Reviewer's report
Title:"Voices of Fear and Safety" Women's ambivalence towards breast cancer
and breast health: a qualitative study from Jordan
Version: 1Date:23 March 2012
Reviewer: Ruth Heisey
Reviewer's report:
Review BMC Women’s Health: “Voices of Fear and Safety” Women’s
ambivalence towards breast cancer and breast health: a qualitative study from
Jordan.
General Comments:
I think that with revision this could be a nice paper that quite possibly will
advance the state of the literature and hopefully translate into improved
screening and early detection of breast cancer in Jordanian women.
General suggestions for improvement:
I found the presentation of the results somewhat confusing. I admire that you
created three general themes but some of the subcategories did not appear to fit
and it left the reader confused.
Prior to presentation of your results a general brief overview of the literature with
respect to: barriers to presentation of asymptomatic women for screening and
barriers to presentation of women breast symptoms to their health care provider,
would help contextualize your results. (I am assuming that you did not establish
in the women you interviewed whether they had breast symptoms or not.)
It seems to me that one of the most significant findings likely more prevalent in
the Middle East than in other parts of the world-fear of husband’s rejection- was
somewhat buried in the text. It would be nice to see some supporting quotations
in this area. A few findings (I suspect) more unique to the Middle East could be
highlighted. (See specific comments)
There are a few places where your writing could be clearer (see specific
comments).
Specific comments:
1. Abstract/ Background: please clarify if the women interviewed had breast
symptoms or not. (Impacts whether you are trying to encourage screening or
detection maneuvers)
2. Abstract/Results: “as a test by God and from acquiring knowledge…” Do you
mean, “ accepting breast cancer as a test by God and having comfort due to their
knowledge and skills…? (Confusing as written here and in Findings section)
3. Abstract/Conclusions: Could be written more clearly e.g. … “could be better
addressed by breast health interventions that emphasize the good prognosis…
involve breast cancer survivors….catalyze family support to encourage access to
health ?screening.”
You can’t really include the perceived knowledge and skills here as written as
you essentially presented that as a barrier to accessing care as written as it
results in “feeling safe”.
4. Background: second paragraph- “the five year survival rate reaches up to 100
percent…” This is just wrong and misleading. In fact the citation you reference
indicates 88% 5-year survival for stage one and 93% for stage 0. (Updated
31/1/2012)
5. You need a linkage sentence between paragraph five and six in Background
section, then a paragraph on existing data on delay before your methods section.
Ideally you could point out variations or delay data specific to the Middle East as
well (assuming there is some).
6. In Methods section paragraph five: what are your free early detection
exams-please define- does this include mammography, CBE? Screening and/ or
diagnostic? At what age do you commence screening? Important as you are
interviewing younger women and appear to have a younger age of onset of
breast cancer in Jordanian women.
7. Study design: please state why you chose a qualitative approach-essentially
rewriting the first line- “ We chose a qualitative approach to get a deeper
understanding…
8. Demographics: did you document their religion?
9. Data collection: Describe the development of the guide and ideally include it.
Was it based on a review of the literature, previous work by the researchers?
10. End of first paragraph under Data collection; typo- “cold”=
“could”. End of third paragraph “took”=”take”.
11. Ethical considerations: Capitalize Health Research Ethics Committee
12. Findings: suggest Feeling safe from breast cancer rather than Feeling safe
(discretionary)
13. Ambivalence in prioritizing own health –children and family come first –Put
first quote after first sentence and second quote after second sentence. Then
state that this did not appear as prevalent in women from the richer areas-third
sentence/third quote. (Assuming that is what you mean)
14. I don’t really understand how the Encouraged to seek breast health care fits
here-Are you saying that a woman’s ambivalence could be impacted by this or
that this is a motivator to overcome ambivalence? Please be more specific.
15. The reference to not needing to ask husband for permission to go –needs
context-perhaps the women appreciate his indirect support? Or lack of a
previously perceived barrier was in fact supportive for the women-is this new?
16. Feeling fear: Position your quotes after the statement to which they support.
17. Fear of risk of diminished femininity. First quote should be after first sentence
then please include supporting quote/s for the comments about men looking for
other women as this is very powerful and I expect more unique to Jordan and
Middle Eastern countries than the rest of the world.
18. I would also discuss here not only the fear of rejection by the husband but
also the apparent lack of knowledge in some husbands with respect to the fear of
transmissibility (include virus quote)
19. Did you notice a relationship between any demographics; Religion/financial
security with respect to women that feared rejection?
20. The second quote here belongs after the discussion on social stigmatization.
21. You need to somehow differentiate the barriers; Lack of knowledge in
husbands and physicians as barriers to care and lack of sufficient female
physicians as a barrier to care-again I suspect these are more prevalent in
Jordan than other countries.
22. Perceiving themselves as not being in the risk zone for cancer: In all the
focus groups “some” women… Last quote actually to be displays fear rather than
“no fear”.
23. Accepting breast cancer as a test by God- reference your quote please.
24. Discussion generally very good but would like to see where your work is
advancing the literature.
25. Conclusion: “activities need” I would love to see you include something about
the role of the fear of rejection by husbands, the lack of information regarding the
(lack of) transmissibility of breast cancer and barriers to accessing care due to
lack of female physicians (if in fact true) as these seem to be more important and
unique in your population and essential to address to assist Jordanian women in
accessing breast screening.
Level of interest: An article of importance in its field
Quality of written English: Acceptable
Statistical review: No, the manuscript does not need to be seen by a
statistician.
Declaration of competing interests:
I declare that I have no competing interests