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: 12 Dec 2018  
 
Reviewer: Juan Félix  
 
Reviewer's report:  
 
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Review of M anuscript: "Attitudes to cervical cancer screening among older women from hard to 
reach groups: A qualitative study in England." BMWH -D-18-00332  
 
 
The authors of this manuscript describe the results of discussions among focus groups of women 
from hard to re ach groups in England. These included women members of ethnic minorities and 
lower socio economic status. The manuscript reports discussed items from 38 women in 6 
different focus groups (each numbering between 4 and 9 women). The authors report "low 
knowl edge of cervical cancer risk factors, low knowledge of the screening process, 
Pain/discomfort, and trust in the medical system" as possible barriers to continued screening. The 
authors conclude that targeted education for these groups to "debunk" these bel iefs would "help".  
 
 
This manuscript fails the reader in many ways.  
 
 
The authors state that they used advertisements and recruited the aid of community groups as 
well as of a market research group. Women were offered 25 pounds sterling to participate. In 
spite of all of these efforts the study recruited only 38 women, 4 of who were over the age 
targeted by the study. The authors did not offer data regarding how women were contacted, how 
many women were contacted or what percent agreed to participate. This d ata is essential in order 
to determine how representative this group was of the targeted population. The lower the rate of 
agreement to participate, the more likely that the population is biased. Data regarding percentage 
of women from the different focus groups would be essential for the reader to know.  
 
 
The Results section was entirely descriptive and in such general terms that there is no ability to 
find distinction between focus groups. Although this reviewer would have predicted from the 
low numerator in each group that significance would be difficult to attain, the authors did not 
even attempt to quantify differences in responses between focus groups.  One item of interest 
discussed in the Discussion section did mention that one focus group didn't even discuss sexual 
behavior, a fact that would lead on e to believe that this issue is of importance to the knowledge 
and attitudes regarding cervical cancer risks. However the authors failed to mention in which 
focus group this occurred, leaving this rare point o useful knowledge of little practical value to 
the reader.  
 
 
As a matter of research protocol, the authors discuss in page 13 lines 5 -12 that while some 
women responded initially not having knowledge of cervical cancer screening, once shown 
photographs (presumably of the procedure) that they acknowledge d having knowledge of it. The 
authors did not describe this in the Methods section (an essential component if this work is to be 
reproduced), nor did they provide the reader with data regarding how many women changed 
their response after being shown photog raphs or in which focus groups they were found. This 
would again represent useful data for the reader.  
 
 
Acknowledging that the topic of cervical cancer is difficult to approach, the questions designed 
by the authors and discussed did not seem designed to y ield quantifiable data. The reader cannot 
assess if the majority of women felt this way, if only a vocal minority opined on the issues. The 
manuscript is entirely descriptive with no way for the reader to assess the likely accuracy or 
relevance of the auth ors opinions. An example of this is found in page 12, Discussion Section, 
beginning in line 59. The authors state that a "number of erroneous beliefs" held by the women 
(unknown number/percentage) were uncovered where "improving knowledge and debunking 
beliefs" would "help". The erroneous beliefs are not specified. This is critical since although 
some beliefs and misconceptions can be changed with education, it is well documented in the 
cervical cancer screening literature that certain beliefs and behaviors  are difficult if not 
impossible to change in these populations.  
 
 
Finally, in the Introduction Section the authors state that "drawing from 22 studies" and then 
listed a series of barriers to screening that are identical to the conclusions of the current study. 
The authors need to effective advocate why their study of 38 women contributes to the body of 
literature on the topic.  
 
 
 
 
 
 
 
 
 
Are the methods appropr iate and well described?  
If not, please specify what is required in your comments to the authors.  
 
No 
 
Does the work include the necessary controls?  
If not, please specify which controls are required in your comments to the authors.  
 
No 
 
Are the conclusions drawn adequately supported by the data shown?  
If not, please explain in your comments to the authors.  
 
No 
 
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 
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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?  
 
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