Reviewer ’s report  
 
Title: Barriers to cervical screening among older wom en from hard -to-reach groups: a 
qualitative study in England  
 
Version: 0 Date: 16 Dec 2018  
 
Reviewer: Shu-Han You  
 
Reviewer's report:  
 
There are quite a few studies focusing on women's knowledge and attitude towards cervical 
screening and cervical cancer. This study concentrated on the low SES and minor ethnicity group 
in age 50 -64 years w omen who had lower cervical screening coverage. The assessment indicated 
that poor knowledge and low perceived risk, such as sexually inactive women and other barriers 
including negative experiences may cause the unattendance of cervical screening. This st udy 
helps us to have more comprehension to the inequalities in awareness of cervical screening and 
also assists the public health issue for women health promotion in the specific groups.  
 
 
Generally speaking, the purpose of understanding the specific group  of women's' attitudes to 
cervical cancer and screening meet the aims and scope of this journal. The study design is 
appropriate to answer the question and the qualitative study is suitable for the in -depth analysis 
in the focus groups. The following are s ome comments and questions in each section.  
 
 
1. Material and methods: This study was a flow online sampling. There are two ways of 
recruitment.  
 
P.5, Line 18 "Four focus groups with ethnic minority women were organised through community 
groups. Community gr oups indicated their interest in helping with the research after seeing an 
advert describing the project that was posted on an online community group network page. 
Community leaders were asked to recruit women and were offered a financial donation for 
helping to do this. Two focus groups with women from lower socio -economic backgrounds were 
organised by a market research company." Are the people characteristics different due to the 
different ways of sampling? For example, those people who may more frequentl y access to the 
network page or the social media. The sampling number is relatively small in qualitative study; 
thus, the possibility of specific characteristics and the bias resulting from the way of sampling 
should be clearly described.  
 
 
2. Results: In table 1, why is the nonresponse (unanswered) rate higher in group 6? Owing to the 
data of self -reported screening history, there should be a recall bias according to the normal or 
abnormal pap smear result. Do you collect the data of pap smear result from the patient? What do 
you think are the reasons for the discordance of "currently up -to-date" and "will go in future"?  
 
3. Result: In "Knowledge of cervical cancer risk factors", it included sexual behavior, age, and 
others. As we know, HPV infection is an important risk factor to cervical cancer, but only one 
woman mentioned about HPV infection. Is the poor awareness of HPV particularly in these 
group of people?  
 
 
4. Results: In "Knowledge of cervical screening", since you have mentioned "Reasons for poor 
knowledge". P.9, Line 7, "One woman in this group discussed a common 'myth' that cervical 
cancer was a disease people got as a result of having 'done bad things'." Do you collect the 
information of religion?  
 
 
5. Results: P.10, Line 39, should be female geni tal mutilation  
 
 
6. Discussion: There is in -depth interpretation of the awareness to cervical cancer and barriers to 
cervical screening in low SES and minor ethnicity women. Can you more distinctively identify 
the association between non -up-to-date and non -intend to future screening? In other words, are 
more up -to-date women decide to be screened in the future or the non -up-to-date women will 
attend future screening? Probably, the barriers of the three types of people: never -screened, non -
up-to-date, and not  intend to be screened are variant despite all of which led to the decreased rate 
of cervical screening. According, I suggest the barriers in the three types of people should be 
analyzed and discussed respectively.  
 
 
7. Discussion: Limitation should include  sampling bias, reliability of self -reported screening 
history, such uncomfortable or distressful experience and abnormal result may cause recalled 
bias. 
 
 
8. In Conclusions, health professional attitude may have more impact on the low SES and minor 
ethnici ty group due to their poorer knowledge or understanding to the purpose of cervical 
screening. The detailed explanation and well -informed in advance could ease their anxiety 
during the procedure and improve the barriers for future screening.  
 
 
 
 
 
 
 
 
 
 
 
 
Are the methods appropriate and well described?  
If not, please specify w hat 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.  
 
Unable to assess  
 
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 manus cript or would you recommend an 
additional statistical review?  
If an additional statistical review is recommended, please speci fy 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:  
 
Needs some l anguage corrections before being published  
 
Declaration of competing interests  
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