PONE-D-24-42572Navigating the risks: stakeholder views on risk-based cervical cancer screening.PLOS ONE

Dear Dr. Remmel,

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 Jan 06 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,

Clement A. Adebamowo, BM, ChB Hons; FWACS, FACS, ScD, FASCO

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. You indicated that ethical approval was not necessary for your study. We understand that the framework for ethical oversight requirements for studies of this type may differ depending on the setting and we would appreciate some further clarification regarding your research. Could you please provide further details on why your study is exempt from the need for approval and confirmation from your institutional review board or research ethics committee (e.g., in the form of a letter or email correspondence) that ethics review was not necessary for this study? Please include a copy of the correspondence as an "Other" file.

3. Thank you for stating the following in the Acknowledgments Section of your manuscript:

“This work was made possible by the funding received from the EEA (European Economic Area) and Norway Grants under grant EMP416.”

We note that you have provided funding information that is currently declared in your Funding Statement. However, funding information should not appear in the Acknowledgments section or other areas of your manuscript. We will only publish funding information present in the Funding Statement section of the online submission form.

Please remove any funding-related text from the manuscript and let us know how you would like to update your Funding Statement. Currently, your Funding Statement reads as follows:

“This work was made possible by the funding received from the EEA (European Economic Ar-ea) and Norway Grants under grant EMP416.

The funding was obtained by Anneli Uusküla , Anda Kivite-Urtane ; Mindaugas Stankūnas ; Mari Nygård.

https://eeagrants.org/

Funders did not play a role in study design, data collection and analysis, decision to publish or preparation of the manuscript.”

Please include your amended statements within your cover letter; we will change the online submission form on your behalf.

4. We note that you have indicated that there are restrictions to data sharing for this study. For studies involving human research participant data or other sensitive data, we encourage authors to share de-identified or anonymized data. However, when data cannot be publicly shared for ethical reasons, we allow authors to make their data sets available upon request. For information on unacceptable data access restrictions, please see http://journals.plos.org/plosone/s/data-availability#loc-unacceptable-data-access-restrictions.

Before we proceed with your manuscript, please address the following prompts:

a) If there are ethical or legal restrictions on sharing a de-identified data set, please explain them in detail (e.g., data contain potentially identifying or sensitive patient information, data are owned by a third-party organization, etc.) and who has imposed them (e.g., a Research Ethics Committee or Institutional Review Board, etc.). Please also provide contact information for a data access committee, ethics committee, or other institutional body to which data requests may be sent.

b) If there are no restrictions, please upload the minimal anonymized data set necessary to replicate your study findings to a stable, public repository and provide us with the relevant URLs, DOIs, or accession numbers. Please see http://www.bmj.com/content/340/bmj.c181.long for guidelines on how to de-identify and prepare clinical data for publication. For a list of recommended repositories, please see https://journals.plos.org/plosone/s/recommended-repositories. You also have the option of uploading the data as Supporting Information files, but we would recommend depositing data directly to a data repository if possible.

Please update your Data Availability statement in the submission form accordingly.

5. 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. 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

**********

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: Yes

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 novel study explores stakeholder views on personalised cervical screening in Estonia. This manuscript is very well-written and articulate, with a particularly strong discussion section. I have very minor comments but the clarification between feasibility and acceptability would serve to strengthen the aim of the paper.

Abstract:

Line 40: The abbreviation ‘RB’ has not been previously introduced, please include this on line 30 where the term risk-based is first used.

Introduction:

Lines 81-83: The focus of this study appears to be acceptability but the authors state that they are aiming to assess feasibility. Acceptability and feasibility are two distinct concepts, and I would avoid using these as synonyms. Based on the rest of the manuscript it seems that the authors are in fact aiming to assess acceptability and that, in the case of stakeholders, feasibility is a component of that.

Methods:

Lines 89-92: Please explain why you chose the TFA to develop your interview guide instead of the CFIR. I am curious as to why both of these frameworks have been used instead of just one, typically if a framework is used to inform the study design then the same framework is used in analysis.

Line 158: The data analysis section is clear and well-explained.

Line 174: Again, it would be beneficial to explain why CFIR was chosen at the analysis stage in favour of the TFA.

Results:

Lines 329-331: The comparison between different types of stakeholders, in this case midwives and gynaecologists, is very interesting. If such differences were observed elsewhere in the analysis, I would encourage drawing these out explicitly.

Discussion:

Overall, this is an extremely well-written discussion which contextualises your findings nicely.

Lines 360-363: This is an interesting and novel contribution to the literature.

Reviewer #2: Thank you for the opportunity to review this paper. I enjoyed reading it.

This paper takes a comprehensive approach to the analysis and reporting of its findings from 17 semi-structured interviews. The use of both frameworks, the Acceptability Framework to guide the development of the interview guide and CFIR for analysis, is nicely done and well-explained, and provides linked conclusions (plus the additional benefit of potential implementation strategies). The tables with quotes aligned to CFIR concepts provide clarity and transparency around findings. The results are clearly written and the discussion insightful and relevant to the international interest in risk-based screening. Recommended for publication with minor revision.

Comments:

1. Line 68: Please add some references to examples (ref 32,33 etc) of existing research

2. The term ‘stakeholder’. The authors rightly acknowledge that community/patients may not be seen as a priority stakeholder group in the study’s context. However, by definition and in other contexts they are. I think ‘Stakeholder’ is acceptable for the Title but suggest clarifying ‘which stakeholders’ earlier in the paper and within Figure 1 to avoid confusion, e.g.,

Line 82: add ‘healthcare service and policy level stakeholders’

Figure 1: Suggest make title clearer or highlight that concepts related to “Individuals-women” are from the perspective of healthcare policy and service level providers, so this figure can stand alone.

3. Line 194-195: Check format of SD is correct i.e., suggest (SD=8.6)

4. Line 266: What is the relevance of digital literacy in this context? Was there a link to inequalities related to digital literacy in your tables? Please add a sentence for clarity. Consider also in the Discussion (Line 402).

5. Line 282: Headings in Table 3 (‘Inner setting and Outer setting’) are back-to-front. Please review and correct.

6. Figure 1: This looks attractive and potentially useful for researchers and planners. Suggest but not required to combine’ Innovation’ heading/graphic and concepts as one box, and ‘Implementation’ heading/graphic and concepts similarly to reduce complexity. See comments above re: title and women

**********

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

**********

[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.

Navigating the risks: stakeholder views on risk-based cervical cancer screening.

PONE-D-24-42572R1

Dear Dr. Remmel,

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,

Clement A. Adebamowo, BM, ChB Hons; FWACS, FACS, ScD, FASCO

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments: