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. 2022 Jan 7;17(1):e0262142. doi: 10.1371/journal.pone.0262142

Communities’ perceptions towards cervical cancer and its screening in Wolaita zone, southern Ethiopia: A qualitative study

Birhanu Wondimeneh Demissie 1,#, Gedion Asnake Azeze 1,*,#, Netsanet Abera Asseffa 2, Eyasu Alem Lake 1, Befekadu Bekele Besha 1, Kelemu Abebe Gelaw 1, Taklu Marama Mokonnon 1, Natnael Atnafu Gebeyehu 1, Mohammed Suleiman Obsa 1
Editor: Violet Naanyu3
PMCID: PMC8740975  PMID: 34995307

Abstract

Background

Cervical cancer is a malignant neoplasm from cells originating in the cervix uteri. Any woman who is sexually active is at risk of getting HPV. Women in sub-Saharan Africa region have higher chance of developing the disease. There are nearly 26 million Ethiopian women who are over the age of 15 and believed to be at risk of getting HPV. Regrettably, Ethiopian women typically present for cervical cancer care at a late stage in the disease, where treatment is most ineffective.

Objectives

To explore communities’ perceptions of cervical cancer and screening among women in Wolaita zone, southern Ethiopia.

Methods

A qualitative research using focused group discussions and in-depth interviews was used to explore communities’ perceptions of cervical cancer and screening among women in Wolaita zone, southern Ethiopia from March 2018-November 2019. The study participants were men, women and communities who were residents of the study settings and were not health professionals. All focused group discussions (FGDs) and key informant interviews were transcribed and entered into Microsoft Word and thematic content analysis was done.

Results

A total of fifty-nine participants participated in both FGD (three with men and six with women) and in-depth interviews (IDIs). Most participants have not heard about cervical cancer but know cancer in general. Participants mentioned that the disease usually relates to many births and unprotected sexual intercourse but none mentioned HPV infection. Most of the participants perceive that cervical cancer is incurable and assume that it could be prevented but they think they are not vulnerable to the disease and screening is not necessary.

Conclusion

This study indicates that rural communities in the zone had limited knowledge about cervical cancer and even less about risk factors, screening, treatment and prevention. There is a great need for cancer education and prevention in Ethiopia.

Background

Cancers that originate in the female reproductive system are referred to as women’s reproductive cancers [1]. Cervical cancer is a malignant neoplasm from cells originating in the cervix uteri. It is one of the greatest threats to women’s lives [2]. A sexually transmitted virus called Human Papilloma Virus (HPV) is responsible for more than 99% of cervical cancer cases and its precursors [3]. Any sexually active woman, including those with only one partner, is at risk of getting HPV at some point in their lives. People infected with HPV could transmit the virus even when they are asymptomatic [4].

Globally, an estimated 311,000 women worldwide died from cervical cancer in 2018; indeed, 85% of the global burden occurs in low- and middle-income countries that lack organized screening and HPV vaccination programs. Moreover, it is the third most common cancer worldwide and the leading cause of cancer deaths in many countries in Africa [5–8]. Besides, it has been projected the incidence of cervical cancer could increase by 60% in the next 20 years [9]; in a sense that cervical cancer could kill more women than maternal mortality in the next few decades. Cervical cancer rates vary worldwide, with the lowest incidence in developed countries of the European region such as Finland, Switzerland and Greece [10]. On the other hand, it is more prevalent in African countries, including Swaziland, Malawi, Zambia, and Zimbabwe [11, 12]. The effectiveness of population-based cervical cancer screening has been reflected by sharp declines in cervical cancer incidence in high-income countries [13].

Cervical cancer progresses slowly from precancer stage to invasive cancer. It is entirely curable if detected early with effective screening; however, service accessibility and community awareness play a significant role in screening more women [14]. Unfortunately, studies have shown that women aged 25 to 64 years in low- and middle-income countries have the least screening rate, only 3.5% in a given three-year period [7]. For instance, a recent study conducted in Eastern Uganda showed only 4.8% of females aged between 25 and 49 years had ever been screened for cervical cancer. The study further reported barriers to accessing screening services, including lack of awareness, negative individual perceptions, and health facility related challenges [6]. Another study from Ethiopia has identified various inter-related barriers and challenges for early health-seeking behaviour for cervical cancer, such as the insidious nature of the disease, individual-level factors, community-level factors, and institutional-level factors [15].

In 2018, cervical cancer was the second leading cause of cancer deaths in Ethiopia for women aged 15 to 44 years [16]. Evidence also shows that nearly 27.19 million Ethiopian women over the age of 15 are believed to be at risk of developing cervical cancer [17]. However, this figure could be low given the nation has no cancer register center. Besides, cervical cancer screening and treatment service is either unavailable or has a considerably diminished chance of success [1, 9]. Regrettably, Ethiopian women typically present for cervical cancer care at a late stage in the disease, where treatment is most ineffective [14]. The reasons for this are not yet established and need to be studied. In addition, to the best of our understanding, no study has yet explored communities’ perceptions of cervical cancer and screening in Southern Ethiopia, specifically the Wolaita zone. Therefore, findings from this study are expected to contribute to policy and program strategies to better address the cervical cancer needs of women in the community. Ultimately, the study will significantly contribute to implementations that reduce cervical cancer-related deaths in the southern part of Ethiopia and the country as a whole.

Methods and materials

Study setting and period

This study was conducted in Wolaita Zone, Southern Ethiopia, located 328kms south of the capital city, Addis Ababa, from March 2018 to November 2019. The zone has an estimated 2.7million population, among the densely populated zones in Ethiopia. For administrative purposes, the Wolaita zone is divided into 15 districts. This study was conducted in two districts of Wolaita Zone, namely Boloso Sore and Sodo Zuriya districts in two urban and two rural Kebeles (the lowest administrative unit in Ethiopia). Boloso Sore district had 29 Kebeles, of which 25 are rural and the rest four are urban kebeles, whereas Sodo Zuriya had 36 Kebeles with five urban and 31 rural Kebeles.

Study design

A qualitative descriptive study design using focused group discussions and in-depth interviews was used to explore communities’ perceptions of cervical cancer and screening among women in Wolaita zone, southern Ethiopia.

Participants

The study participants were men and women who were residents of the study settings and were not health professionals. They were recruited through purposive sampling, and recruitment was done through the health extension workers. Inclusion criteria consisted of: (1) 18 years of age and older; (2) educated and uneducated, traditional birth attendants, religious leaders, and women development armies. Exclusion criteria consisted of: (1) prior history of cervical cancer; (2) those who had any training on cervical cancer and (3) currently on the treatment of cervical cancer. A proportional number of FGDs and IDIs were held in the two selected districts.

Sampling size and sampling technique

This study was conducted in the two randomly selected districts of Wolaita Zone, namely Boloso Sore and Sodo Zuriya districts; it was conducted in two urban and two rural Kebeles. Two (one urban and one rural) kebeles were randomly selected from each woreda (district). We used purposive sampling from each of the selected kebeles to get the study participants who would be willing to share their experience with cervical cancer. Nine FGDs (a total of 51 participants) and eight individual IDIs were held in each of the four selected kebeles. Thus, each FGD had 5–7 participants. The saturation of information determined the number of FGDs and IDIs.

Data collection tools

Interview guides were used to explore communities’ perceptions of cervical cancer and screening (S1 File). The tools were unstructured except for the background information.

Data collection procedure

Before the Focus Group Discussions and in-depth interviews, research assistants (four female and two male nurses) were trained on how to conduct the interview. The research assistants had a Bachelor of Science (BSc.) degree in Clinical Nursing. They were recruited from Wolaita Sodo University Teaching and Referral Hospital based on their experience on prior qualitative research data collection. Research assistants were fluent in the required local languages and they used the general discussion guide to prompt discussion and elicit further details through probes. Health extension workers of the respective kebeles identified the participants. The FGDs and IDIs were conducted in a place convenient for the participants that are quiet and close to their home, except for the Sodo Zuria participants of the women’s development army, who preferred health centres. The Boloso Sore participants were interviewed in Wolaitigna, and the Sodo participants were interviewed in Amharic. The participants were divided into four different groups based on their age, because in the local communities of Wolaita, young people may shy away from speaking if included in the group of older adults and vice versa.

During FGDs, there were two research assistants, a facilitator and a note taker, but one interviewer did the IDIs. The moderator gave codes to each participants before the start of the discussion. The codes were used as a name during the conversation, transcription, and translation as the two members of the team supervised information gathering.

Data quality assurance

The unstructured questionnaires were prepared in English, translated into Amharic and Wolaitigna, and then returned to English to check for consistency. Before actual data collection, two days of training was given to research assistants on tools and procedures of conducting qualitative research and interviewing sensitive topics. The IDIs and FGD guide was revised prior to administration during pre-testing on six individuals and a group of two, respectively with Wolaitegna and Amharic speakers who shared similar demographic characteristics to the study participants but did not participate in the actual data collection. The IDIs took place at the respondents’ houses in private and confidential settings.

Data management

The investigators chose and followed clear file naming, developed a data tracking system, established and document data transcription/translation procedures and proved quality control procedures.

Data analysis

All FGDs and key informant interviews were transcribed and translated verbatim from the local language to English by individuals fluent in both languages. The transcripts were entered into Microsoft Word and thematic content analysis was done. Specifically, the coding process involved identifying major themes in each of the transcripts. Identified themes were compared across the transcripts to determine differences and similarities in the perspectives of the study. Three themes and six subthemes were identified: awareness about cervical cancer, risk factors for cervical cancer, awareness about symptoms of cervical cancer, perceptions about cervical cancer screening, and prevention and treatment of cervical cancer. Audio files, transcripts, and informed consent forms were stored in password-protected files.

Ethical clearance

Participants were briefed on the purpose and objective of the research. We also assured them of the confidentiality of the information. Permission was also requested and any further move was made on their approval. Wolaita Sodo University gave letter indicating the area of research. Ethical approval was obtained from the Ethical Review Board of College of Health Science and Medicine, Wolaita Sodo University. Letters of support were obtained from the relevant authorities of all quarters from where the data were collected. The individual in this manuscript has given written informed consent (as outlined in the PLOS consent form) to publish these case details.

Results

Characteristics of participants

A total of fifty-nine participants participated in both FGD (three with men and six with women) and IDIs. The average age (mean ± standard deviation) was 38 ± 5 years. The study participants were primarily married (79.7%), with 59.3% reporting having less than a secondary level education (Table 1).

Table 1. Socio-demographic characteristics of participants, Wolaita Zone, Southern Ethiopia, 2019.

Characteristics of participants Values
Sex
    Male 17
    Female 42
Age
    <30 8
    30–40 23
    41–50 16
    >50 12
Marital Status
    Married 47
    Divorced 7
    Widowed 5
Educational Background
    No formal education 24
    Primary 11
    Secondary 16
    Above secondary 8
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Awareness of cervical cancer

Regarding cervical cancer awareness, most participants have not heard about cervical cancer but know cancer in general mainly heard from health extension workers. Those who knew cervical cancer mentioned it as “Barka [women’s disease name in Wolaita] that it is related to fistula” and “Yemahitsen ber nekersa” [in Amharic] (34 years old female, Sodo Zuria).

Among the FGD participants, there was a misconception about what cervical cancer is. Seven of the FGD participant groups associated cervical cancer with death. One participant mentioned, “Anything that has the name cancer in it is deadly regardless of the type and no cure to it. It is a disease that rots, spoils, makes you thin and kills” (31 years old male, Sodo Zuria).

On six IDIs, mothers mentioned that cervical cancer is a disease that misplaces blood veins, stating, “cervical cancer misplaces your blood veins particularly veins of your womb…{mahitsani barqatis-barqa} [in Wolaita language]. Traditional healer needs to tie womb {yelokota} and will instruct foods to eat.” (37 years old female, Boloso Sore).

Risk factors for cervical cancer

Except for one FGD and three IDI participants, others mentioned that the disease usually relates to many births and unprotected sexual intercourse, but none mentioned HPV infection. A woman who had similar symptoms to a cervical cancer stated that, “giving many births causes such symptoms, not the one you call [cervical cancer]. I also heard that cervical cancer could be caused by unrestrained sexual intercourse” (40 years old female, Sodo Zuria). One participant mentioned that poor personal hygiene and how we touch our cervix determine whether we get cervical cancer. She stated, “cervical cancer is caused by rarely washing our private parts and touching cervix by napkins; we should be washing only by using water” (29 years old female, Boloso Sore).

The other cause mentioned by two of the women FGDs and two IDIs was expulsion womb. One participant said “During childbirth, most women don’t go to a health facility, and that leads to prolonged labour which eventually exposes them to the expulsion of the womb which leads to cervical cancer” (36 years old female, Boloso Sore). The other participant supported the idea and described, “we the rural women have many things to do, such as bearing and rearing children, looking after domestic animals, sometimes farming, cooking foods, etc. Excessive pressure from such routine tasks may lead to womb expulsion which causes cervical cancer” (31 years old female, Sodo Zuria).

Among all the men FGD participants, they stated that some harmful traditional practices are stated as the risk factor for cervical cancer. One FGD participant stated, “when a young girl who is under 18 years gets married to an older man that might expose her to cervical cancer” (36 years old male, Sodo Zuria).

Awareness of the symptoms of cervical cancer

In IDIs, only four IDI participants were aware of the symptoms of cervical cancer, and the rest were not even familiar with the term ‘cervical cancer’. “I just heard the disease you called [cervical cancer] here, let alone knowing the symptoms” (41 years old female, Sodo Zuria).

When we informed them of the symptoms of cervical cancer, the participants reported regarding their friends who had died from cervical cancer years ago.

“Now I knew that our friends who had foul-smelling, frequent bleeding from her private parts and pelvic pain were suffering from this disease-poor they. None of us knew that it was cervical cancer; they spent months alone. For years, many of our families and neighbours have died from this disease, and we are just beginning to learn about it now. One of my old aunties who suffered from this disease had an odour that comes from her womb would not let you sit around her, so she was stigmatized, assuming that it was HIV. We were not able to be around her, let alone others. She used to say I should have died during my childhood” (33 years old female, Boloso Sore).

In FGDs, male participants associated the symptoms with a curse and other diseases, such as Acquired Immune Deficiency Syndrome (AIDS), and some argued that the disease with such symptoms itself is AIDS.

“The symptoms you just told us are also symptoms we see in AIDS patients, perhaps it is AIDS-related one” (40 years old male, Boloso Sore).

Perceptions regarding cervical cancer screening

Regarding cervical cancer screening, most of the participants were not aware of the availability of such services, and no participant knew that screening is performed for the sake of prevention. In FGDs, most participants explained that one needs to visit the health facility when they experience some discomforts or present with obvious illnesses, such as headache and abdominal pain, amongst others.

“How do we go to the health facility when the disease does not show any symptoms; we have to be sick to be seen by a health professional” (35 years old female, Boloso Sore). One FGD participant mentioned that “what is the point of screening? After all, cancer is a killer; better off not knowing cancer will kill you” (34 years old male, Sodo Zuria).

The need for screening was explained to participants. Although most believed that going for the screening was a good idea, some participants expressed concern about the procedure, having to be done vaginal exam using a speculum. One FGD participant who was 38 years old expressed her fear at which many others nodded their head approving her statement.

“[tenayi edime gitta….wolayi bolcho.] I am an older woman who is no longer giving birth. How do I lie in bed on my back like that and show my private part to a young girl or male at healthcare facility? Hereafter, my body is an honor for me that I should not reveal to anyone. It is an honor!” (38 years old female, Sodo Zuria).

In another IDI, a woman expressed her concern that inserting metal in a body is unsafe, perhaps worse. “What do inserting metals do in a woman who did not show any symptoms of diseases; perhaps the metal will cause another disease condition that was not there in the first place” (29 years old female, Sodo Zuria).

On the other hand, a woman who had the chance to be screened at the health center told her experience by saying, “Once I had pain all over my body and went to a health center. The person [health professional] respectfully treated and prescribed the drug. Still, in the end, he requested me to go to number 13 [cervical cancer screening room], where a woman counselled me for screening, but the moment she instructed me to put off my clothes and lie on a high bed. I was scared! I told her that I felt better and got drugs for what I came for, and then I left the room. When I told my friends how they do the screening, they stated they would never get that kind of screening. The service should not be that way; we should be served for what we go for” (40 years old female, Boloso Sore). Participants believed that the decision to be screened is ultimately up to the individual and that the health care provider should acknowledge the patient’s decision to be screened or not.

Prevention and treatment of cervical cancer

Almost all participants perceived that cervical cancer is incurable and assumed that it cannot be prevented; however, the participants believed that they were not vulnerable to this disease and that the screening was not necessary. One participant mentioned that, “If we go to prevention without any symptoms, what is the point? People might assume [those seeing us visiting the screening room] as we have cancer. The other issue is that if people know that we have cancer, we will be stigmatized, so better not to get known or get treatment” (42 years old female, Boloso Sore).

In FGDs, another point highlighted by men participants was that the health facilities were not working toward the prevention of cancer but were instead providing contraception to their wives. One participant stated, “We don’t want our wives to go to a health facility because they usually go for contraceptives, although we want to continue having children. It sounds as though health professionals are promoting contraception a lot and females ended up not wanting to have children” (32 years old male, Sodo Zuria).

No participant was aware of the treatment of cervical cancer, and everyone perceived this disease to be incurable. One participant clarified that they had never heard that any cancer can be treated.

At the end of each FGD and IDI, participants were asked if they would attend health education sessions about cervical cancer prevention. All expressed high interest learning about the disease but preferred any other free method of screening procedures.

Discussions

This study explored communities’ awareness of cervical cancer, its risk factors, symptoms, prevention, and treatment among rural men and women of Wolaita zone, southern Ethiopia. The country is one of many other low and middle-income countries with a high incidence of cervical cancer that have been unable to establish or enhance appropriate and effective cervical cancer prevention programs. Thus, the findings of our study may add to a small body of published articles and provide a significant opportunity for intervention about cervical cancer prevention and treatment in Ethiopia.

Our finding that the participants had not even heard of cervical cancer is consistent with previous reports from Ethiopia [18], Ghana [19] and Korea [20]. In a study in Ethiopia [18], majority of the participants were unaware of cervical cancer and HPV infection as its risk factor and believed that they were not susceptible to this disease. In another qualitative study assessing the awareness of cervical cancer amongst males in Korea [20], the participants’ degree of awareness of this disease was low and their concern and knowledge in this regard were poor. Likewise, a number of studies have reported the lack of awareness of cervical cancer as an important barrier to participation in screening [7, 21, 22]. In developing countries, a lack of knowledge regarding cervical cancer is most likely linked to poor education and low socio-economic status. A study conducted in a developed country, Virginia USA, on the other hand, shows that participants were able to identify the screening test associated with cervical cancer and friends and families were their sources of information [23]. Further, a recent study showed that in both developing and developed countries, women with a poor socio-economic status were at a high risk of developing cervical cancer but their rate of participation in screening remained low [24]. The study demonstrated that the rate of availing cancer screening depended on the socio-economic status, and this bias was greater in countries that did not offer population-based cancer screening program. These reports indicate that participation in cervical cancer screening is linked to income and education. Specifically, uneducated women with poor socio-economic status tend to show low screening participation.

In our study, womb expulsion due to prolonged labour during childbirth, as a result of failure for not going to the health institution for delivery, was considered by our study participants as a cause of cervical cancer. Our finding agrees with a recent qualitative study conducted in Ethiopia [25], in which the study participants agreed, though not described in detail, that cervical cancer can be caused when a woman gives birth at home. This clearly reflects the need for public information campaign by trusted sources, including health workers, the media, and other stakeholders at the grassroots.

Our finding that pelvic examination is a barrier to screening corroborates previous reports from Minnesota [26], Guatemala [27], China [28] and Bangladesh [29]. In a qualitative study in Minnesota [26], pelvic examination was perceived as invasive and the use of speculum was considered problematic. Moreover, our findings are consistent with reports from Kenya, suggesting that the fear of undergoing a pelvic examination as well as the fear of disease and death impede screening participation [7]. Given the cultural identity and age of the study participants, this finding was not surprising. Nonetheless, as long as performed in an environment with sufficient privacy, speculum examination was perceived by adolescent girls as a ‘modern approach’.

Furthermore, a recent publication from World Health Organization reported that HPV self-sampling offers an additional option to improve cervical cancer screening coverage by creating a more comfortable atmosphere for the patient [30]. A study in Bangladesh has emphasized the availability of female healthcare providers and privacy as a requirement for gynecological examination [29]; In that study, speculum examination was considered acceptable by both women and men as long as it was performed by a female health care provider in an environment with adequate privacy.

Regarding perceptions about cervical cancer screening, our finding shows that most of the study participants explained that they only go to the hospitals or health institutions when they have symptoms and apparent illnesses, including abdominal pain and headaches. A similar finding from Nepal showed that study participants did not feel any need to seek health care unless they experienced symptoms of some kind [21]. Further, our finding is in line with one from a study conducted in Uganda. The investigators found that study participants who had screened for cervical cancer mostly had had its sign and symptom [6]. This might be due to a high level of illiteracy, dependency on traditional practices, poor socio-economic conditions, and poor health awareness.

Implications for research, policy-making and practice

Healthcare providers working with women, particularly older women, should ensure that the information they provide is culturally sensitive and should acknowledge the cultural beliefs of these groups of the population. Further, awareness about cervical cancer and participation in cancer screening can be addressed through culturally relevant health education and communication interventions.

In this study, lack of awareness about the symptoms of cervical cancer combined with its sexual risk factors and association with HIV led the study participants to believe the condition to be the kind of illness that HIV-infected women would get. This leads to the stigmatization of patients with cervical cancer. Therefore, the development of community-based participatory approach stigma reduction interventions, through improving access to information and education, is paramount to the local communities. Moreover, a large qualitative study exploring the prevalence of cervical cancer-related stigma and its association with health outcomes may provide valuable lessons on how to better respond to cervical cancer-related stigma.

Our finding on the participants’ preferences of cervical cancer screening procedures provides initial evidence for researchers to further explore the satisfaction and acceptance of various screening methods. Additionally, based on our findings, important factors that dissuade women from getting screened for cervical cancer are the understanding of the concept of disease prevention, experience of the screening procedure, awareness of the availability of cervical cancer prevention services, and attitude towards cancer in general. Therefore, interventions focusing on strengthening the existing services and increasing awareness regarding the importance of cervical cancer screening prior to the onset of signs and symptoms amongst communities are critical initial steps to establish an effective cervical cancer prevention campaign. Moreover, trained community healthcare workers can be engaged for encouraging women to utilize the screening services. In addition, information and education plans through printed materials as well as facility-, community- and media-based approaches can promote service utilization. Furthermore, such activities can make people aware of the fact that with appropriate treatment, cervical cancer can often be cured. In this regard, lessons can be learned from a study conducted in Ghana [31], which reported a comprehensive community-based educational campaign on cervical cancer and screening focusing on the cause, risk factors, signs and symptoms, complications and prevention methods. This community-based education used lectures, discussions, videos, and leaflets and has been evidenced by facilitating supportive change and improved knowledge and perception about cervical cancer and screening. Thus the study finding can be used as a blueprint to craft a successful community awareness program regarding cervical cancer screening, prevention, and treatment.

Conclusion

This study indicates rural communities in the zone had limited knowledge about cervical cancer and even less about risk factors, screening, treatment, and prevention. Factors such as lack of awareness, fear of pelvic exam, having many contending issues, a belief that cervical cancer is not curable, fear of having a positive result, and the stigmatization of cervical cancer are also key barriers to engaging in cervical cancer screening programs. Furthermore, a comprehensive education and information intervention focusing on cervical cancer-related risk factors, signs and symptoms, treatment, complications, and prevention methods is critical in improving communities’ perceptions of the disease.

Supporting information

S1 File. Supplementary file.

(DOCX)

Click here for additional data file. (21.9KB, docx)

Acknowledgments

We would like to express our heartfelt gratitude to Wolaita Sodo University for providing fund to conduct this research. We also have a special thank for Mrs. Biruktawit Alemu Wolde, Mr. Yohannes Gebeyehu Guta and Mrs. Bekalwa Teshome Amare for their critical review of the manuscript.

Data Availability

All relevant data are within the paper and its Supporting Information files

Funding Statement

The author(s) received no specific funding for this work.

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Decision Letter 0

Violet Naanyu

11 Aug 2021

PONE-D-21-21479

Communities’ perception of cervical cancer and screening in Wolaita zone, southern Ethiopia: A qualitative study

PLOS ONE

Dear Dr. Gedion Asnake Azeze,

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.

Thank you for your submission that covers an important health problem globally, and more so, in the context of Africa. It is well presented but there are key areas for improvement as show by our two reviewers. Ensure you provide the missing details in the methodology. Remember to show findings stratified by key dimensions including sites, age, and gender. Stregthten implications of your findings broadly, but more specifically for the community of research.

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We look forward to receiving your revised manuscript.

Kind regards,

Violet Naanyu, PhD

Academic Editor

PLOS ONE

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Reviewer #1: Yes

Reviewer #2: Partly

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Reviewer #1: N/A

Reviewer #2: N/A

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Reviewer #1: Yes

Reviewer #2: Yes

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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: While I find the manuscript technically sound, and  it has a lot of data - including verbatim reports, I found it a little shallow because it is merely descriptive. The knowledge it generates (that rural communities in the context of study do not have adequate information on the cancer of the cervix and therefore there is need to educate them) is almost obvious. Moreover, I have some concerns:

i) Would the author consider referring to Communities’ 'perceptions' rather than ‘perception’? I am sure that there are many perceptions -and the author presents many of these on different aspects of cervical cancer and screening in Ethiopia. In fact, if consideration was of only one aspect such as cause of cancer, there would be many perceptions within one community - likewise in many communities.

ii) Would the author consider referring to researchers/research assistants instead of 'collectors'? In qualitative data collection, one would not merely be a data collector.

iii) I am curious – were interviews done in a local language? What is the local term for ‘cervical cancer’? In many African communities, there is no word for cancer of the cervix per se. For many people it would be cancer of the stomach. How did the interviewer introduce or describe it?

iv) There is reference to HIV/AIDS as a disease. It is important to distinguish between HIV and AIDS. Again what is HIV/AIDS in the local language?

The manuscript is derived from a qualitative descriptive study design so statistical analysis does not apply.

The presentation is intelligible but like I allude in a previous comment, there is little novelty.

Reviewer #2: REVIEW REPORT: Communities’ perception of cervical cancer and screening in Wolaita zone, southern Ethiopia: A qualitative study

The paper is a qualitative study entitled “communities ‘perception of cervical cancer and screening in Wolaita zone Southern Ethiopia “. This title is quite clear and precise. The abstract is well detailed and addresses the main research question. The study addressed one main objective namely; to explore communities’ perception of cervical cancer and screening among women in Wolaita zone, southern Ethiopia. The manuscript is an excellent demonstration of views and attitudes of a rural area population towards cervical cancer and screening. In their paper the authors used Focus Group Discussions (FGDs) and In Depth Interviews (IDI) to collect data from 59 participants living in Southern Ethiopia. Data collected was on knowledge about cervical cancer, its symptoms perception and attitude towards screening. The study was conducted in two urban and two rural Kebeles –which is the lowest administrative unit in Ethiopia. The sample of the study comprised of non-health professionals who had not had any training on cervical cancer residing in the study area. A proportional number of FGDs and IDIs were held in the two selected districts. Data was qualitatively presented.

The results of the study revealed that most participants had not heard about cervical cancer but had knowledge on cancer in general. Though cervical cancer was perceived to be incurable most participants assumed that they were not vulnerable to the disease and therefore screening was not necessary.

The authors conclude that rural communities in the zone had limited knowledge about cervical cancer and even less about risk factors, screening, treatment and prevention and therefore recommended that there is a great need for cancer education and prevention in Ethiopia.

The strength of this manuscript is that it addresses a pertinent issues concerning cervical cancer, presents findings and as such the paper represent a community’s view which will influence policy in Ethiopia and generally increase knowledge on cervical cancer screening in Sub Saharan Africa. This manuscript does an excellent job in researching on cervical cancer among non -medical/ health participants. Though an issue affecting women, the authors did an excellent job to include men in their study, this brings out a community’s holistic view on cervical cancer. Cervical cancer being a threat in sub-Saharan Africa with screening uptake being very low, this study is very relevant in highlighting some of the barriers to cervical cancer screening. The study is therefore quite relevant and is an attempt in filling the research gap as far as cervical cancer and screening are concerned.

The paper however fails to discuss the interpretation and implications of the findings

Secondly, it does not strongly bring out the new knowledge bone from the research.

While the methodology section provides some information, it is still unclear whether the authors used the same participants for both FGDs and IDI, and if so, what new findings each provided.

No differences were brought out concerning the general findings by gender and age, yet the authors had stratified the population based on age and gender.

Based on the findings I state that though the topic is quite relevant, it is important for the authors to address the key concerns raised so as to make their work more useful to readers. I am available to review a corrected manuscript. Other comments have been uploaded.

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Reviewer #1: No

Reviewer #2: No

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Attachment

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PLoS One. 2022 Jan 7;17(1):e0262142. doi: 10.1371/journal.pone.0262142.r002

Author response to Decision Letter 0

26 Aug 2021

26/08/2021

Violet Naanyu, PhD

Academic Editor

PLOS ONE

RE: PONE-D-21-21479: Communities’ perception of cervical cancer and screening in Wolaita zone, southern Ethiopia: A qualitative study

Dear Dr Naanyu,

Thank you for considering our manuscript and for arranging for it to be reviewed by two reviewers. We have tried to address your comments and the comments / suggestions from the two reviewers.

Please find for your kind consideration the following:

� In the Response to Reviewers, we copy each of the comments / suggestions and provide the RESPONSE underneath (below pages 2-13).

� We also provide a marked-up copy of the manuscript that highlights changes made to the original version and this is uploaded as a separate file labelled “Revised Manuscript with Track Changes”.

� Finally, we provide an unmarked version of the revised manuscript without tracked changes and this is uploaded as a separate file labelled 'Manuscript'.

We have been carefully through the peer review and have revised our paper accordingly. We feel that the paper is much improved as a result of this peer review process, and thank you for taking it to this stage.

While hoping that these changes would meet with your favourable consideration, we hold ourselves at your entire disposition for any further information or other changes you might require.

Best wishes

Gedion Asnake Azeze; on behalf of the co-authors

POINT BY POINT RESPONSE TO THE EDITOR AND REVIEWERS SUGGESTIONS

Response to Academic Editor:

Ensure you provide the missing details in the methodology.

RESPONSE: Given the general nature of the comment, we have tried to add few more details in methods sections.

Remember to show findings stratified by key dimensions including sites, age, and gender.

RESPONSE: Changes were made to all quotes at which sites, age and sex dimensions were indicated.

Stregthten implications of your findings broadly, but more specifically for the community of research.

RESPONSE: we have tried to add more on ‘Implication to practice section’ and for that matter; we have modified this section to ‘Implication for research, policy and practice’

Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming.

RESPONSE: We have checked and have ensured that the manuscript meets the journal’s requirements.

When reporting the results of qualitative research, we suggest consulting the COREQ guidelines: In this case, please consider including more information on the number of interviewers, their training and characteristics. Moreover, please provide the interview guide used as a Supplementary File.

RESPONSE: we have made changes and guide has been added as ‘Supplementary file_1’

We note that your paper includes detailed descriptions of individual patients/participants. As per the PLOS ONE policy on papers that include identifying, or potentially identifying, information, the individual(s) or parent(s)/guardian(s) must be informed of the terms of the PLOS open-access (CC-BY) license and provide specific permission for publication of these details under the terms of this license. Please download the Consent Form for Publication in a PLOS Journal. The signed consent form should not be submitted with the manuscript, but should be securely filed in the individual's case notes. Please amend the methods section and ethics statement of the manuscript to explicitly state that the patient/participant has provided consent for publication: “The individual in this manuscript has given written informed consent (as outlined in PLOS consent form) to publish these case details..

RESPONSE: we have made all the necessary amendments.

Response to Reviewer 1:

We thank the reviewer for reviewing this paper and for the detailed comments and suggestions.

The different points raised by the reviewer include:

While I find the manuscript technically sound, and it has a lot of data - including verbatim reports, I found it a little shallow because it is merely descriptive. The knowledge it generates (that rural communities in the context of study do not have adequate information on the cancer of the cervix and therefore there is need to educate them) is almost obvious.

RESPONSE: we would like to thank the reviewer for encouraging response. By taking this concern of the reviewer and the comments from reviewer#2 on the method, result, discussion and implication section of the manuscript, we have made several amendments and we believe these changes have been useful in improving this paper.

i) Would the author consider referring to Communities’ 'perceptions' rather than ‘perception’? I am sure that there are many perceptions -and the author presents many of these on different aspects of cervical cancer and screening in Ethiopia. In fact, if consideration was of only one aspect such as cause of cancer, there would be many perceptions within one community - likewise in many communities.

RESPONSE: we found this comment very helpful and we have replaced the word ‘perception’ to ‘perceptions’ throughout the document.

ii) Would the author consider referring to researchers/research assistants instead of 'collectors'? In qualitative data collection, one would not merely be a data collector.

RESPONSE: we have replaced data ‘collectors’ by ‘research assistants’.

iii) I am curious – were interviews done in a local language? What is the local term for ‘cervical cancer’? In many African communities, there is no word for cancer of the cervix per se. For many people it would be cancer of the stomach. How did the interviewer introduce or describe it?

RESPONSE: interviews were conducted in local language, ‘Wolaitegna’ and ‘Amharic’ language; the local term for ‘cervical cancer’ is “Barka” in Wolaitegna and “Yemahitsen ber nekersa” in Amharic (line# 193-194).

iv) There is reference to HIV/AIDS as a disease. It is important to distinguish between HIV and AIDS. Again what is HIV/AIDS in the local language?

RESPONSE: we have made corrections on HIV/AIDS. There is no local term for HIV/AIDS and study participants were communicating throughout the discussion mentioning HIV/AIDS as it stands.

The manuscript is derived from a qualitative descriptive study design so statistical analysis does not apply. The presentation is intelligible but like I allude in a previous comment, there is little novelty.

RESPONSE: thank you but we now assume that the manuscript will get some improvements after incorporating and addressing the suggestions and comments.

Response to Reviewer 2:

We thank the reviewer for reviewing this paper and for the detailed comments and suggestions.

We have tried to revise the manuscript in line with these comments and suggestions.

The different points raised include:

The strength of this manuscript is that it addresses a pertinent issues concerning cervical cancer, presents findings and as such the paper represent a community’s view which will influence policy in Ethiopia and generally increase knowledge on cervical cancer screening in Sub Saharan Africa. This manuscript does an excellent job in researching on cervical cancer among non -medical/ health participants. Though an issue affecting women, the authors did an excellent job to include men in their study, this brings out a community’s holistic view on cervical cancer. Cervical cancer being a threat in sub-Saharan Africa with screening uptake being very low, this study is very relevant in highlighting some of the barriers to cervical cancer screening. The study is therefore quite relevant and is an attempt in filling the research gap as far as cervical cancer and screening are concerned. The paper however fails to discuss the interpretation and implications of the findings and secondly it does not strongly bring out the new knowledge bone from the research.

RESPONSE: Thank you for the encouraging comment. We take note of your concern about discussing the interpretation and implications of the findings and we have made several amendments in the revised manuscript.

While the methodology section provides some information, it is still unclear whether the authors used the same participants for both FGDs and IDI and if so what new findings did each provide.

RESPONSE: No, they were exclusive, none of FGD participants included in IDI and vice-versa.

No differences were brought out concerning the general findings between gender and age yet the authors had stratified the population based on age and gender.

RESPONSE: The general finding is not different but it was stratified to help readers know the details of the participants.

Based on the findings I state that though the topic is quite relevant, it is important for the authors to address the key concerns raised so as to attract wider readability after publication.

RESPONSE: thank you. We found this advice very relevant to improve our manuscript and we have tried to address the concerns raised by both authors by adding new sentences, paragraphs and references.

2. Discussion of specific areas for improvement

A. Major

The scope of the study is well provided and the presentation is consistent throughout the manuscript. Though the manuscript is well written and nicely presented descriptively, the area of the study setting is well described and brings out the necessity for this kind of study. Though this manuscript presents a balanced assessment of cervical cancer and shows evidence of being well researched, the authors were mean with pertinent information and therefore the following areas need some revision;

• The scope of the study is well provided and the presentation is consistent throughout the manuscript. Though the manuscript is well written and nicely prese The findings that the study produces are very critical but have no implications, and they only need one or two sentences to bring out the implication of each findings.

RESPONSE: Thank you. We take note of your advice about findings implications and we have made changes accordingly.

• The manuscript is well written with key subtopics availed. The authors however need to be more analytical in data presentation. The excerpts are presented and not interpreted at all. Making it difficult to make exact meaning from the excerpts. It is always good practice to interpret all findings, this makes it easy to come up with the implications of the findings. The manuscript would be more useful to a broader readership if the authors moved from just providing results to interpreting them and giving the implication as well.

RESPONSE: thank you once again for your valuable comments. Since the reviewer provided specific areas for improvements hereunder (especially on the result, discussion and Implication section), we’ve tried to interpret each finding and to put their implication.

• I tend to think that the authors oversimplified the findings thus inhibiting the deeper message that the subject under study could provide.

RESPONSE: for this comment, and including the previous two, we have tried to modify the ‘result’ and ‘discussion’ sections and we have broadened the ‘Implications for practice’ section by adding some valuable implication statements that summarize our findings.in the revised manuscript, this section has been changed to ‘Implication for research, policy and practice’.

• The citations should also have deeper analysis rather than simply being quoted, they should be linked to the study either as an agreement in findings or a deviation from the findings.

RESPONSE: we have tried to discuss in detail on some of cited references. From Line 302 to 308, for instance, there are three cited references. We have mentioned that the findings of these studies were in agreement with ours. So, from these three citations, we picked two and we tried to discuss in detail (line 303 to 308). Similarly, we followed the same thing on line# 315–319; line# 322–326 and line# 328–333.

• The manuscript provides a recommendation but has no summary on suggested direction that people in the study area need to take and as such there is no takeaway.

RESPONSE: After this comment, we have tried to put some directions on our recommendations particularly on ‘Implication for research, policy and practice’ section.

Background

• Line 46- What is the source of this definition?

RESPONSE: We put a citation on the mentioned definition (line# 48)

• Line 50- Any woman who is sexually active is at risk of getting HPV- this needs to be explained further so that it does not appear hanging.

RESPONSE: now, we believe that the statement is well explained (line# 51-53 )

• Some brief literature review of a country where cervical cancer is low could improve the background.

RESPONSE: we have made a literature search and we added a new statements that describes low cervical cancer prevalence (line# 60-64)

Sampling size and sampling technique

• How did you get the sample? What was the inclusion and exclusion criteria?

RESPONSE we have modified both the ‘participants’ and ‘sample size and sampling technique’ sections; adding inclusion and exclusion criteria on ‘participants’ section and sampling method on ‘sample size and sampling technique’ (line# 108-112)

• Line 86-state why the two districts were selected to participate in this study ( Boloso Sore & Sodo Zuriya).

RESPONSE: the two districts, namely Boloso Sore & Sodo Zuriya of Wolaita zone, were selected randomly (line# 113) from the total of 15 districts of Wolaita zone.

• Line 110-112 – 4 females and 2 male nurses were trained- are they research assistants? If so explain why they had all to be nurses to participate in data collection.¬¬

RESPONSE: Yes, those 4 females and 2 male nurses were our research assistants. These research assistants were fluent in the required local languages; they were used to prompt discussion and elicit further details through probes during FGDs. We have replaced words like ‘collectors’ or ‘data collectors’ with ‘research assistants’ throughout the document because this comment was raised by reviewer#1. They were all nurses because of their previous qualitative data collection experiences (line# 128-132).

• Line 136- which themes were they- mention the themes here to complete this statement.

RESPONSE: thank you. We have mentioned the themes and completed the statement.

• Line 153-154 Awareness about cervical cancer- authors talk of ‘most participants’-though this is a qualitative study, it does no wrong to mention roughly how many participants instead of using the term “most”.

RESPONSE: We understand the reviewer’s point. Nevertheless, we find this comment a little difficult to address since we did not take a note on the exact number of participants who have not heard about cervical cancer. During the analysis, when a term or a concept gets repeated several times by different group of participant we take that as most indicating that it is more of their conclusion or what most assume to be true.

• Line 158- Authors talk about misconceptions but only present one misconception from the FGDs and not IDIs do the authors imply that all the respondents had similar misconceptions? Secondly, what is the implication of these misconceptions?

RESPONSE: Thank you. First, since we have got only one misconception from FGDs, we made a correction on the word ‘misconceptions’ and we replaced it with ‘misconception’. Not all participants but most of them had the mentioned misconception. Secondly, since this misconception is associated with lack of awareness on what cervical cancer is, we have tried to put the implication (together with other awareness related issues) on ‘Implication for research, policy and practice’ section (line# 378-9).

Data collection procedures

• It is not clear whether they are the same participants who were in the FGDs and interviews? Explain to clarify this. If they were different how did you choose those to participate in the FGD and who to participate in the IDI? If they participated in both what new information were you looking for and how did you carry out this? How many participants did you get per area?

RESPONSE: No, participants who participated in FGDs and IDIs were not the same. We used the same criteria to select participants. A total of eight participants were interviewed and there were fifty-one participants in FGD, each FGD has 5–7 participants.

• L118- authors have used the term “Unapproachable’’ I advise that they get a better term that is not judgmental.

RESPONSE: changes made as suggested (line# 138).

• Line 120-121-Make it clearer- which collectors? Are they data collectors? - A bit confusing. Did the data collection exercise take place concurrently in both districts or did the same researchers finish work in one district before going to another.

RESPONSE: as explained earlier, we have replaced ‘data collectors’ or ‘collectors’ with the phrase ‘research assistants’ in the current revised manuscript after a comment given by reviewr#1. They were research assistants for our study. The same research assistants participated in both districts after finishing the other.

Data management

• Line 127-129- which quality control procedures did the authors establish for their study?

RESPONSE: the quality control procedure for the study that we followed include: recruiting research assistants with qualitative study experience, training provided for the research assistants and pre-testing the instrument.

Results

• Table 1 – needs some write up to explain the figures rather than simply putting the table and leaving it that way,

RESPONSE: we have introduced a sentence and we have now tried to describe the table. Since there are limited variables in the table, we failed to add more description.

• It is important to state how many participants were in IDIs

RESPONSE: In methods section (line# 119), we have indicated number of IDIs and each IDI had one participant. We have not had any group interviews.

• Did all the 59 participate in IDIs?

RESPONSE: No, IDI and FGD had different participants.

Line 166- 183 Risk factors for cervical cancer

• This section is well explained though again the urban responses are not distinguished from the rural areas yet such distinctions can be quite important for recommendations

RESPONSE: Although the participant mentioned of rural, it is worth to note that she is from urban setting. The thing is little to no difference was observed among the residents of urban and rural, indicating that there is poor awareness from both sides. Hence, the overall recommendation would work for both settings.

• Line 181-183 talks about the men FGDs what came out from the women FGDs? This would also bring out gender differences as far as views on cervical cancer are concerned thus enriching the study.

RESPONSE: we have made changes accordingly after reviewing the transcriptions and code report (line# 212).

• The authors had also mentioned earlier that younger men/women were in different FGDs- what was the difference in the findings based on age?

RESPONSE: no difference was observed based on their any of socio-demographic characteristics, the detailed descriptions were just to aid readers and to further contextualize in any future research.

Line 184-200-Awareness about symptoms of cervical cancer

• What are the implications of these awareness of the symptoms?

RESPONSE: we have added on the implications of poor or lack of awareness on the symptoms of cervical cancer (line# 360-367; 377-384).

Line 201-Perception about cervical cancer screening

• This section should bring out differences based on gender age and location (urban & rural) and also between the two districts of Wolaita zone- namely Boloso sore & Sodo Zuriya as well as the two urban and two rural Kebeles to strengthen the findings. If the findings are similar in these regions, what is the implication? What if they are different? Do the authors imply that all the 9 FGDs and 8 IDIs had similar findings?

RESPONSE: like we mentioned earlier, it has no difference based on age, sex, place of residence or any other characteristics, however descriptions were reported to aid readers. If this is found to be unnecessary do let us know the reason then we shall remove it.

Line 229- prevention and treatment of cervical cancer

Let the authors bring out the key points concerning cervical cancer prevention as discussed by

i) The urban dwellers

ii) Rural dwellers

iii) Young girls

iv) Young men

v) Older men/women

RESPONSE: the analysis showed that there is no major difference observed, quotes were picked up when found to be more expressive but the overall summary before quotes shows the perceptions of majority of the participants. Hence, classification based on the above guide was not found to be necessary.

• What are the implications of the same to treatment? Even if it is a qualitative study it needs to be detailed in presentation of results so as to clearly bring out the implications of the findings.

RESPONSE: based on the given comment, attempts were made to make changes

• Though it is a quantitative study, the authors should avoid using terms like “several, many” etc just state how many. And where possible put figures or percentages or eg out of the 4 FGDs, 3 were of the view that e.g cervical cancer is similar to HIV/AIDS.

RESPONSE: Thank you. Changes have been made after reviewing the transcription and code reports.

Risk factors for cervical cancer

• Line 175-180-Interpret the findings and give meaning to what the participants mean by talking about womb expulsion.

RESPONSE: comment was accepted and we have made changes (line# 321–326)

• Line 206-208- what is the implication of such results?

RESPONSE: our finding supports the need for cervical cancer prevention education. In our revised manuscript, we have tried to show the implication of such findings under the section ‘Implication for research, policy and practice’(line# 373-379).

• Interpret the excerpts and give their implication eg line 221-228- looks disjointed when not explained before getting into another section.

RESPONSE: thank you. Together with the comment given below, we have tried to interpret and explain the finding and we have tried to put the implications (271-273; 368-369).

• Line 245- What do the authors mean by “any other free method of screening”? Explain further, is it the financial free method or is it the screening procedure that the participants prefer.

RESPONSE: from our finding one can see that provider initiated pelvic examination was identified as a barrier for screening uptake. Therefore, by saying “any other method of screening”, we mean the preferred screening procedures but not the financial fee. For this, we have tried to put implications (368-369).

Discussion

• Line 262-264 what does this imply based on this study findings?

RESPONSE: Changes have been made (line# 316-320).

• Line 265-266 what was the most common finding of these studies that was common to the authors’ study?

RESPONSE: what makes the study findings similar with that of ours is that having pelvic examination was taken as a barrier for undergoing cervical cancer screening. We have tried to explain by taking and explaining one of these cited reference (line# 329-332).

• Line 264- link this to your study. Did the authors also establish in their study that women of low socio-economic status were at a higher risk of cervical cancer? If so according to their study what is the contributing factor and what new information came from this study?

RESPONSE: Thank you for this valuable comment. We have made changes accordingly (line# 316-320).

• Line 265-Let it be pelvic examination rather than pelvic exam

RESPONSE: we have made a correction.

• Line 274-275- after noting the importance what were the results or the response?

RESPONSE: we have tried to show the results of the mentioned study (line# 341-344).

• Discussion section should be improved by linking the study findings to earlier works on the subject area.

RESPONSE: we have tried to modify the discussion section based on the given comment.

Minor Issues

• The study needs quick edit, there are a few mistakes on typos, tenses and spellings

RESPONSE: the manuscript was reviewed and we have tried to make corrections

• There are a few minor observations especially on repetition

RESPONSE: this has been adjusted accordingly

• The study did not have any funding- check financial disclosure section- which states-the authors received no specific funding for this work pg 2 then on pg 22 line 302 - Wolaita Sodo University provided funding for this study, so which is which? Or what is the authors’ interpretation of funding?

RESPONSE: we have added a new section, ’Funding’, and this has been clarified

Attachment

Submitted filename: Response to Reviewers.docx

Click here for additional data file. (40.2KB, docx)

Decision Letter 1

Violet Naanyu

15 Sep 2021

PONE-D-21-21479R1Communities’ perceptions of cervical cancer and screening in Wolaita zone, southern Ethiopia: A qualitative studyPLOS ONE

Dear Gedion Asnake Azeze, 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.

Thank you for addressing Reviewer comments.Edit grammatical error and submit a refined copy.

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We look forward to receiving your revised manuscript.

Kind regards,

Violet Naanyu, PhD

Academic Editor

PLOS ONE

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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.

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Reviewer #1: All comments have been addressed

Reviewer #2: All comments have been addressed

**********

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Reviewer #2: Yes

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Reviewer #1: _ Right from title, the authors should refer to perceptions - It cant be one perception among many communities - well within one community the perceptions are many.

-

Reviewer #2: The authors have addressed all the concerns raised. Just polish up grammatical errors like line 138, line 172-173 and line 244.

**********

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Reviewer #1: Yes: Eunice Kamaara

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PLoS One. 2022 Jan 7;17(1):e0262142. doi: 10.1371/journal.pone.0262142.r004

Author response to Decision Letter 1

22 Sep 2021

22/09/2021

Violet Naanyu, PhD

Academic Editor

PLOS ONE

RE: [PONE-D-21-21479R1]: Communities’ perceptions of cervical cancer and screening in Wolaita zone, southern Ethiopia: A qualitative study

Dear Dr Naanyu,

Once again, we would like to thank you for considering our manuscript and for arranging for it to be reviewed by reviewer(s). We have tried to address your comments and the comments / suggestions from the reviewer(s). In the ‘Response to Reviewers’, we copy each of the comments and provide the RESPONSE underneath. We also provide a marked-up copy of the manuscript that highlights changes made to the original version and this is uploaded as a separate file called “Manuscript with Track Changes”. Finally, we provide an unmarked version of the revised manuscript without tracked changes and this is uploaded as a separate file labelled 'Manuscript'.

We have been carefully through the peer review and have revised our paper accordingly. We feel that the paper is much improved as a result of this peer review process, and thank you for taking it to this stage.

While hoping that these changes would meet with your favourable consideration, we hold ourselves at your entire disposition for any further information or other changes you might require.

Best wishes

Gedion Asnake Azeze, on behalf of the co-authors

Journal requirement’s:

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 Reference list and also include a citation and full reference for the retraction notice.

Response:

We have reviewed our reference list and we have checked and updated all the URL links.

Response to reviewers

We would like to thank both the reviewer for reviewing this paper and for their comments and suggestions.

Reviewer #1

Right from title, the authors should refer to perceptions – It can be one perception among many communities –well within one community the perceptions are many.

Response:

Thank you. We have addressed this comment during the first revision and we have also checked the consistency in this current revision.

Reviewer #2

The authors have addressed all the concerns raised. Just polish up grammatical errors like line 138, line 172-173 and line 244.

Response:

We have made revisions to correct grammar and language use throughout the document. In this revised manuscript, we also believed we improved the overall tone and readability. We hope that our revisions meet your expectations.

Attachment

Submitted filename: Response to Reviewers.docx

Click here for additional data file. (15.7KB, docx)

Decision Letter 2

Violet Naanyu

17 Dec 2021

Communities’ perceptions towards cervical cancer and its screening in Wolaita zone, southern Ethiopia: A qualitative study

PONE-D-21-21479R2

Dear Gedion Azeze,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

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Kind regards,

Violet Naanyu, PhD

Academic Editor

PLOS ONE

Acceptance letter

Violet Naanyu

31 Dec 2021

PONE-D-21-21479R2

Communities’ perceptions towards cervical cancer and its screening in Wolaita zone, southern Ethiopia: A qualitative study

Dear Dr. Azeze:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org.

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Thank you for submitting your work to PLOS ONE and supporting open access.

Kind regards,

PLOS ONE Editorial Office Staff

on behalf of

Prof. Violet Naanyu

Academic Editor

PLOS ONE

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