview guide
is well described. Please check the sentence starting with Additional messages (line 136) – some
words missing.
Qualitative data management and analyses is clearly described.
The heading sampling approach refers. This heading does not describe the sampling approach
but talks about data collection. There is no mention of the sample size and how it was determined.
What sampling method was used? Convenience sampling? Any inclusion criteria?
A structured questionnaire was used as data collection instrument – but where did the
questionnaire come from? Was it self-developed based on literature and expert opinion or from
another study, adapted with permission?
The results of the focus group interviews and survey is clearly presented and very interesting.
The qualitative findings are presented in a rich manner and combined with the quantitative
results guided the messages. The lack of funds were highlighted and I wondered whether patients
pay out of pocket for screening (as previously mentioned) and cancer treatment. I think a short
paragraph in the introduction on what treatment is available to women with cervical cancer and
who pays for this would prevent the reader from asking these questions.
Expert Stakeholder Engagement and Development of Text Library refers. The stakeholders are
indeed experts. What I find sad is that women, who are the real experts in terms of what they
need and their life situations were not included. Maybe this could be included in the limitations?
This would recognise the women and prevent readers to think this is once again one of those
“from us (learned, experts) to them (not so smart)” programmes.
I found the frequency of the text messages very interesting and could have never foreseen the
outcomes. I also wondered how the information needs and the preferences in terms of the length
of the messages would be aligned.
Results from the pretesting refers. It seems as if the pretesting focused on opinions on the
messages received.  Is there a reason why women were not asked whether the messages would
motivate them (not women in general) to be screened?
In summary – interesting and well written in general. Pity about not including the real experts
when the messages were developed. However, I am sure you would consider this in future.