Reviewer ’s report  
 
Title: Breast cancer screening practices of African migrant women in Australia: a descriptive 
cross -sectional study  
 
Version: 0 Date: 20 Nov 2016  
 
Reviewer: Ikechukwu Iloabachie  
 
Reviewer's report:  
 
The third aim of the paper t o investigate the relationship between African immigrants' cultural 
beliefs and their breast cancer  screening practices is a good one as it should help inform 
measures aimed at promoting awareness and improving uptake of breast cancer screening. This 
paper  however fell short of that stated aim. The reference section of the paper includes other 
research articles with similar themes done in the UK and US (Ndukwe E.G et al and Jones C.E.L 
et al) and both those papers employed interviews and focus group discuss ions to identify the 
breast screening practice and behaviours behind it. Had the method been employed with the 
insights already provided by the existing studies a better picture of the screening practices and 
the attitudes informing them would have been ob tained. This in my opinion was not the case. 
The main instrument for this study was not broad enough in scope to capture all the various 
possible reasons why women may not want to attend screening services. The two studies already 
mentioned identified a lo t more barriers which could have been explored in this paper.  
It is always a sensitive issue when studying a particular ethnicity or group of people like this 
study did and therefore a certain level of tact is required. I failed to see what was inherently  
African in the tool used by the authors that could not apply to any other group of people. It was 
mentioned that the tool is culturally sensitive but it was still administered in English and had 
nothing in it that would suggest it had any relation to any particular African culture. It also 
seemed that the instrument used was not validated prior to the onset of the study as was 
mentioned in the study. Note is made however that a study validating the instrument by the same 
authors was found, interestingly us ing the same cohort of participants.  
I also note in the background section of the study the tendency to assume that African women are 
a homogenous group. Practices identified in a particular group of women were used as evidence 
for statements describing a ll African women and this was despite other studies already 
mentioned and this one as well cautioning against doing just that.  
The citing of articles in the background section could be better. One of the studies cited as 
evidence that women from culturall y and linguistically diverse backgrounds presented for 
screening less than Australian born women was done in the US and the other was by the authors 
themselves. Out of four studies that were cited to back the claim of low participation in screening 
measure s among African 'immigrant' women, two were conducted in West Africa and one of 
them, as the title suggests, was on female genital mutilation. The study by Jones et al was used in 
support of the claim that African women believe breast cancer is a curse inf licted by evil spirits. 
However, having read the article and conducted a search of the article, there was no mention of 
evil spirits in it. There was also in the whole section as regards beliefs, a tendency to state 
findings from interviews in qualitative studies that had no statistical analysis based on the nature 
of the studies as facts that can be applied to the whole community of African women.  
The discussion of the findings does not seem balanced and wants a certain level of objectivity. 
High particip ation rates in mammography in African women is treated with caution while low 
rates of CBE and monthly breast awareness was considered alarming.  
Furthermore the discussion explains findings of the study based on factors identified by other 
studies in othe r countries. One of these is the explanation of findings based on the  beliefs of 
African women which could have been but was not examined in this study and was yet discussed 
as it was, (page 10 second paragraph).  
"Even though low participation rates ha ve been reported among other migrant populations in 
Australia [18] and the USA [15], this appears to be one of the lowest rates  among CALD groups 
in Australia." The latter part of this statement is not supported by an appropriate reference.  
Collaboration with religious organisations is highlighted as a way of improving screening 
attitudes and a quasi religious slogan is offered to help educate the women even though a study 
referenced, Jones CEL et al, states that in a systematic review found limited eviden ce for 
religiosity and late presentation with breast cancer.  
It is also difficult for me to reconcile the following statement, "Most were married (66.2%), had 
attained secondary  or tertiary or education qualifications (58.3%), spoke English at home 
(74.6 %) and rated their English level as very good (56.8%)." with "There are information 
booklets and pamphlets on breast cancer prevention visibly displayed in medical centres. But 
then, it is  possible that these resources are not available in languages spoken  by many African 
migrants and it is also possible that the African migrant women are  not literate in their own 
languages." or this "The study had some limitations that need to be considered. The African 
version of the BCSBQ was available only in English. T his would have disadvantaged some 
illiterate African migrant women who were not able to read or write in English." In addition, 
going by data presented in the article, 91% of the participants had a secondary education or more 
and 85% rated their English as  good or very good. It becomes confusing how illiteracy is an 
issue in discussing the findings or limitations of the study.  
The final conclusion on screening being suboptimal is not entirely supported by the finding of 
high participation in mammography and could be phrased better. All in all the study is not clear 
on what demographic factors or attitudes influence breast screen ing behaviour of African 
migrant women in Australia. A host of reasons had been identified in other studies and I doubt it 
will be immediately apparent which are relevant in Australia or what area needs to be tackled to 
improve participation in the migrant  women.  
Are the methods appropriate and well described?  
If not, please specify what is required in your comments to the authors.  
 
No 
 
Does the work include the necessary controls?  
If not, please specify which controls are required in your comments to the authors.  
 
Unable to assess  
 
Are the conclusions drawn adequately supported  by the data shown?  
If not, please explain in your comments to the authors.  
 
No 
 
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 spec ify what aspects require further  
assessment in your comments to the editors.  
 
I recommend additional statistical review  
 
Quality of written English  
Please indicate the quality of language in the manuscript:  
 
Acceptable  
 
Declaration of competing interests  
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