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: 03 Sep 2018  
 
Reviewer: Allen Kabagenyi  
 
Reviewer's report:  
 
Reviewer's report  
 
BMWH -D-18-00332  
 
Title: Attitudes to cervical screening among older women from hard -to-reach groups: a 
qualitative study in England  
 
 
Authors: Laura Marlow PhD,  Emily McBride MSc, Laura Varnes MSc, Jo Waller PhD  
 
 
Date: September 3th, 2018  
 
Journal: BMC Women's Health   
 
Reviewer: Allen Kabagenyi, Department of Population Studies, Makerere University.  
 
 
Summary  
 
This is an important study particularly for scientists and researchers intereseted in this field. It 
was aimed to understand reasons why some women aged 50 -64 years from hard -to-reach groups 
with poor awareness and understanding of cervical screening. The study further sought to 
examine why some women had not decided not to continue going for screening, having 
previously taken part. Using Frame Analysis for qualitative data analysis, the researchers present 
the key findings from the hard to reach female pop ulation related to the attitudes that were linked 
to cervical screening.  
 
 
Major Compulsory Revisions  
 
1. The beginning sentence in on page 4, line 2, while it is good to provide the statistics for 
England, it would be good to relate to the statistics prov iding a global perspective. For 
instance, if each 3000 women are diagnosed annually what is that ratio with regard to 
global rates?  
2. Relatedly, in the background section it would be good to provide statistics and 
information related to the deaths or fata lities of Human papillomavirus (HPV).  What is 
the magnitude, is it a problem in the country? Such information would perhaps explain 
why women feel scared or uncomfortable to have the screening results. Also it would be 
good to know the resulted statistics  for some that have been screened in the country or 
global statistics whether they have been negative or positive.  
 
 
3. Please double check if the reference numbers should be after the full stop. Through out 
the document this needs to be checked if is agree able with the journal then you can 
proceed. Otherwise, on page 4, onwards Line 53 and 57 where do the reference belong, is 
it with the new sentence or the sentence that is completed with a full stop (.)?  
 
 
4. What study design was used for this research? In  the methods section there is no mention 
of the study design apart from indicating the method - of data collection that is the focus 
group discussions. You begin with the recruitment of the study participants.  Use the 
standard format used by the journal r equirements in the presentation of the methods 
sections.  
 
 
5. What is the justification for the selection of only 6 focus groups? how did you 
identify/determine that you reached saturation during the data collection process.  
 
 
6. Please include page numbers on your document, which are lacking all through.  Also 
follow the journal guidelines for further review and editing for improvement of this 
manuscript. https://bmcwomenshealth.biomedcentral.com/submission -guidelines  
 
 
7. While the title shows attitudes to ce rvical screening among older women, the researchers 
did not classify whether all the submissions were attitudinal, negative or positive 
attitudes.  
 
 
 
Minor Essential Revisions   
 
Abstract  
 
1. The use of poor knowledge: what was the classification for knowled ge? What 
justification or measure did you use relating to the qualitative findings?  Who had good 
or higher knowledge? What is poor knowledge as defined in your study?  
 
 
 
Methods  
 
1. What is the justification for the selection of the 50 -60 year olds non whit e British?  The 
explanation for the ethnic minority non white British group does not seem to come out 
well.  
 
 
2. What was the composition of the focus group discussions? What is the number of 
participants per group?  
 
 
3. What languages were used during data c ollection? Where it required say for interpreters 
during data collection and moderation, were other languages used other than English?  
 
 
4. How did you control for bias given the multiplicity of ethnic groups/languages 
represented from the difference countr ies highlighted as indicated on page 6,  
 
 
 
line 34 -37 referring to "were from a range of ethnic backgrounds including Bangladeshi, 
Pakistani, African, Caribbean and White British"   
 
 
Results  
Information regarding the languages used in the data collection should be transferred to the 
section on focus group discussion.  
 
Did it matter the duration the participants had spent in England from the time they had moved 
there to the time of the surv ey? Could this have had an influence on the results in any way or 
not?  
 
Would be good to know the number of times / frequency or if the theme identified was running 
through all the focus group discussions. For instance, for the findings on line 6, discom fort and 
embarrassment, was it from all the 6 FGDs?  
 
Nothing is mentioned if the FGD participants were in agreement with the submission of one 
participant in the group. Line 11 to 12 show one of the participants mentioned "It's a very 
sensitive area, the  private area, for every woman", (P6, group 6).  
 
On a lighter note, extreme negative experiences -Line 26 presents well the magnitude of the 
problem as highlighted in Line 26, Page 10. It would be good to have similar presentations in 
some of the write up and quotations made.  
 
Page 9, line 22 there are typos, please correct them.  
In the discussion section, it would be good to show how why this study is unique and very 
important for the study population with regard to other studies that have been done elsew here. 
Would we have had different findings if the methodologies changed? Say if we used quantitative 
methods?  
 
Recommendation:  
 
This is a good article that provides key information that could be used for program intervention 
regarding these special popul ation groups.  I recommend the article to be published on 
completion of reviewer comments  
 
Quality of written English  
 
Does not require proof reading. The manuscript is well written.  
 
Declaration of competing interests  
 
I declare that I have no competing in terests.  
 
 
Are the methods appropr iate and well described?  
If not, please specify what 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.  
 
Yes 
 
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 i s recommended, please speci fy what aspects require further 
assessment in your comments to the editors.  
 
Not relevant to this manuscript  
 
Quality of written English  
Please indicate the quality of language in the manuscript:  
 
Acceptable  
Declaration of competing interests  
Please complete a declaration of competing interests, considering the following questions:  
 
1. Have you in the past five years received reimbursements, f ees, funding, or salary from an 
organisation that may in any way gain  or lose financial ly from the publication of this 
manuscript, either now or in the future?  
 
2. Do you hold any stocks or shares in an organisation t hat may in any way gain or lose 
financially from the publication of this manuscript, either now or in the fut ure? 
 
3. Do you hold or are you currently applying for any patents  relating to the content of the 
manuscript?  
 
4. Have you received reimbursements, fees, funding, or salary from an o rganization that 
holds or has applied for patents relating to the content of  the manuscript?  
 
5. Do you have any other financial competing interests?  
 
6. Do you have any non -financial competing interests in relation to this paper?  
 
If you can answer no to all of the above, write 'I declare that I have  no competing interests' 
below. If your reply is yes to any, please give details below.  
 
I declare that I have no competing interests  
 
I agree to the open peer review policy of the journal. I understan d that my name will be included 
on my report to the authors and, if the manuscript is accepted for publication,  my named report 
including any attachments I upload will be posted on the website along with the authors' 
responses. I agree for my report to be made available under an Open Access Creative Commons 
CC-BY license ( http://creativecommons.org/licenses/by/4.0/ ). I understand that any comments 
which I do not wish to be included in my named report can be in cluded as confidential comments 
to the editor s, which will not be published.  
 
I agree to the open peer review policy of the journal