Title: Does women's empowerment and their socioeconomic condition affect the uptake of
breast cancer screening? Findings from NFHS-5, India
Version: 3 Date: 20 Aug 2022
Reviewer's report:
I am glad to see that the writing has improved and the methodology of the paper is clearer.
However, there are still some typos and writing errors (I pointed out some of these below but not
all of them). Moreover, there is still a major flow in the method related to the implementation
of screening programmes across Indian states which is not accounted for in the methods and the
results. The main issue is that screening programmes have been implemented in some districts of
the Indian states, and research has shown that screening programmes strongly affect screening
uptake. Thus, Supplementary Table 2, Table 2, Table 3 and Figure 1 can be misleading since
screening programmes may be driving screening uptake levels rather than SES or WES. If some
states had “stronger” or earlier implementation of programmes, for example, this may induce
higher screening uptake in those states and may confound the results. Results could be valid
if it is the case that programmes were implemented “simultaneously” and “homogeneously”
across states (that programmes were “equally” distributed across states and had a similar effect
in those states), but more details on the programme implementation and solid references are
needed to argue for this (such as programme monitoring report for example). For the moment,
there are not enough details on this in the introduction nor the methods. Too little information
is given on those programmes while this is a direct determinant of screening uptake, was their
implementation completed by 2020 in all 667 districts or are these still rolling out? Are there
implementation reports (with % of invite and screened women)? Are these population-based
programmes sending letters to all women from the screening target population? What are the
actions taken by those programmes?
INTRODUCTION
The mechanism linking SES to screening uptake is now explained in the paper, but not how
“women empowerment status” may relate to cancer screening uptake (I had suggested references
on gender inequality and cancer screening which explain these mechanisms in the first review
(Jolidon 2022, Willems 2020))
METHODS
Some paragraphs have spaces and others not (consistency), for example: Data source, study
variables (p.6)
Please revise : “Dancey et.al” (p.7)
Please revise: “Thirdly” -> “firstly” and “secondly” are missing (p.7)
DISCUSSION
Please revise: “This ecological study analyzes populations in all states and UTs in India and
discusses the association of the socioeconomic and women empowerment indices with breast
cancer screening uptake using NFHS 5 dataset” -> This ecological study analyzes breast cancer
screening uptake across all states and UTs in India and its association with socioeconomic and
women empowerment indices
Please correct capital: “fundamental Cause Theory”
Please delete “The authors,” (p.11)
Please revise incorrect writing: “… implying lack of women empowerment which leads to lower
participation and poorer quality of health seeking among women”
Please revise: “This highlights that improved screening uptake will need more focused efforts
than women literacy, empowerment and socio-economic development.”
Revise capital letter: “Cancer stigma”
CONCLUSION:
Please revise: “This study underlines the improvements in socio-economic status (SES) and
women empowerment status (WES), improves breast cancer screening uptake in India”
LIMITATION
Please revise: “Better” -> higher
REFERENCES :
Thanks for adding the reference, but the year is missing: “NCG of India TMC. Consensus
Evidence Based Resource Stratified Guidelines on Secondary prevention of Cervical, Breast &
Oral cancers.”
Please fix the typo in: ”Dandona L, Dandona R, Anil Kumar G, Shukla DK, Paul VK,
Balakrishnan K, et al. Nations within a nation: variations in epidemiological transition across the
states of India, 1990â€“2016 in the Global Burden of Disease Study. Lancet. 2017;390:2437–
60.”