PONE-D-22-18410Facilitators and barriers to colorectal cancer screening in Malaysia: a qualitative studyPLOS ONE

Dear Dr. Su,

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Additional Editor Comments:

Well conducted qualitative study. Will need to address comments by reviewers

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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: Partly

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

Reviewer #1: No

Reviewer #2: N/A

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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?

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Reviewer #1: No

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: This paper presents facilitators and barriers to colorectal cancer screening in Malaysia. I greatly appreciate the time and efforts the authors put into it. However, several major issues should be addressed before it is published:

1. The study title is slightly misleading, as the exploration of barriers and facilitators is limited to stool-based screening test (iFOBT), which is recommended only for average-risk individuals in Malaysia. High-risk individuals, such as those with a family history of cancer, are not covered in this study.

2. The abstract, particularly the result section, is hard to follow, as all the factors are jumbled up. A clear key message is absent.

3. The description of the CRC program in Malaysia is inappropriate and likely to be incomprehensible for the readers who are not familiar with it - What do you mean by “no compulsory registration” and “identifying people and inviting them”?

4. The study objective is not specific and confusing. Terms like “enables” and “benefits” could carry the same meaning.

5. While this is supposed to be a qualitative study, it is described as a survey under the methodology.

6. The authors claim that the discussion guide was designed based on the relevant literature, but only one reference is cited. This raises a concern if a thorough literature review was performed. Was any framework adopted for the thematic analysis?

7. Why must the authors emphasize “a female researcher”? Were there any gender-sensitive issues in the FGD? If so, it is questionable that how appropriate it was to conduct an FGD mixing male and female participants.

8. It is hard to visualize how participants speaking different languages could be gathered with the assistance of translators for an FGD, which is meant to be interactive.

9. How could identifiable information be technically removed from audio recordings? Why was this necessary?

10. Were the transcripts returned to FGD participants for validation?

11. How did the authors confirm data saturation?

12. It is inappropriate to conclude that “certain groups tended to ….”, as no quantitative analysis was performed.

13. Each point under a theme should be supported only by one quote to avoid redundancy.

14. The points under each theme seemed to be disjointed.

15. Some of the themes did not even have a direct relationship with CRC screening.

16. The references cited in the discussion are not directly related to the findings in most cases.

17. Grammatical errors are present throughout the paper. An edit for succinctness and brevity is also required.

Reviewer #2: Thank you for inviting me to review this manuscript.

The authors have reported on a topic which is highly relevant and important for bowel cancer control. This qualitative study has uncovered several critical issues that may require further attention in order to encourage uptake of bowel screening amongst the Malaysian population in the future.

There are several areas in the manuscript which require further clarification:

1. Sampling

- Purposive sampling was conducted for this study and this was aided by a community organization called SEACO. Some inclusion criteria were mentioned but were there exclusion criteria – would prior personal experience of bowel screening affect recruitment into the study. What measures were taken to minimise sampling bias?

- The cohort of individuals recruited into the study are primarily from a rural community and where most of the interviewees’ educational level are up to secondary education. I feel the word rural community needed to be included in the title as these findings may not be truly representative of Malaysia as a whole nation. This should be mentioned in the limitation’s chapter.

2. Methodology

- During the FGD, were attempts made to reduce bias from dominance effect, halo effect and group thinking?

- The data analysis was described in phases but could do with further elaboration. The authors used an iterative approach but what method was used to move from codes to themes (e.g. inductive? Deductive analysis?).

- There was no mention of attempts made to determine whether data saturation was achieved?

3. Results

- The results section was mainly descriptive and significant sections lacked in-depth analysis. For example lines 208 -228: Cancer awareness theme, section of Barriers to CRC screening. Statements were made to summarise the included quotes but there was limited analysis of how these subthemes may relate and influence decisions to screening. The theme on Barriers to CRC screening is also rather short – particularly on stool collection - this is probably one of the most important subthemes that has been uncovered and warrants further elaboration and specifics.

- There were statements which did not fully reflect the included quotes e.g. line 247. The statement about participants’ perception of self susceptibility to CRC is not supported by the included transcript.

- Under Theme 5 – suggested strategies to improve iFOBT uptake or completion, are the authors implying that certain strategies are more likely to be suited for specific ethnic groups as several statements have attempted to draw associations with certain ethnic groups?

4. Conclusion

Line 39 – ‘Another barrier that people faced was financial constraints’.

Whilst I can see what the authors are alluding to, the data could also be interpretated as bowel screening is affordable to everyone through the public health system in Malaysia, but this is limited by capacity – long waiting times etc. An alternative would be to seek private health care screening facilities, but this would incur costs to the patient and would thus limit access to those who cannot afford it. I would therefore recommend clarifying the first sentence to this paragraph.

5. Others

- Is there a typo on Line 106 – 3rd section mentioned but 2nd section was not mentioned

- Typo on Line 180? – ‘stated that they would not ask for other preventative health screenning’ – is this true given the subtheme here is about participants reporting that they would actively ask their doctor about cancer screening

- Line 358 – missing or incomplete sentence

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Reviewer #1: No

Reviewer #2: No

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Attachments

Attachment

Submitted filename: PLOS Qualitative barriers to bowel screening.docx

Facilitators and barriers to colorectal cancer screening using the immunochemical faecal occult blood test among an average-risk population in semi-rural Malaysia: a qualitative study

PONE-D-22-18410R1

Dear Dr. Su,

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.

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Kind regards,

Sanjiv Mahadeva, MRCP, MD

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

The revised manuscript is much improved. This paper is of importance within this area of research

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

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

Reviewer #2: N/A

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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 #2: 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 #2: 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 #2: My comments from the previous review have been adequately addressed in this latest draft. Recommend acceptance of the manuscript.

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

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Reviewer #2: No

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