Title: “Day or night, no matter what, I will go”: Women’s perspectives on challenges associated
with receiving follow-up after abnormal cervical cancer screening results in Iquitos, Peru: a
qualitative study
Version: 1 Date: 06 Mar 2023
Reviewer:  Diego Rios-Zertuche
Reviewer's report:
The manuscript presents a qualitative study conducted in Iquitos, Peru, with the aim of
identifying reasons why women with positive cervical cancer screening results are lost to follow-
up. This is a fantastic manuscript! The study's importance lies in its identification of not only
barriers to accessing follow-up care but also critical organizational and operational issues that
impede access to quality care. The manuscript is well-written and easily understood, but there
are a couple areas where improvements can be made to increase its effectiveness.
Below are specific comments:
Methodology:
The authors have included most of the data required by the Consolidated criteria for reporting
qualitative research (COREQ) [1]. However, some additional information could be included,
such as explicitly describing the sampling approach as purposive (the sampling approach is
already clearly described) and detailing the criteria for data saturation. These clarifications
would enhance the manuscript's transparency and make it easier for readers to assess the validity
of the study.
Results:
In line with COREQ recommendations [1], the results section could benefit from a table
summarizing the major and minor themes identified. This addition would aid in quick reference
for readers and facilitate the identification of the study's key findings.
Discussion:
Although the findings are nicely framed in respect to previous studies, I believe it is currently
lacking recommendations about potential pathways to address the issues identified. I suggest the
authors to discuss potential solutions, some of which could include, for example: implementing
continuous quality improvement initiatives in the healthcare network [2]; optimizing processes
of care to ensure all steps are explicit and followed in each facility [3]; measuring quality of
care to monitor performance [4], and establishing stronger referral and counter-referral systems
[5]. Furthermore, the findings may also prompt a wider discussion of how cancer screening is
prioritized by the national and regional health authorities in a context of gender equity [6].
Minor comments:
1. In Figures 1 and 2, include a box to clarify where the process starts.
2. Although "obstetras" may be the local way of referring to nurses and nurse-midwives in the
study location, in other parts of Latin America, this term is also used to refer to Obstetricians
(Medical Doctors). To avoid confusion, I suggest using a different term.
3. For authors consideration, the overuse of abbreviations can make the text harder to understand.
For example, it would be clearer to use "health network" or "micro-network" instead of "MRIS".
Similarly, it may be helpful to spell out "LTFU" in some instances to ensure clarity for readers.
References:
1.  Tong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research
(COREQ): a 32-item checklist for interviews and focus groups. International Journal for Quality
in Health Care. 2007;19: 349–357. doi:10.1093/intqhc/mzm042
2.  Leatherman S, Ferris TG, Berwick D, Omaswa F, Crisp N. The role of quality improvement
in strengthening health systems in developing countries. International Journal for Quality in
Health Care. 2010;22: 237–243. doi:10.1093/intqhc/mzq028
3.  Wiler JL, Bookman K, Birznieks DB, Leeret R, Koehler A, Planck S, et al. Rapid Process
Optimization: A Novel Process Improvement Methodology to Innovate Health Care Delivery.
Am J Med Qual. 2017;32: 172–177. doi:10.1177/1062860616637683
4.  Rios-Zertuche D, Zúñiga-Brenes P, Palmisano E, Hernández B, Schaefer A, Johanns CK, et
al. Methods to measure quality of care and quality indicators through health facility surveys in
low- and middle-income countries. International Journal for Quality in Health Care. 2018 [cited
21 Jun 2018]. doi:10.1093/intqhc/mzy136
5.  Kapoor R, Avendaño L, Sandoval MA, Cruz AT, Sampayo EM, Soto MA, et al. Initiating a
Standardized Regional Referral and Counter-Referral System in Guatemala: A Mixed-Methods
Study. Global Pediatric Health. 2017;4: 2333794X1771920. doi:10.1177/2333794X17719205
6.  Gupta GR, Oomman N, Grown C, Conn K, Hawkes S, Shawar YR, et al. Gender equality
and gender norms: framing the opportunities for health. The Lancet. 2019;393: 2550–2562.
doi:10.1016/S0140-6736(19)30651-8