PONE-D-20-01502

Role of gender in perspectives of discrimination, stigma, and attitudes relative to cervical cancer in rural Sénégal

PLOS ONE

Dear Dr Sykens,

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1. Please include additional information regarding the survey or questionnaire used in the study and ensure that you have provided sufficient details that others could replicate the analyses. For instance, if you developed a questionnaire as part of this study and it is not under a copyright more restrictive than CC-BY, please include a copy, in both the original language and English, as Supporting Information.

2. We note that your report two different date ranges for the present study (either Oct 2018-Jan 2019 or Dec 2018-Feb 2019). Please include in your Methods section the exact date ranges over which you recruited participants to this study.

3. We note you have included a table to which you do not refer in the text of your manuscript. Please ensure that you refer to Table 6 in your text; if accepted, production will need this reference to link the reader to the Table.

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Yes

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2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

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3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

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4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

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5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Abstract

With some copy-editing and focus on the key points, the abstract can be considerably shortened. An example is the sentence: “Furthermore, men are more likely than women to say that they have the final say at home….while women are more likely than men to state that their spouse has the final say..” This can be reworked into something more straightforward, such as “Men and women were both more likely to state that men have the final decision around the home..”

Introduction

Second sentence: what does fatal mean in this case? Usually, cancer statistics are given in terms of 5 or 10 year survival or fatality.

Can you provide the reader with more of a sense of screening availability In Senegal? Although gendered attitudes likely do play a big role, if screening is not available or accessible, that will likely play the biggest role in limiting coverage.

Methods

How was your sampling plan and methodology determined? Did you calculate a sample size? Given the small number of women screening, would you have enough of a sample size to determine differences associated with screening?

Results

First paragraph: In the sentence about married, what does “51.5% of participants were in a polygamous household as related to significant gender differences in marital status” mean?

Much of the data presented in tables is repeated in the text. It would make the paper more readable and allow the authors to highlight the key findings if they referred readers to the table, rather than repeating all of the information in both places.

In the “Education Effect on Gender Perceptions”, third sentence, can you clarify what you mean by “we identified statistically significant findings for a woman’s role as caretaker (p<0.001), etc.

Much of the subsequent paragraph in this section is a list of significant findings—I think these should all go into a table with a summary or highlight of important points in the text.

Discussion

Generally, the discussion should start with a summary paragraph of the main findings of your study, followed by a deeper dive into how specific results fit into the overall scientific field, and why they may or may not support existing evidence. This discussion section starts with a repeat of the specific findings, which lacks a summative component. I think the paper would be strengthened with a section that brings together the main findings with some synthesis.

Reviewer #2: Overall comments:

- The subject matter of this paper is very timely and a necessary contribution to the literature on cervical cancer prevention in LMICs.

- The paper was very well written and organized with relevant and up-to-date citations.

INTRODUCTION:

1) There is one sentence at the end of the first paragraph that could use some tweaking for clarity:

"Cervical cancer is an important indicator of larger health system problems, including poor access and the lack of culturally competent communication..."

I understand the point the authors are trying to make here but the way it reads could potentially be misconstrued to those that are not as well versed in the literature. Perhaps including words like "The high incidence and mortality of cervical cancer is an important indicator...

Additionally, it would be helpful to add poor access "to care and screening" to identify the specific access issues in the context of cervical cancer disparities.

METHODS:

1) Do the authors have the numbers for the response rate? It would be good for other researchers attempting this sampling strategy to be aware of the realities of obtaining survey responses through this approach and ways to improved if necessary.

2) Data analysis - did the authors give any thought to looking at regional differences (i.e. urban vs rural) or other breakdowns of the regions with gender differences and cancer attitudes? Sometimes attitudes may vary by urban and rural communities particularly when access to screening is more accessible in urban areas.

RESULTS:

1) The sample size is small for recruitment in 9 different districts. Is there a breakdown of respondents by area or do we assume that the language stratification implies area differences? Some clarification here would be helpful.

DISCUSSION:

1) Screening behavior - the 2nd paragraph of this section gives some discussion on the percentage of women that believe cancer was personal fault and the authors suggest that there may be some issues with how the question was interpreted. Was the question field tested prior to the start of the study? Could it be that the cancer stigma questions did not specify a specific cancer and therefore were answered in the context of cervical cancer only?

2) Last sentence, " ..."prevent cervical cancer through EARLY screening..." perhaps it would be more straightforward to omit the word "early" since ongoing screening is necessary throughout a woman's lifetime.

3) It is not clear what the authors mean by ensuring that attitudes and beliefs are prioritized. In other words, what is the situation in which attitudes and beliefs (positive or negative) are prioritized for cervical cancer screening?

4) It is also important to include and address cancer stigma, especially for cervical cancer and HPV.

5) I did not see where discussion of the findings from this study were linked back to existing literature to draw similarities or differences with other similar works.

CONCLUSION:

1) Sound conclusions and thoughtful approaches for next steps.

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Reviewer #1: No

Reviewer #2: No

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Role of gender in perspectives of discrimination, stigma, and attitudes relative to cervical cancer in rural Sénégal

PONE-D-20-01502R1

Dear Dr. Dykens,

We are pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it complies with all outstanding technical requirements.

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With kind regards,

Mellissa H Withers, PhD, MHS

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #2: All comments have been addressed

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2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #2: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #2: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #2: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #2: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #2: (No Response)

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7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #2: No