Reviewer ’s report  
 
Title:  Factors associated with cervical cancer screening p articipation among immigrants of 
Russian, Somali and Kurdish origin: A population -based study in Finland  
 
Version: 0 Date: 07 Nov 2016 
 
Reviewer:  Michael  O’Rorke  
 
Reviewer’s report:  
 
Specific comments:  
 
1. Among the Finnish general population, cervical cancer screening participation is 70%. 
Comparing this rate to the immigrant populations, Somali women in particular, had the lowest 
participation rates (34.7%). Coincidentally, Somali women also had the low est response rate in 
the original Maamu study (51%). Firstly, this calls into question the representativeness of Somali 
women in the current study with some 500 of an invited 1000 taking part (are those women that 
didn't take part in the survey significant ly different to those that have?). I think the authors 
should cite as a limitation in their discussion that the study findings may not be wholly 
representative of Somali immigrants. Secondly, this finding is important as it highlights that 
Somali women may  be a worthy target for future cervical cancer screening awareness initiatives 
in Finland. Although the authors highlight in their discussion that factors such as language 
barriers, living outside metropolitan areas (access to screening) and 
embarrassment/ discomfort/mistrust might be issues affecting higher participation rates in this 
group. I would echo the authors' final conclusion that qualitative studies are needed to learn more 
about the cultural barriers to cervical cancer screening, particularly in S omali women, but I 
wonder if their participation in such studies would be problematic also.  
 
2. Methods, page 4. The dependent variable was self -reported participation in PAP smear in 
the past five years in Finland and women were eligible for this study pr ovided they had resided 
in Finland for at least one year. Is there the potential for misclassification of exposure in 
immigrant women with short residency that lie outside the national screening interval? And does 
this period exclude PAP -smear attendances in the home country prior to immigration? In any 
case, it's evident from Table 1 that the majority of women interviewed were resident in Finland 
for 10 years or more, so the potential for misclassification here may be small, can you quantify 
this proportio n in anyway?  
 
3. Tables 3 and 4. These tables should stand alone from the results text with more 
descriptive heading and footnotes; I had some difficulty following them. In table 3 there appear 
to be 21 (n=599 not 620) fewer observations. Similarly in Table  4 the final count is 573 ( -47). Is 
this attributable to missing data in the factors under investigation? Also, there are some very 
wide CIs i.e.: OR 8.05 (95% CI 2.18 -29.7) and OR 9.34 (95% CI 1.58 -55.1) here. It would be 
nice to know the numbers of obser vations within categories to help the reader determine 
underlying statistical power in these models. This is especially true of Table 4, where there 
appear to be a lot of N/A.  Do these multiple logistic regression models adjust for any factors, if 
so, cou ld these be indicated in the footnotes.  
 
 
Minor comments:  
 
1. It wasn't clear from reading the paper why only three countries of origin were included in 
the Maamu study, do these represent the three largest ethnic minority groups in Finland?  
 
2. Introduction,  page 2. 'Previous studies have reported immigrants lower cervical cancer 
screening participation compared with non -immigrant women in different countries…' Can you 
provide references to these studies?  
 
3. Methods, page 4. Data collection and variables. 'Ba sed on previous studies on potential 
factors associated with cervical cancer screening participation…' Can you provide a reference for 
these studies?  
 
4. Table 2. Replace 'Cannot be estimated' with n/a or n/e as in other tables.  
 
Are the methods appropriate and well described?  
If not, please specify what is required in your comments to the authors.  
 
Yes 
 
Does the work include the necessary controls?  
If not, please specify which controls are required in your comments to the authors.  
 
Yes 
 
Are the conclusions drawn adequately supported by the data shown?  
If not, please explain in your comments to the  authors.  
 
Yes 
 
Are you able to assess any statistics in the manuscript or would you recommend an 
additional statistical review?  
If an additional statistical review is recommended, please specify what aspects require further 
assessment in your comments to the editors.  
 
I am able to assess the statistics  
 
Quality of written English  
Please indicate the quality of language in the manuscript:  
 
Acceptable  
 
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