PONE-D-20-25493

Understanding no-show behaviour for cervical cancer screening appointments among low-income women in Bogotá, Colombia: a mixed-methods approach

PLOS ONE

Dear Dr. Barrera Ferro,

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PLOS ONE

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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: Partly

Reviewer #2: Yes

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

Reviewer #1: No

Reviewer #2: I Don't Know

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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: No

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: Thank you for the opportunity review this article. It is important and its findings merit publication. This reviewer has a few concerns regarding the following broad areas: (1) there are few details regarding the screening program eligibility criteria and these details are needed for interpretation of your results; (2) the prediction model is interesting, however, given the limited variables used as inputs – the paper should de-emphasize the results of the model and underscore its use as way to identify women for the qualitative interviews; (3) authors should focus more on the qualitative results and improve the interpretability of Figure 4 – currently, this reviewer does not understand its utility; and (4) the literature review is useful, however, please expand to include PubMed as I believe the authors are missing quite a few relevant pubs.

Specific comments:

• The introduction includes the necessary points and rationale for conducting the study. However, it could be better organized. Please ensure that the final paragraph of the introduction outlines the objectives of the study. Lines 68-87 could be moved to the discussion.

• Methods

o Lines 110-111: Details regarding the program would be useful here such as: eligibility criteria for women, what areas of Colombia are included in this program (i.e. was it just Bogota or other cities in Colombia as well), how many women were eligible based on census data, what percentage of women were contacted for appointments, how were the woman contacted (door to door or via telephone, or both)? Regarding eligibility criteria for women – can the authors also comment on how they define low-income per the programs description?

o Line 110: of the 23,384 appointments scheduled, were these all unique patient appointments or might have there been repeats? If there are repeats, is it possible to get the number of unique appointments?

o Lines 128 – 131: Can you provide the number of women that fell into each category of the eligibility criteria so the reader can get a sense of each criterion?

o Table 2: In Line 131, the text mentions 75 participants were included. However, Table 2 mentions 60 interviews. Please clarify this discrepancy.

o Table 3: Please provide a footnote that defines “Inductive category” clearly. From the text, I believe it means an emerging theme or an understudies topic.

o Line 153: I am concerned that the SCOPUS database only retrieved 394 records when the authors searched cervical cancer screening and uptake. I did the same search in PubMed and found over 1500 results. Can the authors include PubMed given the comprehensive nature of this database? I find it difficult to believe that there were no papers that identified “cancer diagnosis” or “health” as a potential benefit of cancer screening.

o Table 2: Can the authors describe what “conditions” means under protective behavior?

o Line 165 – typo

• Results

o Lines 208-213: A comment here regarding the validity of the model is needed. The patient specific inputs are very few. More data regarding other factors such as marital status, number of children, employment status, educational level etc. are needed for this prediction model to be useful.

o Table 4: Is it possible to create more categories of Poverty? Why did the authors decide to create only a binary variable? It would be important to show that high poverty areas were less likely to attend.

o Line 215: What is “RF”?

o Figure 3 is not useful. I am not sure how to interpret it given how unreliable the model is. I would suggest the authors remove this and delete text 214 – 223.

o Figure 4 is very blurry. Can the authors provide some footnotes on Figure 4 to explain why it is arranged the way it is? Do the boxes mean something? Is there a reason some boxes are shaped differently than others? The figure is not self explanatory and should be able to stand alone.

• Discussion

o Line 271; Summary of overall main findings would be useful here.

o Line 329: Define SDS

Reviewer #2: Thank you for the opportunity to review this manuscript. This is a well written manuscript with an interesting research question and methodological approach. It is great to see mixed-methods approach being used in this setting. The authors have done a nice job in describing the methods and results. Non-compliance to cervical cancer screening is furthermore an important topic to address and understand, in order to design future policies to improve compliance rates.

Minor questions that may be adressed:

1) For the qualitative interviews, what questions were asked? How did you design the interview guide/questions?

2) In Table 3, could you add more description to the first order categories? These are interesting and may be useful to others; however, while some are self explanatory, others are not.

3) Results Table 4, could you elaborate what drives the differences between days and months?

4) The discussion section would benefit from a brief summary of main findings at the beginning, including a discussion of how the qualitative and quantitative methods complemented each other.

5) In the discussion of implications and future policies, could HPV self-sampling be an option? Home-based self-collection of samples is currently being rolled out worldwide as an approach to reach underscreened women. Is this relevant for this setting? What is the status of HPV testing?

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Reviewer #1: Yes: Jessica Islam

Reviewer #2: No

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PONE-D-20-25493R1Understanding no-show behaviour for cervical cancer screening appointments among hard-to-reach women in Bogotá, Colombia: a mixed-methods approachPLOS ONE

Dear Dr. Barrera Ferro,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Please submit your revised manuscript by May 23 2022 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

• A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
• A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
• An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols. Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols.

We look forward to receiving your revised manuscript.

Kind regards,

Joel Msafiri Francis, MD, MS, PhD

Academic Editor

PLOS ONE

Journal Requirements:

Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

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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 #3: All comments have been addressed

Reviewer #4: (No Response)

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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 #3: Yes

Reviewer #4: Yes

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

Reviewer #3: Yes

Reviewer #4: Yes

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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 #3: Yes

Reviewer #4: No

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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 #3: Yes

Reviewer #4: Yes

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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 #3: Thank you for the opportunity to review the revised version of this manuscript. The authors’ responses to the comments from previous reviewers were satisfatory.

This exploratory sequential mixed methods study was meticulously conducted. The quantitative component interestingly applied machine learning techniques, the qualitative component was properly conducted, whereas the systematic review was adequately performed using two major literature databases, all of which were presented in compliance with standard reporting guidelines.

Nonetheless, I strongly believe that the references could be more concise—at least by moving several of them in the systematic review component to be supplementary file.

Reviewer #4: The authors have done an excellent job of responding to reviewer comments and the revisions have resulted in a presentation of the results that is clearer to the reader. There are a few minor points that I think would improve the structure and flow of the paper.

Lines 97-118 have been added in response to Reviewer 1; these are quite lengthy and can be summarized to focus on the clinical guidelines and current situation that may impact the study question and outcomes.

The results section (Starting in line 229) would be stronger if the authors started with a more clear description of their findings, rather than an explanation of the model. Lines 229-232 can all be placed in the methods.

Throughout the methods, there are opportunities to more clearly present what the findings show. Have the authors considered rephrasing the findings so that the odds ratios represent a greater odds of attending appointments? Rather than the counterintuitive “higher odds ratio=lower no show.” The other option is to flip the outcome variable, so that no-show is the outcome of interest, and the odds ratios would be flipped (i.e. a greater odds ratio would mean a greater odds of no-show).

In addition, the authors state that some restrictions apply to the data, likely the qualitative data.

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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.

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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 #3: Yes: Assoc. Prof. Dr. Krit Pongpirul, MD, MPH, PhD.

Reviewer #4: No

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

Understanding no-show behaviour for cervical cancer screening appointments among hard-to-reach women in Bogotá, Colombia: a mixed-methods approach

PONE-D-20-25493R2

Dear Dr. Barrera Ferro,

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

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org.

If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

Kind regards,

Joel Msafiri Francis, MD, MS, PhD

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 #3: 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 #3: Yes

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

Reviewer #3: 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 #3: Yes

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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 #3: 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 #3: The responses are satisfactory. Thank you very much for revising the manuscript. I believe the current version is ready for publication.

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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 #3: Yes: Assoc. Prof. Dr. Krit Pongpirul, MD, MPH, PhD.

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