Reviewer ’s report  
 
Title: Barriers to Cervical Cancer Screening Faced by Immigrant Women in Canada: A 
Systematic Scoping Review  
 
Version: 1 Date: 29 Mar 2018  
 
Reviewer: Sheila Dunn  
 
Reviewer's report:  
 
Thank you for the opportunity to review this manuscript.  This scoping review of peer reviewed 
and grey literature summarizes and categorizes barriers to cervical scre ening experienced by 
immigrant women in Canada.  Although barriers to cervical screening among immigrant women 
has been the subject of a significant amount of international research, this manuscript provides a 
useful, rich and thorough overview of the subj ect.  Barriers are described and categorized by 
theme, and further sub -categorized from the perspective of the patient, health care provider or 
system stakeholder.  While this sub -categorization is interesting, there was considerable 
repetition of the barr iers, which some thoughtful editing could improve.  Using a thematic 
analysis of the barriers helps to organize the material, but grounding the themes in a theoretical 
framework (eg Ecological Model, Health Behaviour Model) would be helpful.   
A systemati c approach to searching the literature was used, but I am aware of at least one 
relevant article that was not included (Hulme J, Moravac C, Ahmad F, Cleverly S, Lofters A, 
Ginsburg O, Dunn S. "I want to save my life":  Conceptions of cervical and breast ca ncer 
screening among urban immigrant women of South Asian and Chinese origin.  BMC Public 
Health 2016 (16):1077.  DOI 10.1186/s12889 -016-3709 -2). 
My main critique of this paper is that it confuses sociodemographic characteristics associated 
with lower rat es of screening with barriers.  For example, lower level of education is identified as 
a barrier.  However, this is actually a characteristic that gives rise to the barrier, lack of 
knowledge about screening.  This distinction needs to be addressed.  One w ay of doing so would 
be to present characteristics known to be associated with lower screening rates in immigrant 
women (eg. lower education, age, single marital status) in a separate paragraph.  Barriers related 
to these characteristics are already presen ted later in the text under various themes.  The initial 
Discussion uses the term 'factors contributing to low screening rates' to encompass both 
characteristic and barriers.  Please use precise and consistent terms that accurately reflect the 
concepts des cribed throughout the paper.  
The relevance of this review of Canadian immigrant women's screening barriers to an 
international audience should be presented.  Since Canadian immigrants are extremely diverse 
group, it is likely findings unrelated to the hea lthcare system will be relevant to other settings, 
despite the statement in the limitations.  The significance of some of the Canadian references eg. 
provincially covered health care (p 4 line 47 ); Ontario and British Columbia (page 8, line 45); 
and patie nt enrollment model (page 13, line 15), may need more explicit explanation for an 
international audience.  
 
Abstract: The study populations in the papers included Canadian immigrant women (don't think 
the word "legal" is needed or desirable here), health ca re providers serving immigrant women 
and other stakeholders.  Revise the conclusion to present what you can conclude from the study, 
not what the study provides.  
Page 4 Lines 29 -31 - the greatest impact of screening derives from its detection of precancer ous 
changes that can be treated before they progress to cancer.  
Page 4 Lines 49 -52:  While there is very good evidence that immigrant women are 
underscreened, the evidence in recent literature does not support that they have increased 
morbidity and mortality from cervical cancer.  The reference cited is very old and th is newer 
reference is preferable (Voruganti T1, Moineddin R1, Jembere N1, Elit L1, Grunfeld E1, Lofters 
AK1. Comparing stage of diagnosis of cervical cancer at presentation in immigrant women and 
long-term residents of Ontario: a retrospective cohort study . CMAJ Open. 2016 Aug 
12;4(3):E424 -E430).  
 
Methods:  consider putting Tables 1 and 2 in a supplementary file.  How the different MESH 
terms and keywords for screening were combined (AND/OR) should be described.  Consider 
putting Table 3 content in the text  rather than in a table.  You could eliminated the exclusion 
"conducted outside of Canada".  Provide a rationale for excluding refugees and undocumented 
migrants.  
Page 8: Characteristics of selected studies - There were 28 studies included.  You state tha t 12 
used qualitative methods and 9 used quantitative methods.  Since this adds to 21, what 
methodology did the other 7 use? Please clarify this.   
Page 11 Line 28 - what "specialized tests" were concerning??   
Page 12 Lines 53 -60:  this is an interestin g point but how does it relate to barriers to screening?  
Page 117, Line 9:  suggest removing "false"  
 
Discussion:  interesting discussion of the interrelation of many of the barriers.  References are 
needed for some of the statements, particularly on page  20. 
Page 21 Line 30: can you use another term than "non -migrant"?  
Page 21/22: regarding studies from other provinces/territories, I think readers will need more 
information to make sense of this.  Ontario and BC are large and populous provinces with lar ge 
immigrant populations.  Not so, these other provinces, where there may be unique barriers 
experienced.  And what about Quebec?   
Limitations: I would suggest that the only articles relevant that might be missed would be those 
in French in the grey lite rature.  
 
Conclusion:  as with the abstract, rather than restate what the article provides, what can you 
conclude?  
Table 5:  Barrier would be a better header for column 2 than Taxonomy.  Regarding the last 
point on the list "carelessness about female healt h", could you reword that?  
Are the methods appropriate 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.  
 
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 stati stics in the manuscript or would you recommend an  
additional statistical review?  
If an additional statistical review is recommended, please specify 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:  
 
Needs some language corrections before being published  
  
Declaration of competing interests  
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