Title: Inequalities in reported use of cervical screening in Estonia: results from cross-sectional
studies in 2004–2020
Version: 1 Date: 22 Sep 2022
Reviewer's report:
Dear authors, the article you present is of quality and interesting, but I still believe that the
discussion should be reviewed in depth because it presents some gender bias that should be
taken into account.
Below I leave a series of comments in case you want to take them into account when revising
your manuscript.
Abstract:
The abstract is quite well structured, however in the introduction part there is no mention of
inequalities in the object of study and I think it would be important to briefly contextualise this
as it is the object of study.
Introduction
The introduction is adequate, but lame in the part of health inequalities, I think it is important
to expand on this topic since it is the objective of the study.
Lines 45-52: The first paragraph of the introduction tells us that despite the efforts being made
to implement Pap testing, Estonia still has one of the highest rates of cervical cancer. But in all
social classes, because if we are going to address the presence of inequalities in Pap testing I
think it is important to say that cervical cancer rates are equally distributed in the social strata
or not.
Lines 60-62 “….. Estonian study found that over half of the women with confirmed CC diagnosis
had not got a Pap smear at least seven years before the disease (8)” I think it would be important
to explain or contribute what reasoning the authors themselves give.
Methods
Lines 75-80: One question that may need to be expanded upon is whether the samples are
comparable to each other.
Could you explain more about how the methodology of these surveys manages the missing data
or if it provides weighting factors to be able to correct the sampling errors? and if it does provide
them, could you indicate if they are used to perform the analysis? another doubt that arises when
I think about it, perhaps it would be necessary to explain even more if the data are comparable
when changing the sampling method, perhaps with a small review it would be clear for readers
who are not experts in health surveys or in sampling methodology.
Lines 91-95: Can you better explain the level of education to which level of training it
corresponds, if you have used the international classification of education? Can you explain what
corresponds to unemployer?, students in which category they are collected and not working to
which they correspond? those women engaged in domestic work it is advisable to use the term
unpaid household labor.
I think it is necessary to better explain the variables as they were collected in the surveys, what
questions were used, if the variables were recoded and based on what evidence, as they are now
generate many doubts, another example is the self-perceived health, how this information was
collected? because it has been grouped into three categories and not in two?
Statistical Analyses
We have already indicated this above, but the authors have used some treatment or weighting
factor in the analyses to correct for possible sampling errors? these data are provided by the
survey itself?
Results
The results seem to me to be adequate and relevant. They are clear and well understood
Discussion
Lines 184-194: I do not think it is appropriate to compare the increase in the performance of
the Pap test in Estonia with Spain and say that Spain has not observed this increase, when the
data provided for Estonia 2004-2020 and Spain 2003-2009, there are more than 11 years of
difference and I do not think you can make this statement, the same with the other country that
is compared Switzerland during 1992-2012. I think they are not comparable data to make that
statement, I advise you to review the literature and compare with more current data to make the
statement that is made.
Lines 190-194: “On the other hand, it is surprising that in 16 years the organized CC screening
program has not had an effect on CC incidence  (7). Furthermore, the stage distribution has
shifted towards later stages, and the mortality trend has decreased only slightly (7). These results
reflect the ineffectiveness of the nation-wide screening program and should be investigated
further”
Lines 206-210: One of the main risk factors for cervical cancer is the number of sexual partners,
I think this paragraph has an important gender bias and statements that in an article for a specific
health and women's journal should not be put and even less without bibliographic citations. The
authors say that this test is offered in prenatal and postnatal consultations, putting these women in
an advantageous position... on what basis do they make this statement? because then the system
is failing and they should dedicate efforts to reach those women who do not have children. I
think this paragraph should be rewritten making a proper interpretation of why women who
cohabit are more likely to be screened than those who are single or widowed, on the other hand
and continuing to reflect cohabit what does it refer to? sexual partner, cohabit with children,
with parents, with roommates without sexual relationship ????
Lines 225-232: I believe that there is a lack of literature citations to support the claims made
about barriers to screening for obese women.
Lines 233-239: In relation to the finding of the association between depression and increased
probability for screening, I believe that the authors should point out that the data should be
considered with caution. As noted above, nowhere is it indicated which question or scale was
used for the variables collected, a fact that casts further doubt on the interpretation that is
subsequently made in the discussion. Likewise, they do not provide scientific evidence to justify
that depressed women may be more concerned about their health and therefore, more tests are
done. It is necessary to provide more information and clarify this statement.
Another fact that is not addressed in the discussion is the impact of the COVID 19 pandemic on
the performance of this type of tests; it would be very interesting if the authors would include
this fact in the discussion, as they do with the war in Ukraine.
Conclussion
The conclusion seems appropriate to me, but throughout the manuscript it has been discussed
that despite the effort in screening the incidence of this cancer is still high in Estonia, I think
this fact should be addressed in the conclusion, as well as the implications from a public health
point of view.
Tables and Figures.
The tables should be self-explanatory, and it would be interesting to include an explanation of
all the variables in the table footer so as not to have to resort to the methodology. Likewise, the
significance of the ORs should be put with asterisks, the confidence intervals are well observed
but it is a piece of information that it is not superfluous to put it.