Involving men in cervical cancer prevention; a qualitative enquiry into male perspectives on screening and HPV vaccination in Mid-Western Uganda

Marlieke de Fouw; Yaël Stroeken; Ben Niwagaba; Mwalimu Musheshe; John Tusiime; Isingoma Sadayo; Ria Reis; Alexander Arnold Willem Peters; Jogchum Jan Beltman

doi:10.1371/journal.pone.0280052

Peer Review History

Original SubmissionJanuary 4, 2022
9 Mar 2022 Decision Letter - Anne F. Rositch, Editor PONE-D-22-00308Involving men in cervical cancer prevention; a qualitative enquiry into male perspectives on screening and HPV vaccination in Mid-Western UgandaPLOS ONE Dear Dr. de Fouw, 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 Apr 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. 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If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice. [Note: HTML markup is below. Please do not edit.] 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: Partly ******** 2. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: N/A Reviewer #2: N/A ****** 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 ****** 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 ****** 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 is important work addressing a critical barrier to women's engagement in cervical cancer screening in Uganda and I'm thrilled to see this work is happening. I would suggest condensing Figure 1 and its current format is more of a distraction than beneficial to the background of the paper. In the results section the quotes chosen for specific themes did not always seem intuitive and sometimes even detracted from what was being emphasized, perhaps the theme itself was a bit of a stretch or a different quotation could be used to ensure a more coherent message. Finally there has been other work in Uganda looking at men's attitudes to screening including the ASPIRE group (Understanding Men’s Perceptions of Human Papillomavirus and Cervical Cancer Screening in Kampala, Uganda, Moses et al 2018) which would be a good reference to add. Reviewer #2: The study presents relevant insights on the need to engage the male gender in improving health literacy and potentially practice of cancer prevention strategies for cervical cancer. Their key role within the household is often overlooked and this presents a unique opportunity to improve knowledge, communication and uptake of screening and vaccination while also demystifying cervical cancer and reduce stigma. The other strong component of this paper are the opportunities for intervention from the documented false perceptions identified within the communities. I have a few questions listed thus: As documented in the limitation - "We are aware that socially desired answers cannot be ruled out and that they can mask taboos. The large acceptance of screening after the FGD might not be reflected by screening of their wives in practice" - Was there any suggestion from the FGDs that could mitigate against this threat? This would provide further opportunities that can be exploited to improve practice of screening. I'm concerned that the method of participant selection may have contributed to the suspicion of "socially desired answers" and this may not allow for further interrogation on the possible barriers to increasing uptake. Overall, I think the study contributes to the body of knowledge by showcasing the need to study the local setting, identify key stakeholders and adapt interventions. It also describes relevant local challenges and opportunities for improving cancer detection and is reproducible, but may require more stringent methods of stakeholder engagement to avoid bias. ****** 6. 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 #1: No Reviewer #2: Yes:** Nwamaka Lasebikan [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. https://doi.org/10.1371/journal.pone.0280052.r001
Revision 1
30 Aug 2022 Author Response Reviewer 1 I would suggest condensing Figure 1 and its current format is more of a distraction than beneficial to the background of the paper. Thank you for your suggestion to make the table more informative. We have removed the last column of the table (number of participants with a relative with cervical cancer) and the median in the column with number of daughters per relatives. We also combined two categories of educational level (secondary and higher education) in a percentage as this is most relevant. Reviewer 1 In the results section the quotes chosen for specific themes did not always seem intuitive and sometimes even detracted from what was being emphasized, perhaps the theme itself was a bit of a stretch or a different quotation could be used to ensure a more coherent message Thank you for your comment about the quotations we selected. We have reviewed all quotations with the team of authors following your review and discussed about their relevance for each theme, it is one of the challenges in qualitative research. We decided to delete some quotes which could distract the reader and which was already sufficiently reflected in the text. For some themes the topics mentioned were indeed surprising. On the other hand, we used the themes in our FGD guide to structure the discussion but followed the topics and discussion the men raised during the FGD. Therefore the topics and quotes might sometimes not feel entirely coherent. Furthermore, the English grammar of some quotes is not entirely correct but we decided to keep the quotes as close to the original version as possible. We feel that the current quotes do reflect the perspective of men as expressed during the different FGDs. Reviewer 1 Finally there has been other work in Uganda looking at men's attitudes to screening including the ASPIRE group (Understanding Men’s Perceptions of Human Papillomavirus and Cervical Cancer Screening in Kampala, Uganda, Moses et al 2018) which would be a good reference to add. Thank you for this literature suggestion, this manuscript is included as reference number 25. Reviewer 2 As documented in the limitation - "We are aware that socially desired answers cannot be ruled out and that they can mask taboos. The large acceptance of screening after the FGD might not be reflected by screening of their wives in practice" - Was there any suggestion from the FGDs that could mitigate against this threat? This would provide further opportunities that can be exploited to improve practice of screening. I'm concerned that the method of participant selection may have contributed to the suspicion of "socially desired answers" and this may not allow for further interrogation on the possible barriers to increasing uptake. Thank you for your remark and suggestions for future research in this field. During the FGDs we noticed active engagement of all participants with good interaction between the participants themselves and the participants and the moderators. After the FGDs men indicated that they felt relieved they could talk about the subject and that we were seriously interested in their perspective. From our experience in the screening project in Kagadi we found that many men would want their wives to be screened and stay healthy, but lack of knowledge about cervical cancer and the impact of screening, and poor access to screening are important barriers for their support. We purposely selected different age groups because in this context younger men will not feel comfortable to speak freely out of respect for elders. In addition, we had a separate FGD with influential men in the community. In future research we would consider approaching husbands of women that did not participate in screening, where this has been actively offered to all women in the community, for in-depth interviews. Another alternative could be to ask women coming for screening if they felt supported by their men, and approach their men for in-depth interviews (from both women who felt supported and who felt not supported), however, this will be difficult in practice to obtain consent and to get in contact with them. In order to gain more insight, we hope our research shows that men like to be involved and therefore we advise to include men from the beginning in cervical cancer awareness and programming of prevention, and involve them actively in community engagement. This will also help to better understand their perspective and possible barriers and opportunities. Attachments Attachment Submitted filename: Rebuttal letter PONE-D-22-00308.docx https://doi.org/10.1371/journal.pone.0280052.r002
10 Oct 2022 Decision Letter - Anne F. Rositch, Editor PONE-D-22-00308R1Involving men in cervical cancer prevention; a qualitative enquiry into male perspectives on screening and HPV vaccination in Mid-Western UgandaPLOS ONE Dear Dr. de Fouw, 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 Nov 24 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 you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter. 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, Anne F. Rositch, PhD, MSPH 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. Additional Editor Comments (if provided): While the authors addressed the original reviewer comments in the response document, not all translated to revisions of the manuscript itself. Specifically, I would like to see the manuscript edited to reflect the question/discussion on the final reviewer item, especially since the information provided by the authors with regards to age-based selection and additional FGD's with influential participants isn't outlined/consistent with methods. Reviewer 2 As documented in the limitation - "We are aware that socially desired answers cannot be ruled out and that they can mask taboos. The large acceptance of screening after the FGD might not be reflected by screening of their wives in practice" - Was there any suggestion from the FGDs that could mitigate against this threat? This would provide further opportunities that can be exploited to improve practice of screening. I'm concerned that the method of participant selection may have contributed to the suspicion of "socially desired answers" and this may not allow for further interrogation on the possible barriers to increasing uptake. Thank you for your remark and suggestions for future research in this field. During the FGDs we noticed active engagement of all participants with good interaction between the participants themselves and the participants and the moderators. After the FGDs men indicated that they felt relieved they could talk about the subject and that we were seriously interested in their perspective. From our experience in the screening project in Kagadi we found that many men would want their wives to be screened and stay healthy, but lack of knowledge about cervical cancer and the impact of screening, and poor access to screening are important barriers for their support. We purposely selected different age groups because in this context younger men will not feel comfortable to speak freely out of respect for elders. In addition, we had a separate FGD with influential men in the community. In future research we would consider approaching husbands of women that did not participate in screening, where this has been actively offered to all women in the community, for in-depth interviews. Another alternative could be to ask women coming for screening if they felt supported by their men, and approach their men for in-depth interviews (from both women who felt supported and who felt not supported), however, this will be difficult in practice to obtain consent and to get in contact with them. In order to gain more insight, we hope our research shows that men like to be involved and therefore we advise to include men from the beginning in cervical cancer awareness and programming of prevention, and involve them actively in community engagement. This will also help to better understand their perspective and possible barriers and opportunities. [Note: HTML markup is below. Please do not edit.] Reviewers' comments: [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. https://doi.org/10.1371/journal.pone.0280052.r003
Revision 2
24 Nov 2022 Author Response We reviewed our reference list and updated the references and their lay-out with track changes in our revised manuscript according to the PLOS ONE guidelines. We did not identify incorrect or retracted references. In addition to our previous rebuttal letter, we would like to clarify our revisions: 1. The first reference of Gakidou et al, was replaced by Bruni et al, because this is the most recent publication about the coverage of cervical cancer screening in LMICs and this paper was not yet available at the time of our initial submission. 2. For reference 8 we included the updated link, to access the National Strategic Plan of Uganda. 3. The other revisions are the adjustment of the presentation of the journal titles to the uniform Vancouver system. Thank you for your suggestion to edit our manuscript to bring these considerations to the attention or the reader, and not only the reviewers. We have adjusted the relevant sections in methods, results, and discussion in track changes. Attachments Attachment Submitted filename: Rebuttal letter PONE-D-22-00308R1.docx https://doi.org/10.1371/journal.pone.0280052.r004
20 Dec 2022 Decision Letter - Anne F. Rositch, Editor Involving men in cervical cancer prevention; a qualitative enquiry into male perspectives on screening and HPV vaccination in Mid-Western Uganda PONE-D-22-00308R2 Dear Dr. de Fouw, 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, Anne F. Rositch, PhD, MSPH Academic Editor PLOS ONE Additional Editor Comments (optional): Reviewers' comments: https://doi.org/10.1371/journal.pone.0280052.r005
Formally Accepted
20 Jan 2023 Acceptance Letter - Anne F. Rositch, Editor PONE-D-22-00308R2 Involving men in cervical cancer prevention; a qualitative enquiry into male perspectives on screening and HPV vaccination in Mid-Western Uganda Dear Dr. de Fouw: I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department. If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. 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. If we can help with anything else, please email us at plosone@plos.org. Thank you for submitting your work to PLOS ONE and supporting open access. Kind regards, PLOS ONE Editorial Office Staff on behalf of Dr. Anne F. Rositch Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0280052.r006

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