PONE-D-24-19264Exploring Breast Cancer Awareness and Screening Practices Amongst Gambian Women in the Gambia; Community-based- cross-sectional studyPLOS ONE

Dear Dr. Kinteh,

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 20 2024 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,

Denekew Bitew Belay, Ph.D

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 the online submission form, you indicated that [The data used to support the findings of this study are available from the Corresponding author upon reasonable request at: bakarykinteh461@gmail.com]. All PLOS journals now require all data underlying the findings described in their manuscript to be freely available to other researchers, either 1. In a public repository, 2. Within the manuscript itself, or 3. Uploaded as supplementary information. This policy applies to all data except where public deposition would breach compliance with the protocol approved by your research ethics board. If your data cannot be made publicly available for ethical or legal reasons (e.g., public availability would compromise patient privacy), please explain your reasons on resubmission and your exemption request will be escalated for approval.

3. Please amend either the title on the online submission form (via Edit Submission) or the title in the manuscript so that they are identical.

4. Please include a separate caption for each figure in your manuscript.

Additional Editor Comments (if provided):

The authors used the two different terms in the study "multivariate logistic regression” and "multivariable logistic regression “interchangeably. Please use the later term consistently.

The authors used "multivariable logistic regression” and use this term throughout. The overall writings should be revised.

[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: Partly

Reviewer #2: Yes

Reviewer #3: Yes

Reviewer #4: Partly

**********

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

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

Reviewer #4: No

**********

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

Reviewer #3: Yes

Reviewer #4: 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

Reviewer #3: No

Reviewer #4: No

**********

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: The authors have described findings from of breast cancer awareness and screening practices among rural Gambian women in a community-based cross-sectional study. Although awareness was high with 87.7% of women being aware of breast cancer, only 13% practised screening.

Major issues;

1-The distance or proximity of the closest medical facility to the subjects. What kind/level of service are they able to receive, when available?

2-Did cultural or religious practice affect the practice of screening for breast cancer seeing the rather low number (13%) in relation to an 87.7% awareness level of cancer. These were not explored in the study. It will be helpful to give more information on factors that could influence your results such as cultural beliefs, healthcare infrastructure, and accessibility.

3-study design and setting – what health facility is located in this study areas, how accessible are they to study subjects and what infrastructure is on ground to help with breast cancer detection? Providing detailed information on the healthcare infrastructure or specific barriers faced by women in accessing these services will be helpful in appreciating the magnitude of the problem to readers.

Minor issues;

1. What informed the choice of rural women for this study seeing similar study had been done in female undergraduate students in the past?

2. Strengths and limitations (page 11) – although the population is nearly homogeneous for example proximity to health care facility with screening services could affect their screening practices regarding breast cancer.

Reviewer #2: Topic: Exploring Breast Cancer Awareness and Screening Practices amongst Gambian Women in the Gambia; Community-based- cross-sectional study

Dear Editor PLos One Journal,

Many thanks for the opportunity to review this paper from the Gambia. I am grateful.

General Comments

A good and interesting paper. It adds to the breast cancer literature from the Gambia. However, the topic needs revision.

The background outlined the key issues related to breast cancer awareness and screening practices in the Gambia

The statistical analysis were appropriate

The findings presented were relevant and the discussion gave an in-dept explanation on the topic.

Conclusion: the conclusion is generally sound and based on the findings; however, it needs a slight revision.

Specific Comments

1. Tropic: One of the study variables looked at nationality: Gambian and non-Gambino. Therefore, the authors should consider removing the term Gambian on the topic. The proposed topic should read, "EExploring Breast Cancer Awareness and Screening Practices amongst Women in the Gambia: A Community-Based cross-sectional Study.”

2. What was the justification to choose simple random sampling to select participants in households with more than a single eligible respondent on line 130-131? Secondly, how were/were households with no eligible respondent dealt with in the study?

3. Were the research assistant from Solace foundation trained for the data collection at the community level?

4. In Table 1 and table 2, authors were using participants and in other tables respondents. They should be consistent with the terms. Table 2 should read “Breast cancer awareness of respondents.”

5. In lines 202 and 207, the term “our respondents” should be changed to “the respondents” all throughout the document.

6. Table 2: all variables with multiple respondents should be indicated, eg “ Knew the preventive methods of breast cancer risk.”

7.Line 239 Kinteh et al , no year was added to the reference. Similar to Sanyang et al., line 290. Therefore, it should be rephrased

8. Conclusion Line 330-332: “The predictors of breast cancer screening practices were influenced by the parity of the women and the current occupation of the respondents” . Do they mean ethnicity? Parity was not, even though some of its sub categories indicated so.

Reviewer #3: The article provides interesting findings on breast cancer in The Gambia. I think the paper is worthy of publication, but I have a few questions and suggestions for improvement with regard to the methodology and the evaluation strategy.

The authors should better justify the statistical model they chose with mathematical expressions for the models. The descriptive results are not sufficient, charts can be used to support the results.

Although, the article demonstrated scholarly argument, the article is poorly written with a lot of typos and grammatical errors. The paper needs some editing and proof-reading as well as some double-check for consistency in spelling ( I have indicated some out of so many).

Accept with major revision

Reviewer #4: General comment

The study aimed to explore breast cancer awareness and screening practices of rural Gambian women. This is titled “Exploring Breast Cancer Awareness and Screening Practices 1 Amongst Women in The Gambia; Community-based- cross-sectional study”. The study is premised on the limited strategies for addressing breast cancer in The Gambia.

Major comment

Research on breast is laudable. However, the more specific and focused research is, the better. The study focused is inadequately articulated and contextualised. Absence of the operational definition of the main outcome variable of interest is a concern. Nonetheless, I suggest the authors focus solely on breast cancer screening practices.

Specific comments

Title:

• I suggest modification of the title to read as “Barriers and associated characteristics of breast Cancer Screening Practices amongst women in northern part of The Gambia;”

Abstract:

• Background

o Lines 20-21: could be replaced with justification relating to breast cancer screening practices

o Line 22: study objective may thereafter reflect the modified title.

• Methods: consider recasting the statement to reflect the following

o Line 25: Why among rural women?? This is not reflected in the body of the work

o Lines 26-27: authors should recast … interviews may be conducted using structured questionnaires deploy using Kobo toolbox

o Line 28: delete the phrase “SPSS version 28” - Avoid inclusion of software in abstract.

o Line 29: … to determine correlation?? Pearson Chi-square is used to examine association between two categorical variables

o Line 30: replace test with model

o Provide a statement to indicate that adjusted odds ratios was reported in the Results section

• Results:

o Line 34: replace the pronoun “our” with “the”, avoid the use of such pronoun as much as possible

o Lines 36-37: I could not find the result in the body of the work to justified the inclusion of the statement as “risk factors”. However, I guess the authors meant to say respondents’ characteristics

o Lines 39-42: please improve on the reporting style for the statement as only occupation and parity are reported.

• Conclusions:

o Line 43: average of what??? The statement is unclear!

o Line 44: what makes it optimal ... this is not indicated in the result nor in the method section

o Line 45: ... could not be traced to any of the result presented in the Results section of the abstract. Nonetheless, if the suggested title is sustained, it could be appropriate provided that it is linked to the results section.

Introduction:

o Lins 58-59: the statement requires appropriate referencing

o Lines 83-86: the two statements are contradictory; first, lack of knowledge and second, good knowledge

o Line 99 as commented earlier – operational definition of the main outcome of interest is required

o The study justification is rather weak with respect to with the BC awareness or its screening practice among the target population, Most importantly, non-inclusion of the targeted population known practices towards BC screening

Methods:

• Study design and setting

o Lines 107-111: Authors should mention no of districts per the Local government authorities in the northern part of the Gambia. This should be followed by the average numbers of communities per district. Expectedly, the setting should also include the spread of the screening centres

• Sample size determination

o Line 120: the statement “confidence interval of 99% with 50% precision” is unclear! Cross sectional one population study estimated sample size usually utilised within 1 – 5% level of precision. Authors are advised to state the correct parameters used to arrive at 985 as the estimated sample size.

• Sampling strategy

o Lines 123-125: This is not a selection stage.

o Lines 125-131: Questions that ought to have been answered by the “setting” section

Districts selected - out of how any districts?? Total districts in each LGAs should have been mentioned under the study setting

what is the average community per district??

How many households selected per community???

how many participants selected per household ... where more than one was eligible??

• Data collection and management

o Line 132: replace the sub-section title with “Data collection instruments”

o Line 150: it may be necessary to provide justification for using 3 local languages

• Authors are advised to insert a subsection titled “Study variables”. This should clearly state the operational definition of the outcome variable and the selected characteristics of the women.

•

• Statistical analysis

o Line 158: replace the sub-section title with “Data management and analysis”

o Lines 164-165: replace with “All analysis was conducted at a 5% level of significance”

Results:

• insert “Women’s characteristics” as a subsection

• Line 175: How figure (1012) was obtained needs to be clearly stated in the Methods - sampling strategy subsection

• Association of the selected women’s characteristics and breast cancer screening

o Line Technically, the statement “In total, 529 households were included in the study, with 273 children aged 12-59 months enrolled” could be not right. More than a child could come from a household but NOT the other way round.

o Again, there is no table/figure that is referenced

• Table 1

o While combining the distribution of women by their characteristics and the characterises association with breast cancer is welcome, I will suggest that

o 1. Total column should come before the columns for Yes and No for breast cancer screening

o 2. Yes and No columns of breast cancer screening percentages should be presented in row-wise”.

o The use of chi-square becomes inappropriate in situations where there is zero value in any of the contingency table cells

o Authors should ensure all the variables listed in Table 1 are clearly defined under the methods, study variables subsection

o Table 2 – should appear before the presentation of the “Association between the selected women characteristics and the breast cancer screening practice

• Discussion

• The unclear focus of the study, lines 234-237 in particular, is a concern here. Nonetheless, authors are advised to avoid writing the results under the discussion section – see lines 302 – 317

**********

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: Yes:  Francis Akor

Reviewer #2: No

Reviewer #3: Yes:  OLUWAYEMISI OYERONKE ALABA

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.

Attachments

Attachment

Submitted filename: PLOS ONE REVIEWERS COMMENTS.docx

Attachment

Submitted filename: Breast cancer review.docx

Attachment

Submitted filename: PONE-D-24-19264.pdf

PONE-D-24-19264R1Exploring Breast Cancer Awareness and Screening Practices Amongst Rural Women in The Gambia: Community-based Cross-sectional StudyPLOS ONE

Dear Dr. Kinteh,

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 Feb 16 2025 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,

Denekew Bitew Belay, Ph.D

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 #1: All comments have been addressed

Reviewer #2: All comments have been addressed

Reviewer #4: (No Response)

**********

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 #1: Yes

Reviewer #2: Yes

Reviewer #4: (No Response)

**********

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

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #4: (No Response)

**********

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 #1: Yes

Reviewer #2: Yes

Reviewer #4: (No Response)

**********

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 #1: Yes

Reviewer #2: Yes

Reviewer #4: (No Response)

**********

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 #1: Well done for the responses to the queries and with the modifications as suggested in the reviews. No further comments from me

Reviewer #2: No further comments. All comments and concerns have been adequately addressed by the authors.

The paper adds valuable literature of breast cancer awareness to the Gambia.

Reviewer #4: (No Response)

**********

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 #1: Yes:  Francis Akor

Reviewer #2: Yes:  Jainaba Sey-Sawo

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.

Attachments

Attachment

Submitted filename: PONE-D-24-19264_RFA.pdf

PONE-D-24-19264R2Exploring Breast Cancer Awareness and Screening Practices Amongst Rural Women in The Gambia: Community-based Cross-sectional StudyPLOS ONE

Dear Dr. Kinteh,

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 Feb 28 2025 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,

Denekew Bitew Belay, Ph.D

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:

The reviewer’s comments and concerns need to be carefully addressed.

[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 #4: (No Response)

**********

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 #4: (No Response)

**********

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

Reviewer #4: (No Response)

**********

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 #4: (No Response)

**********

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 #4: (No Response)

**********

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 #4: The comment is attached!

The responses to the comments are appreciated. However, I would like to see the following comments addressed in order to further enriched the manuscript.

Specific comments

Abstract:

• Background:

o Lines 21-23: replaced with the statement “This study aimed to assess breast

cancer awareness and identify associated factors influencing screening uptake among rural women in The Gambia”

• Methods:

o Line 25: replace the word “Gambia” with “The Gambia”, and elsewhere in the manuscript

o Line 29: replace the phrase “Chi-squared and/or Fisher’s exact test” with “Chi-squared or Fisher’s exact test, as appropriate”

o Line 29: replace the phrase “were reported was in the results.” with “were reported”

• Results:

o Line 36: replace the phrase “Multivariable analysis revealed that students” with “Students”

• Conclusions:

o Lines 43-44: Authors are advised to include result(s) suggesting the phrase “primarily due to limited knowledge of the urgent need for accessible and affordable screening services” in the Results section of the abstract

o Lines 44-45: Let the recommendation statement be presented in a separate sentence.

Material and Methods:

• Study design and setting

o Lines 94: the phrase … northern region of … should be addressed as commented earlier

o Line 105: I suggest the deletion of the phrase “Healthcare Access and Barriers”

o Lines 105-115: There is a need to reference some of the factual statements in the paragraph

• Study population and eligibility criteria

o Line 119: replace with “Study population”

• Sample size determination

o Lines 146-148: Authors should ensure the correctness of the following stated figures!

1. Estimated minimum sample size becomes 1103 (not 1092 as indicated) if adjusted for 10% non-response with 1.5 design effect

2. Besides, let’s assume 1092 is correct! Then, only of 1012 (not 1092) that 97.3% response rate would yield 985 completed the study

• Sampling strategy

o Lines 151-162: replace with “A four-stage sampling method was employed. First, the northern region was purposively selected due to its geographical location, high population density of underserved rural women, and absence of mammography services. This selection aligns with the study's aim of understanding screening uptake in rural, as it represents a significant proportion of rural communities with limited healthcare access. The northern region of The Gambia comprises of Kerewan and Kuntaur local government areas (LGAs), with four (Upper Baddibu, Lower Baddibu, Central Baddibu, and Jokadu) and three (Upper Saloum, Lower Saloum, and Niani) districts, respectively. Second, five communities were randomly selected from each district, yielding 35 study communities in total. Third, within each selected community, households were sampled using probability proportional to size, selecting an average of 25-35 households per community. Finally, one eligible woman was selected from each household.”

o Also important to note, selection of 25-30 households in each of the 35 communities would not yield the minimum sample size estimated (30*35=1050; this cannot lead to 1092 assuming its correct). However, 25-35 households per community will do!

• Data management and statistical analysis

o Lines 197-199: The women age was not covered with the present statement. I refer the authors to my previous advice to replace the statement with “Descriptive statistics such as means with standard deviations (SD) for continuous variables, and frequencies and percentages for categorical variables were used present the women characteristics including their breast cancer awareness and screening practices”.

o Line 199: replace “We employed Pearson's chi-squared and/or Fisher’s exact test to” with “As appropriate, Pearson's chi-squared or Fisher’s exact test was used to … ”

o Lines 204-207: Authors are advised to place the statement “Despite its non-significance at the bivariate analysis level, ethnicity was retained in the model owing to its theoretical importance and our specific interest in understanding its effects on breast cancer screening uptake in relation to other predictors” immediate on line 211 after “bivariate level.” to facilitate a smooth narrative.

Results:

• Figure 1:

o Line 251: replace “practices” with “uptake”

• Table 1

o For sake of clarity to the potential Plos One readers, my previous suggestion is necessary!

Column 2 to be presented as Total (column percentage), while others remain as they were

By so doing, statements on women’s characteristic in lines 240-247 could be referenced adequately.

o Additionally, I suggest that the title should read as “Distribution of women’s socio-demographic characteristics by breast cancer screening uptake

• Lines 291: I suggest the paragraph subsection title be read as “Breast cancer screening practices” as this includes BC signs and symptoms.

• Lines 299-302: The statement “These findings highlight the complex interplay of structural, knowledge-based, and personal barriers influencing breast cancer screening uptake in this rural population, suggesting the need for targeted interventions to address these multiple barriers to screening.” should be moved under Discussion section

Thank you!

**********

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 #4: Yes:  Rotimi Felix Afolabi

**********

[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: PONE-D-24-19264R2_RFA.pdf

PONE-D-24-19264R3Exploring Breast Cancer Awareness and Screening Practices Amongst Rural Women in The Gambia: Community-based Cross-sectional StudyPLOS ONE

Dear Dr.  Kinteh,

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 02 2025 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,

Denekew Bitew Belay, Ph.D

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 #4: (No Response)

**********

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 #4: (No Response)

**********

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

Reviewer #4: (No Response)

**********

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 #4: (No Response)

**********

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 #4: (No Response)

**********

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 #4: The authors are commended for their efforts in improving this manuscript. The revisions are largely satisfactory; however, a few comments appear to have been addressed inappropriately, likely due to a misunderstanding of their intent. To ensure clarity, I have relisted those comments below for your reference

Abstract:

• Conclusions:

o Lines 43-44: Authors are advised to include result(s) suggesting the phrase “primarily due to limited knowledge of the urgent need for accessible and affordable screening services” in the Results section of the abstract

• The comment requests that the authors report the reasons for the poor uptake of breast cancer screening. Simply referencing “limited knowledge” without presenting supporting data in the Results section would be inappropriate.

• Besides, it is not necessary to include those percentages under the Conclusion section of the abstract. It is better reported under the Results section.

Sample size determination

• Lines 146-148: Authors should ensure the correctness of the following stated figures!

1. Estimated minimum sample size becomes 1103 (not 1092 as indicated) if adjusted for 10% non-response with 1.5 design effect

2. Besides, let’s assume 1092 is correct! Then, only of 1012 (not 1092) that 97.3% response rate would yield 985 completed the study

• Regardless of the statistical software used for sample size computation, the minimum sample size of 662 is accurate based on the presented indices. However, when accounting for the design effect, the minimum sample size increases to 993 (662 * 1.5). If we then adjust for a 10% non-response rate, the required sample size becomes 1103 (993 * 0.9).

• Authors are requested to address this appropriately!

Results:

• Table 1

o For sake of clarity to the potential Plos One readers, my previous suggestion is necessary!

Column 2 to be presented as Total (column percentage), while others remain as they were

By so doing, statements on women’s characteristic in lines 240-247 could be referenced adequately.

• The comments request that the authors include column percentages for the Total column. To avoid any further confusion, I suggest renaming the Total column heading to “n (%)” so that the reported percentages are clearly indicated on a column-wise basis (NOT 100, as presently reported).

Thank you!

**********

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 #4: Yes:  Rotimi Felix Afolabi

**********

[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: PONE-D-24-19264R3_RFA.pdf

Exploring Breast Cancer Awareness and Screening Practices Amongst Rural Women in The Gambia: Community-based Cross-sectional Study

PONE-D-24-19264R4

Dear Dr. Kinteh,

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 will be generated when your article is formally accepted. Please note, if your institution has a publishing partnership with PLOS and your article meets the relevant criteria, all or part of your publication costs will be covered. Please make sure your user information is up-to-date by logging into Editorial Manager at Editorial Manager®  and clicking the ‘Update My Information' link at the top of the page. If you have any questions relating to publication charges, 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,

Denekew Bitew Belay, Ph.D

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 #4: (No Response)

**********

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 #4: (No Response)

**********

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

Reviewer #4: (No Response)

**********

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 #4: (No Response)

**********

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 #4: (No Response)

**********

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 #4: The authors are commended for their efforts in improving this manuscript. The revisions are satisfactory.

**********

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 #4: Yes:  Rotimi Felix Afolabi

**********