‘Between Inner Strength and Fighting Prejudice’: Psycho-Social Processes Implemented by Women with Leukemia Along the Illness Trajectory: A Grounded Theory Study

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

This was a very interesting paper. I was particularly intrigued by the "memoing" process you described as well as the result describing how the women "collaborated" with the disease. My only concern was the essentializing of "women." In the context of the culture wars you should be prepared to have pushback on this. The results of the study and responses of the women are very clearly gender specific to femininity, which some who are biologically women, yet don't identify as such, will resist. Your theoretical framework does not, at least as far as I could see, address that possible issue. 

Author Response

Please see file in attachment with authors' response to review 1

Author Response File: Author Response.pdf

Reviewer 2 Report

Comments and Suggestions for Authors

Thank you for asking me to review this grounded theory study of women’s experience of the leukaemia journey. I offer the following to improve the reporting of this study.

1.    Title – there is a spelling error

2.    Introduction – “bio-approachpsycho-social” this term is not recognised in google so either explain more or use recognised terminology. Psychosocial is not hyphenated. Line 63/63 needs supporting references. The introduction doesn’t really give a compelling argument on why a study specifically should be done. I would have expected to see some outcome data presented showing gender differences in survival, patient-reported outcome, experience etc. I also think there needs to be clarity on what the definition of woman is – are you talking about gender identify or gender at birth. I also think there needs to be an explanation of what is being defined as psychosocial processes. My perception of this is totally different to my medical colleagues so it is important to clarify what this is. Bear in mind this is a predominantly biomedical journal and audience, so they will need to be introduced to some of these concepts.

3.    Methods – where they outline the team, can they include the initials of who represented each area of expertise. Important to specify if the qualitative expert was an expert in grounded theory – a general qualitative researcher will not have the required skill to lead a grounded theory study. A purposive sampling technique was used so please can the criteria in which they purposefully selected participants be specified. If this was just based on the inclusion criteria then I would say it was a convenience sample. If the study was looking across the cancer trajectory then why were patients recruited only at the end of this time point. Nuances experienced at earlier parts of the pathway will potentially be missed. Table 3 and 4 needs the reference style changing in line with the journal guidance.

4.    Results: Table 5 is reporting at too granular level is no longer an acceptable way of reporting qualitative participants (you give the date of data collection and location of the hospital so there is a risk these patients could be identified). Please report the patient characteristics as a summary table. Section 3.2, you specify that this is a psychosocial study but this all pertains to the biomedical aspect of the journey. I would remove the figure and only refer to these side effects where they had an influence on the psychosocial experience. The themes are presented more like vignettes with patients words used as the text rather than an interpretive narrative with supporting quotes. It feels as if the narrative is being forces to be able to incorporate patient’s quotes rather than a cohesive narrative providing detailed explanation of the theory. Table 7 would not be required if there was sufficient narrative because the quotes would reflect/support this text.

5.    Discussion: I don’t see in the results what is different in women with leukaemia to patients per se with leukaemia or with other type of cancer. The gender aspect of this study does not emerge in the results and is not the focus of the discussion.

6.    Limitations: more reflection is required because there are a lot more obvious limitations to this study than the ones presented.

Comments on the Quality of English Language

I appreciate English is not the native language but this paper needs to be more carefully proof read for grammar and spelling errors and missing words.

Author Response

Please see file in attachment: response point by point to reviewer 2

Author Response File: Author Response.pdf

Reviewer 3 Report

Comments and Suggestions for Authors

This study addresses a qualitative, original, and highly interesting topic, and I believe it could make interesting contributions to the field of health sociology. Methodologically, it is solid, and theoretically, it could perhaps be improved with a more thorough review of studies in the introduction. However, in my opinion, there is a significant confusion that needs to be addressed, which is the conflation of a gender approach with an intersectional approach.

The gender approach focuses on power relations and inequality between genders, analyzing how gender roles, expectations, and norms influence people's lives, affecting their opportunities, rights, and well-being. A gender perspective seeks to make visible and correct the inequalities derived from gender, especially those that disadvantage women. I do not see that this article takes this direction, except for the lack of studies in the medical literature that go beyond sex differences.

In contrast, intersectionality considers how gender interacts with various dimensions of social identity and lived experience, such as health, body image, family dynamics, and emotional resilience, to create unique challenges. It explores how their experiences with the disease intersect with societal expectations of body image, family roles, and emotional strength. A woman undergoing treatment for leukemia may not only face the physical challenges of the illness but also feel societal pressure to maintain a certain appearance (e.g., hair loss or weight changes due to treatment affecting her self-image). Additionally, gendered expectations around caregiving may place extra strain on her family relationships. If she is a mother or primary caregiver, she might experience guilt or pressure to continue fulfilling those roles despite her illness. I believe this is precisely the direction the authors intended to follow.

My suggestion would be to speak of intersectionality rather than a gender approach and to center the introduction on this concept. Additionally, following this suggestion, I find a lack of depth in the analysis of the main intersectional factors:

• Body image: How leukemia affects a woman's physical appearance and how societal expectations about femininity influence her self-esteem.
• Family relationships: Gendered expectations of caregiving roles may complicate her relationships with family members as she balances her illness with societal and familial pressures.
• Resilience: The pressure to be resilient and "strong" may interact with these challenges, creating a complex emotional and social experience that is shaped by her gender and the illness itself. Women may feel the need to "be strong" and downplay their emotional or physical struggles to meet societal expectations of endurance, while at the same time managing the impacts of the illness on their self-esteem and relationships.

In this intersectional view, the experience of leukemia in women is not just about the illness, but also how it interacts with societal norms regarding beauty, caregiving, and emotional strength, creating a distinct and multifaceted experience.

Verbatims could be selected/added to better illustrate these points, and this aspect could be further developed in the introduction and discussion.

In the field of health sociology, there is indeed a broad literature on these topics that aligns with what the authors aim to contribute in the specific case of leukemia. Perhaps some pioneering and relevant studies could be cited using descriptors such as "sociology of health" or "medical sociology," "health research," "intersectionality," and "grounded theory." This would allow the authors to find related studies, even in the case of leukemia and other serious illnesses, which could be reviewed and referenced:

https://scholar.google.es/scholar?hl=es&as_sdt=0%2C5&q=grounded+theory+gender+sociology+of+health+leukemia+women&btnG=

 

Comments on the Quality of English Language

Regarding the English, I think the translation is not very good; some paragraphs read poorly, and there is even a typo (there is a "con" instead of "with" in the title). I suggest that the authors correct the errors and style, either with a native speaker or with the various AI tools that translate and improve style and fluency fantastically and for free.

Author Response

Please see file in attachment: responses to reviewer 3

Author Response File: Author Response.pdf

Round 2

Reviewer 2 Report

Comments and Suggestions for Authors

Thank you for asking me to re-review this paper following corrections. While the authors have made changes based on some of my recommendations, I don't support their arguments for not making changes on all of them. For example, I stated that "The themes are presented more like vignettes with patients words used as the text rather than an interpretive narrative with supporting quotes. It feels as if the narrative is being forces to be able to incorporate patient’s quotes rather than a cohesive narrative providing detailed explanation of the theory".

The authors say that this is innovative and a more effective way of presenting the results. I disagree and they use a mixed methods reference and not a GT reference to support their argument. The results presented in this way are not interesting to read and the narrative feels forced, to accommodate the patients words (especially as the patients words would have been in Italian not English). This is a biomedical journal not a social science journal so the authors might want to consider their audience. I stand by my original comment - if the narrative was presented traditionally as recommended for GT then the quotes in table 7 would interject with the text to support the interpretation. I find I am moving back and forth between the table and text to check that they align. It is a lot to ask of a reader. I think the authors also need to make it clear in the limitations (as I suggested reflecting on what other limitations there were in this study), that the participants represent, a small number of white, middle aged women from a specific region of Italy. They are all educated so they will have the capacity for some degree of reflection. I would be interested to know about the younger and older women's experiences, especially the younger adults who are still developing their identify. If the study is look at psychosocial impacts, it would also have been good to know how many had a history of mental health problems or required MH support through treatment, as this will impact their perceptions.

 

 

Comments on the Quality of English Language

Improved

Author Response

Dear reviewer,

Thank you for your valuable suggestions for our work. We have attached our answers to your questions in the file.

Best regards

Giovanna Artioli

Author Response File: Author Response.pdf

Reviewer 3 Report

Comments and Suggestions for Authors

The changes done seem fine to me

Author Response

Dear reviewer,

Thanks very much!

Best regards

Giovanna Artioli

 

Round 3

Reviewer 2 Report

Comments and Suggestions for Authors

Thank you for correcting your manuscript. The findings are much clearer and easier to read.