Reviewer's report
Title:Psychological impact, support and information needs for women with an
abnormal Pap smear: comparative results of a questionnaire in three European
countries
Version: 1Date:17 November 2010
Reviewer: Maarit Leinonen
Reviewer's report:
There is increasing amount of talk about psychological consequences of having
an abnormal Pap test result. This is a valuable work as the same questionnaire
was administered in different countries. The study question is well defined and
methods are appropriate to study the issue. . Writing is mainly acceptable,
though there were sentences that were very hard follow. While I generally think
that this is good study, I have many concerns that should be taken into account.
Major Compulsory Revisions:
1. As what I consider a major point is that there appears now tabulation only by
country. The material allows more, however. For instance, authors write in the
Background that women often feel stressed and anxious when they are told to
have abnormal Pap test result and that this is irrespective of the grade. However,
it would be very interesting to see how the emotions in Table 2 are related to
severity of the Pap abnormality. Of great importance this cross-tabulation
between Pap result grade and the emotions would be in Table 4. Treatments
given (disease management) are strongly related to severity of Pap test and
hence data from disease management between countries do not give any
additional information for the manuscript unless the severity of the Pap test is
known. Also the treatment affects the emotions and results of feelings should be
presented by treatment. It has been discussed (Discussion, 3rd par.) that
treatment type did not have a large impact on worry but this data has not been
shown. Similarly, whether type of announcement affects emotions. All these
cross-tabulations can still me made by country.
2. Second, authors use the term “diagnosis” in two different contexts. They either
mean the initial abnormal Pap test result or the final histological diagnosis. An
abnormal test result does not necessarily mean that women would really have a
histological diagnosis. As a matter of fact, about 25% of women were diagnosed
to have diagnosis “nothing serious but requires monitoring”. The text should be
revised throughout and use test result instead of diagnosis when referring to Pap
test result.
3. The aim was to study how women are informed about the abnormal Pap test
result and how they experience it. I agree the conclusions in the main text and
that conclusions are based on the study. However, in the abstract conclusions
start “In the context of HPV vaccination…” This study really has nothing to with
HPV vaccines, so these kinds of phrases are dangerous as they can be later on
pulled out of the context. To expand results of this study to somewhat cover with
needs of vaccination programs is to my point of view more or less artificial and
should be avoided, at least it should not be emphasised. For the same reason,
the Background in the Abstract should be rewritten to better correspond to main
text.
4. In the Methods 1st par. authors do not explain the design of the study properly,
i.e. it is not obvious that was the questionnaire administrated before or after the
abnormal Pap result. Please clarify. Was the Pap test taken for cervical
screening or due bleeding symptoms and how women were informed before
sampling?
5. Limitations of the study has not been stated or discussed. Results are not
adjusted. For instance, demographic characteristics were reported to be similar
between the three countries. However, there were statistically significantly more
young participants in France than in Spain or Portugal. Young age is a known
determinant for an abnormal Pap smear which may affect the comparison
between countries. Moreover, there were significantly more single women in
France and Spain than in Portugal which may affect the results in Table 3.
6. The questionnaire was distributed in several countries, why results are here
reported only for three of them? Please clarify in the text.
Minor Essential Revisions:
1. In the Results, 7th par. authors write that scores concerning womens feelings
about consequences of their illness were generally low. More correct would be
term close to average.
2. In the Discussion 2nd par. “correlating with the higher level of stress”.
Correlation was not tested or the data is not shown. In case that it was not
tested, please use association instead.
3. Authors write that almost 80% oh the interviewed said that they definitely
needed more informations on cervical cancer and HPV-related diseases
(Results, 8th par.). This is the only results that has not been given by a country.
Moreover, where do this data come from? Personal interview or a question
number 14 in the form? In the latter case, the question was would woman like
more information not that would she need. Please clarify and correct the word if
needed.
4. A statistical test that has been used to test for differences between countries
has not been giving in the Methods nor in Footnotes. Please complete.
Discretionary Revisions:
1. Reporting follows choises in the questionnaire. However, for instance in Table
2 there are less words describing the feelings than in the form. It is not obvious
wheter there was no these choises at all or are they combined with the choise of
“Other”, could be clarified e.g. in the footnotes. Please consider to give all
choises as in the questionnaire form.
2. In the Results, in 3rd, 4th, 5th and 7th paragraphs the scale from one to ten
has been repeated in evey context even though explanation has been already
given in the Methods, 2nd par. Explanantions could be removed from the Results
and left on the footnotes as they already is.
3. When representing results on e.g. impact on quality of life (Results, 5th par.),
mean scores could be represented in descending order, thus giving the most
important (highest score) first.
4. The last sentence in the Background section in the Abstract describes
methods and could be removed to the Methods section. In the Methods, a
threshold for an abnormal Pap smear result could be given.
5. There could be cross-tabulation between information source and information
on how well-informed women felt themselves to be (Table 5).
Minor issues not for publication:
-An extra full stop in the Background, 2nd par. after the reference number 8.
-The questionnaire collected data on how the abnormal result was communicated
(Background, 5th par.)
-Can the copy of the questionnaire be provided as an appendix instead of
referring to a website?
-a scale from one to ten (Methods, 2nd par.)
-Overall, participants considered themselves to be reasonably well informed
about their disease and treatments (Results, 7th par.).
Level of interest: An article of importance in its field
Quality of written English: Needs some language corrections before being
published
Statistical review: Yes, and I have assessed the statistics in my report.
Declaration of competing interests:
I declare that I have no competing interests.