Title: Using Delphi method to develop Chinese women’s cervical cancer screening intention
scale based on planned behavior theory
Version: 2 Date: 21 Aug 2022
Reviewer:  Francesca De Nard
Reviewer's report:
Dear authors,
This article illustrates the development of a theoretically based cervical cancer screening
participation intention scale for Chinese women, using the Delphi methodology.
The topic of cervical cancer screening participation in China is relevant.
The scale was developed based on the theoretical framework of the reasoned action approach/
theory of planned behavior. I believe that this framework will provide interesting insights on
the topic, relevant for policy makers. The methodology of the study is solid and generally well
reported.
However, in my opinion the paper might benefit from some minor revisions.
The paper is interesting to read and generally easy to understand, but some sentences are unclear
and might need proof reading.
The methodology is well described, but the quality of the reporting could be improved.
It seems that a modified Dephi methodology has been conducted: usually the Dephi (or e-Delphi)
does not include the possibility for participants to add/amend items. The modification of the
original Delphi method is appropriated for the purpose of the study, but the modified protocol
could be furtherly described in the methods.
Another unanswered question is: How was participants’ feedback collected and presented to the
whole panel during the second round? In other words, how was controlled feedback guaranteed
for this telematic Delphi?
In the introduction:
Line 45, worldwide incidences of female cancers are reported. The cervical cancer indicator
for comparison is missing, and the observation period (2018?) should be specified, in order to
clarify the indicator used (incidence).
Line 49: the cited article [3] does not seem to be the original source of reported data: it cites the
Globocan report. The 2020 Globocan report is available online.
Line 58: I don’t understand the meaning of ‘good’ cervical cancer screening, a more specific
term should be used.
The background section could benefit from a brief description of the state of the art of cancer
screening services in China: population-based vs opportunistic, public funding, free vs out of
pocket…
Line 71: The term conventionally used to describe the will to perform a behavior in the TPB
is behavioral intention, not intent.
Line 78: The TPB does not promote a behavior: it can explain its determinants, and inform
strategies to increase its adoption/compliance.
Line 81: the cited reference [12] does not seem to cover screening behavior, but physical activity
in cancer survivors.
Line 91: I don’t understand what is meant by ‘general situation investigation’
Line 92: Knowledge, attitude and practice model.
Line 96: an intention scale for cervical cancer screening participation
In the methods section:
Line 112: why was the search strategy limited to articles published after 2012?
Line 116-118: unclear sentences that might be rephrased with ‘two researchers performed the
title/abstract screening independently…’
For the transparency of the questionnaire construction, the 43 papers chosen as a source should
be reported (among the references and/or as Supplementary tables).
Line 133 were the Delphi questionnaires administered as online questionnaires (e-Delphi)?
Line 146: Why should the panelist eliminate the item if the item’s score is between 4 and 5?
Line 151: importance score equal or greater than 4?
Line 158: how was controlled feedback provided to panelist in order to inform the second round
decisions?
Line 167: Is experts’ specialization the fifth criterium?
In the results section:
Line 220: The phrase ‘replaced with a strong intensity’ is not clear to me
Table 2: I don’t understand if the reported changes were made after round 1 or after round 2.
Table 3. Subjective norms: the selected items largely cover injunctive norms (how significant
others would judge me if I participate in the screening program), but do not cover descriptive
norms (do significant others participate in screening?). The issue of an uncovered TPB
dimensions should be mentioned in the limits section.
Line 246: how were authoritative coefficients calculated?
In the discussion section:
Line 267: I wouldn’t define the Delphi methodology as ‘unbiased’. It certainly is the preferred
methodology for reaching expert consensus, but it is not free from bias.
Line 270: preventing or prevented/allowed preventing?
Line 297: I would mention the need for external validation of the newly developed scale.
In the ethics section:
Were data collected and analyses handled anonymously? If so, how?