PONE-D-23-08979Health system factors affecting equitable access to quality cervical cancer services at public health centers in Addis Ababa, EthiopiaPLOS ONE

Dear Dr. Hussein,

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. Up on my own review and the reviewers comments I recommend Major Revision to this manuscript. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process. Please pay attention to editor and reviewers comments below.

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ACADEMIC EDITOR: Please pay attention to the following points in addition to feedback given by reviewers:

• There are major flaws in grammar and language throughout this paper. In the revised version, try to address this. Authors are highly recommended to get editions services of this manuscript with experts, to have a qualified scientific paper. 
• The abstract section of the paper  should clearly show the rationale for this paper, and how the proposed aim was answered. But, this issues are shallow and lacks clarity. The method section in the main body is not also clearer and doesn't help for replication. Therefore,  authors are suggested to revise this section and better if the methods is re-organized in the follows sections: study settings and period, Study design and participants, data collection,  study variables,  data quality control, data processing and analysis,  ethical consideration 
• In the topics and aim of the paper, key terms like equity, quality of cervical cancer services and the like are described.  However, authors didn't adequately define this terms in any section of the paper,  not described the measurement methods employed, and displayed the measured results.  Though two frameworks are employed in the current paper, how this framework employed to guide the measurements lacks clarity. Please provide explanations to this, and as well address this issues within the manuscript. 
• Make sure that the manuscript has addressed the journals requirements in terms of contents, particularly after the conclusions section of the paper. Refer the journal guideline and correct this part. 
• Change the citation formats to square brackets (e.g., [1]).
• Adequately discuss the present study findings with that of literature in other settings(out of Ethiopia). Discuss the strength and limitations of the study, focusing on the methods used, and have a separate section to discuss the policy and practice implications of the study. 

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Please submit your revised manuscript by Sep 17 2023 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.

We look forward to receiving your revised manuscript.

Kind regards,

Dawit Wolde Daka

Academic Editor

PLOS ONE

Journal Requirements:

When submitting your revision, we need you to address these additional requirements.

1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at

https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and

https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf

2. In your Data Availability statement, you have not specified where the minimal data set underlying the results described in your manuscript can be found. PLOS defines a study's minimal data set as the underlying data used to reach the conclusions drawn in the manuscript and any additional data required to replicate the reported study findings in their entirety. All PLOS journals require that the minimal data set be made fully available. For more information about our data policy, please see http://journals.plos.org/plosone/s/data-availability.

Upon re-submitting your revised manuscript, please upload your study’s minimal underlying data set as either Supporting Information files or to a stable, public repository and include the relevant URLs, DOIs, or accession numbers within your revised cover letter. For a list of acceptable repositories, please see http://journals.plos.org/plosone/s/data-availability#loc-recommended-repositories. Any potentially identifying patient information must be fully anonymized.

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We will update your Data Availability statement to reflect the information you provide in your cover letter.

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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: 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: Manuscript Number: PONE-D-23-08979

Manuscript Title: Health system factors affecting equitable access to quality cervical cancer services at public health centers in Addis Ababa, Ethiopia:

Dear Editor,

Thank you for inviting me to review the scientific quality of this article.

Dear Authors,

It is very interesting to get research done on this very interesting area of women's health.

However, I recommend you the following points be addressed before your article gets published

1. Either modify the title or re-do the analysis because there is no result to talk about the quality of service. Also, there is no strongly concluded point about equity to the service user.

2. The 150,000 new cases that Ethiopia reports is not clear. Line 46

3. Font Color of lines 56-59 is different: a light blue. Better to make it similar throughout the document. The sentence is direct copy and paste. Rephrase

4. I was expecting to read what “quality cervical cancer services” are mean in the introduction, particularly in Ethiopia. How did it become your concern? Any other previous evidence on the case and what is the gap?

Material and Method

1. The method needs rearrangement. For example, why data collection method under the session “Study design and period”?

2. Organization of Ethiopian health service delivery system line 93-95 needs reference.

3. It is described how the health facilities were sampled and selected. How about the service providers? Who were they? How were they selected? It should not be indicated under the session “Data collection procedure and data analysis”

4. The data collection procedure is not indicated well. Face-to-face interview? FGD? Checklist data extraction???

5. Avoid unnecessary repetitions. For example, the study period on lines 91 and 118.

6. The data analysis procedure lacks a detailed explanation. Is it not important to explain the used analysis method, and cutoff points,…the analysis is rough and do not fully support the study aims.

7. It is important to describe measurements in this study. For example,

o How the fulfillment of the input was measured? Was it the summation of all the available inputs or any of them? Was 100% input expected?

o What indicators were used to measure (effectiveness, availability, timeliness, and patient-centeredness): the Outputs?

o How was equity of cervical cancer services measured? When did you say there is equity in the services?

o What is quality service as per your study?

Result

1. What is the importance of writing in different colors again? Line 134-139

2. You have no data extraction method. How was the data for the information provided in Table 3 were obtained?

Discussion

1. Lines 192-194: “The study revealed that the prevailing health system challenges at the primary healthcare level had negatively impacted the quality of cervical cancer 194 services.” How can you say it affects the quality without showing the status of the quality of the service?

2. Ideas in lines 197-216 seem taken from literature; how does the idea on line 217 connect with it? Which findings are being compared?

3. Line 233-234, client report. Where did you get it? You have no client involvement or data extraction in the data collection method.

4. In general, I recommend doing the discussion ideally under sub-headings of input, output, and equity in access to cervical cancer screening. It is a copy of the result. Make it short and discuss using guidelines on recommended minimum importance.

Conclusions

Lines 312-313: do you have data on the poor engagement of school and drop-out girls?

Similarly, in lines 316-317; do you have information on “HPV DNA and Pap smear testing attract more women for screening”?

� the conclusion should be done depending only on the data that can be accessed in this manuscript. It seems discussion.

Reviewer #2: General Comments: Thank you for the updated manuscript. Any study on equitable access to quality cervical cancer services in LMIC countries is important as efforts are made to control/eliminate CC globally from the perspective of health system factors. The manuscript has paramount but needs modification to make it publishable.

I have pointed some out below but get this fixed throughout the manuscript.

Specific comments

Abstract

Lines 19-20: be consistent in the use of terms (women vs girls) use either of the two throughout your documents, again in the use of health center and health facilities

Introduction

1. Line 39: add references at the end of the paragraph.

2. Line 56-59: be alert while taking documents from other sources and I will recommend you to re-write again.

Methods

3. Lines 92 – 101: what is your study population: healthcare providers or health centers??

4. A proportionate number of 51 facilities were randomly selected using Microsoft Excel out of a total of 90 public health centers actively providing cervical cancer services. How do you select healthcare providers from each health center? Do you think equal numbers of healthcare providers were in each HC?

5. Line 113-114: you said cervical cancer service providers in facilities (11 nurses, 10 midwives, 4 health officers, and 26 cervical cancer focal persons) were approached

What is your justification to select nurses, midwifery, and health officers? Why not used cervical cancer focal persons throughout all health facilities

6. Line 114: add health be for the word facilities, again be consistent in the use of health centers and facilities( I recommend using health facilities throughout your documents)

7. You need to provide more details on the study recruitment process and data collection.

o How exactly were the healthcare providers recruited from 51 health centers?

o How do you select 51 health centers from 11 sub-cities? Clearly shown in sampling procedures

o Where was the data collected, and for how long? Etc. etc.

o Since these healthcare providers were not interviewed in the local language even if they were understanding English? What measures were in place to ensure that the translation process, did not affect the content of what was said?

o Lines 120: change ethical consideration to Ethics approval and consent to participate. I recommend you strictly follow journal guidelines

o Lines 125-126: All methods were performed in accordance with the relevant guidelines and regulations (Declaration of Helsinki). Do the PLoS One guidelines follow such terms?

o On line 174: table 3: I think you have used document review for data retrieval, my concern is what are your data collection methods( state clearly)

Results

General comments

If the socio-demographic variables were in your tools, better to add the description of socio-demographic characteristics of health care providers ( age, sex, profession, etc)

8. Lines 130-131: your description were 20, 17, and 13 health facilities. The total was 50 versus 51 health facilities.

9. Lines 131-132: Rephrase the sentence at lines 131 and 132 to make correct meaning

The recommendation is to minimize use respectively when your list of activities were more than three. In 40 (78.4%), 38 (74.5%), 18 132 (35.3%), and 25 (49%) facilities had nurses, midwives, health officers, and health extension 133 workers (HEWs) who received cervical cancer training, respectively

You can write as 40 (78.4%) nurses, 38 (74.5%) midwives, 18 (35.3%) health officers, and 25 (49%) health extension workers (HEWs) received cervical cancer training

10. Line: 142: table 1: revised all tables based on journal guidelines formats

11. Lines 161-165: this whole text descriptions were not in line with the tables and need to be corrected

12. Lines 170: How do you measure the effectiveness of services? needs operational definition in the methods part

Discussion and conclusions

Detail and clear description of each section

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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: No

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[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.

PONE-D-23-08979R1Health system factors affecting access to cervical cancer prevention, screening, and treatment services at public health centers in Addis Ababa, Ethiopia.PLOS ONE

Dear Dr. Hussein,

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 Dec 30 2023 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.

We look forward to receiving your revised manuscript.

Kind regards,

Dawit Wolde Daka

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.

[Note: HTML markup is below. Please do not edit.]

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

Reviewer #3: (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 #2: Yes

Reviewer #3: Yes

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

Reviewer #2: Yes

Reviewer #3: 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 #2: Yes

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 #2: Yes

Reviewer #3: No

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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: All my concerns were clearly stated and responded. Still your conclusion was so long and seems result , try to revised it.

Reviewer #3: (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

Reviewer #3: No

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[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.

Attachments

Attachment

Submitted filename: The manuscript overall would benefit from some significant editing services.docx

Assessing the influence of the health system on access to cervical cancer prevention, screening, and treatment services at public health centers in Addis Ababa, Ethiopia.

PONE-D-23-08979R2

Dear Dr. Hussein,

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,

Dawit Wolde Daka

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: Partly

**********

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

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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: No

**********

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: The author will be alert during revision. Some part of the manuscript were totally changed and finally come to unclear concepts.

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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

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