Title: Does women's empowerment and their socioeconomic condition affect the uptake of
breast cancer screening? Findings from NFHS-5, India
Version: 1 Date: 10 Jun 2022
Reviewer's report:
This paper on the role of women's empowerment and socio-economic conditions in breast cancer
screening participation in India provides important evidence for the field of cancer screening
participation research, as well as for policy-makers. The paper addresses at an essential issue
and a relevant research question, however, it has considerable shortcomings in theoretical
(conceptual) background, methodology, and writing (language), as detailed below.
Firstly, the manuscript needs to be revised by someone with strong academic writing experience
in English language, an English native speaker, or a language editor service, since the writing
is not up to international publication standards. I also recommend the authors to have peers in
similar field of study to review the manuscript in order to improve the (scientific) writing quality
and overcome several inconsistencies in the writing. I only revised the writing up to the methods
part, but the results and discussion parts also warrant further revision for the writing.
TITLE
- “increase” should not be used since this study does not take into account the evolution of WES
nor SES across time.
ABSTRACT
- The abstract needs to be revised and improved. An abstract should be “stand-alone”, that is, a
“profane reader” should be able to understand it, and understand the study without having read
the entire manuscript. For example, the reader may not understand what a “factsheet” is in this
context, or what a “self-operated bank account” is.
- Acronyms should be carefully defined (in the manuscript as well). First, “dimension indices
(DI)”, and then it can be written as “DI” onwards.
Writing:
- Frist sentence: “due to the disease” should be revised (there seems to be a mistake in writing).
- Second sentence: the sentence is too general, “proportion of women undergoing breast cancer
screening are minimal”, in which context? It should be more specific.
- Please revise the writing “gets influenced by…” (it should be: “is affected by”, or “is influenced
by…”)
- It should be “we found THAT”, and not “we found”
- “State level indicators show”, and not “State level indicators shows”
- “Women literacy rate and women having self-operated bank account found the significantly
associated with the BC screening. “, what is “self-operated bank”?
- I recommend writing “The highest screening uptake WAS FOUND in (or was observed in)”
instead of “The highest screening uptake seen in”
- Correction: “Women literacy rate and women having self-operated bank account WERE found
TO BE significantly associated with breast cancer screening UPTAKE”
- Correction: I recommend “…IN WHICH WOMEN WERE FOUND TO HAVE LOWER
SCREENING UPTAKE LEVELS”, for example, instead of “but do not screen adequately”
BACKGROUND
Paragraph 2 (p.4) (“This initiative prioritized health promotion and outreach screening at
community level for early diagnosis of breast cervix and oral cavity cancers.”): more background
on screening programme implementation across Indian states is needed. Information on
screening programs is essential, as these are key determinant of screening participation at
population level. Were some breast screening programmes implemented at the state level? Or
these were only implemented locally? Do we know how many states (or union territories) have
implemented such programmes or initiatives? Which ones? The list of states where screening
initiatives were implemented (up to the NFHS-5 survey year) should be provided in appendix.
See for example:
- Figures 1a and 1b in Willems B et al (2020) Cancer Screening Participation and Gender
Stratification in Europe. Journal of Health and Social Behaviour. -> countries where screening
programmes were implemented are identified
- Table S1 (supplementary material) in Jolidon V et al (2022) Revisiting the Effects of Organized
Mammography Programs on Inequalities in Breast Screening Uptake: A Multilevel Analysis
of Nationwide Data From 1997 to 2017. Frontiers in Public Health. -> regions of Switzerland
which implemented screening programmes are listed out and identified
Information on screening programme initiatives is essential for results interpretation (in the
discussion section)
Paragraph 3 (p.4):“The literature has documented that low socio-economic status (SES) and
women empowerment status (WES) correlates with poor participation in screening activities.”
The underlying mechanism for this association should be explained. Why women’s lower SES
or WES would negatively affect their screening participation? See:
- Willems B et al (2020) Cancer Screening Participation and Gender Stratification in Europe.
Journal of Health and Social Behaviour
- Jolidon V (2022) Gender inequality and mammography screening: Does living with a partner
improve women's mammography uptake? Social Science & Medicine
- Rapp KS (2021) State–Level Sexism and Gender Disparities in Health Care Access and Quality
in the United States. Journal of Health and Social Behaviour
Writing:
- p.4, first paragraph, first sentence: this sentence should be revised, the comma after “India,”
is in the wrong place
- p.4, first paragraph, third sentence: “for improving” should be revised as: “to improve; “Breast”
should not be capitalised here
- p.4, second paragraph, last sentence: “… continues to be poor” should be revised as: continues
to be LOW
- p.4, third paragraph, last sentence: “…poor participation” should be revised as: “LOWER
participation”
- p.5, last paragraph, second sentence: “Programs” should not be capitalised
METHODS AND RESULTS
This study seem to rely on an “ecological approach” (that is, states and union territories (UTs)
are used as unit of analysis), which should be mentioned (also in the abstract if possible) for
better clarity for the reader. Please see this study which also uses an ecological approach:
- Noriaki T N & Mutsuhiro N (2021) Social-life factors associated with participation in
screening and further assessment of colorectal cancer: A nationwide ecological study in Japanese
municipalities. SSM-Population Health. 15:100839.
The implementation of screening programmes in some states plays an essential role in screening
uptake and is not sufficiently taken into account in the methodology. With the current analyses
(Table 2 and 3), I see a potential major flaw as breast screening uptake might be due to the
screening programme implementation and not to women’s SES and WES. Namely, the statistical
strategy does not allow to isolate the effect of SES nor WES from screening programme
implementation. In particular:
- The implementation of programme may confound the results presented in Table 2 and 3.
Were the regression analyses adjusted for programme implementation? As it may be difficult
to control for this variable, I strongly recommend to SEPARTELY analyse (using stratified
analysis) the group of states which had screening programmes (at the time of the NFHS-5),
and those which never had screening programmes (similar strategy as Table 1 in Jolidon V
(2022) Gender inequality and mammography screening: Does living with a partner improve
women's mammography uptake?), if it is possible to identify those states which had screening
programmes.
- I recommend colouring the bubble of the states which had screening programmes in Figure
1 for a better representation
METHODS
Subsample characteristics and size should be stated (women aged … to … and size of subsample
N= …). If this is an ecological study then the number of observations (sample size) should be
the number of states and union territories included in the statistical analyses. Unit of analysis is
not explicit enough (individuals? states?). Are table 2 and 3 correlations and regressions based
on individuals or state?
First paragraph, first sentence (p.5): Please revise as: “…data from the fifth wave (2019-2020)
of the National Family Health Survey (NFHS-5)”
Paragraph 3 (p. 6): Please add a reference at the end of the sentence: “Clinical breast examination
has been the recommended approach for screening and early detection for breast cancer in India
by the operational guidelines from The Government of India.”
Paragraph 7 (“The determinants of breast cancer screening ...”), (p.7): the implementation
of statistical analyses needs to be described more rigorously and with more details (for
example: “First, spearman correlation between [independent variables] and [dependent variable]
are examined… Second, we plotted states’ screening uptake levels by SES… Third, linear
regression was used…”.
Was the linear regression adjusted for all the independent variables simultaneously? Or each
independent variable was examined in separate regressions? This should be noted.
Writing:
- Second paragraph, second sentence: Please revise the writing “…comprising of representative
households”
- Please revise writing for consistency: “Setting and data source” (first paragraph) and “Study
design & Variables” (second paragraph)
- I suggest to replace “mentioned” by “reported” in: “We considered the SES and WES, derived
from the population, household profile and women empowerment indicators mentioned in the
state fact sheets of NFHS 5”
- Paragraph 3 (p. 6): In a new section of the paper, please define acronyms for better clarity,
that is, in sentence 6, I suggest to revise: “We considered the socio-economic status (SES) and
women empowerment (WES)…”
- Paragraph 5 (p.6): I would suggest to revise this sentence as “… greater value indicates A
BETTER performance whereas value towards 0 indicates A WORSE performance
- Paragraph 6 (“We categorized the weighted composite score…”) (p.7): please revise and
correct the line break after “score”
- Please kindly revise: “Dancey C. P and Reidy Pearson”
- Last paragraph: I recommend revising the paragraph and start as follow, “Data quality and
ethics review: This study is based on secondary data and summary indicators of the NFHS-5
survey collected by the IIPS. The informed consent…”
Tables 1:
- In the title of the table, please write SES and WES in full as follow: “Socio-Economic Status
(SES) and Women Empowerment Status (WES)” for better clarity; Please include the source of
indicators in a note at the bottom of the table (Source: …); « Population in the households living
with electricity » is unclear, did you mean “Population living in households with electricity”?
or « Number of people in the households living with electricity »?
- “Women having self-operated mobile phone” is unclear (not self-evident), please rephrase, or
define it in bracket or in a note at the bottom of the table
- Please improve consistency between table 1 and table 3, especially between “Women who have
a bank/savings account” (Table 1) and “Having self-operated back account” (Table 3) (please
also correct “back account”)
RESULTS
It seems more logical to me that Supplementary Table 1 should be Table 1, and Table 1 should
be Supplementary Table 1 (I would switch the place of these tables). However, I understand if
the authors disagree and have different views.
I suggest the results section to start by introducing the descriptive statistics of Supplementary
Table 1 (and also maybe Supplementary Table 2) before presenting the correlation results (this
is way I think that Supplementary Table 1 should be Table 1).
“The current study showed that the states of Tamilnadu, Pondicherry…”: at the end of
this sentence, it should be indicated were these results come from in bracket for example
(supplementary table 1?)
“Women having self-operated bank accounts and higher literacy rates had better participation
in breast cancer screening” If this is an ecological study and units of analysis in Table 2 and 3
are states then it is not possible to formulate this sentence in this way. It should be: “States and
UTs where women have more self-operated bank accounts and higher literacy rates had better
participation in breast cancer screening”
However, units of analysis in table 2 and 3 are not clear (women or states?), as recommended
below the sample size of these tables should be noted, which would also clarify what is the unit
of analysis
Table 2 and 3: titles of the tables are incomplete, these should include the subsample (women
aged … to … years or “states and union territories”, if these are the units of analysis) and sample
sizes  (number of observations (N= …)  individuals or states?), as well as further information
on the associations examined, e.g. “Spearman's rank correlation coefficients on the association
between breast cancer screening uptake and socio-economics and women empowerment status
indicators [among … to … years old women (N=…)] or [in Xnumber of Indian states]”, note
that capital letters are not necessary in a table title
Table 3: Was the linear regression adjusted for all the independent variables simultaneously? Or
each independent variable was examined separately? This should be explained in the methods,
as noted above. Standard error of coefficients, intercept (constant) of the model, and model fit
(such as R-squared) should be reported (or a full table of the regression model including these
parameters could be reported in appendix)
Supplementary Table 1: Please correct “Supplementary Table-1”; Please revise “state wise list”
as “state-wise list”; If acronyms are used (e.g. “DI”), their definition should be noted at the
bottom of the table in a note; Please revise writing: “for women belongs to 30 to 49 years age” (it
should be “for women aged 30 to 49 years” for example)
Supplementary Table 2: All acronyms should be defined in a note at the bottom of the table
(DI? DNH? DD?)
DISCUSSION
Please cite the relevant study at the end of this sentence: “A systematic review including Indian
studies on breast cancer screening showed that women had low cancer awareness irrespective
of the SES and education.”
The limitation section needs to be further developed, please refer to similar cancer screening
participation studies (cited above).
Writing:
- Paragraph 2 (p.10), please revise “poor women”, “poor screening practices”, “better educated
woman”, for example: women with lower income, lower screening participation, women with
higher education level.
- Paragraph 3 (p.11) Please revise “were wealthier and more educated” (e.g. had higher income
and level of education)
- Please revise sentence: “Also reproductive risk factors like late menopause, late first pregnancy,
may not be necessarily known to an otherwise educated woman” -> “to an otherwise educated
woman” is unclear
CONCLUSION
The last two sentences are quite general