Title: Multi-level determinants of breast cancer screening among Malay-Muslim women in
Singapore: A sequential mixed-methods study
Version: 2 Date: 05 Jul 2022
Reviewer's report:
Comments:
This is an excellent manuscript that combines the strengths of open-ended, in-depth interviews
with a population-based survey to answer important questions about barriers to mammography
in the Malay-Muslim population. I really appreciate the idea that different factors may influence
whether women get a mammogram ever, versus whether they continue regular screening. I think
this is important in thinking about how different interventions may facilitate mammography. I
do have some comments that I hope will strengthen this manuscript.
Major points
1. It was not clear to me how the key informant interviews from spouses, physicians, and
religious leaders interviews were used. Were those interviews used to inform the survey? If
so, I would reframe the IDI methods as interviewing a broad group of stakeholders rather than
focusing on women alone. If those interviews did not inform survey development, I might
consider removing those interviews from this manuscript as they feel sort of out of scope.
2. Similarly, the analysis plan/research questions for the in-depth interviews were not always
clear. As an example, I didn’t expect to see interview themes analyzed jointly between women
and religious teachers until I saw the list of facilitators of mammograph in the Results section.
Why was this analysis chosen versus, for example, another group of key informants (like
physicians or spouses)? Are religious teachers the most influential figures in a screening
decision? If so, I’d add some justification in the methods and set this up as a specific analysis.
Also, all of the themes listed seem to focus on screeners, and not necessarily religious teachers.
3. The discussion really focuses on religious beliefs are an important determinant of screening
behavior. I have a few comments about this:
a. Regarding findings about the relationship between religious beliefs about modesty and
mammography use, has this been documented in other health settings? It seems like the
phenomenon should not be unique to mammography. Has it been studied in the setting of cervical
cancer screening or even other chronic health conditions that may require physical exams?
b. The discussion really emphasis religious beliefs as important potential barriers/facilitators of
mammography but medical factors, socioeconomic status, etc actually have effects similar in
magnitude. I think somehow it is important to contextualize that religious factors (beliefs about
punishment, modesty) are not the only thing that are important but may have influence similar
in magnitude to some of these more well established barriers/facilitators.
c. Lastly, because religious belief is so emphasized, it would be helpful to know how many
women fall into various categories of religious belief. For example, is it the majority of women
who score high on the PMIR scale or who have strong beliefs about modesty? If so, then these
are really important factors. But if its only a minatory of women who espouse these beliefs, on
the population level, these are not as important, even if the odds ratios associated with them
are large.
Minor points:
1. This is stylistic and optional, but the methods contain many details that might be able to be
moved to an appendix. Some examples include the details of the scales used in the survey and
details of how survey responses were categorized. This information is important but including it
in the main manuscript makes it somewhat difficult for readers to follow and is a level of detail
that may not be necessary in the main text.
2. Small point: beginning on line 464, the word “deference” is used I think to mean “defer” or
put off, but deference in common usage typically means to respect or yield to. So the meaning
of sentence is hard to discern.
3. The discussion mentions how findings corroborated a nationwide survey—is there a reference
for that survey?
4. Are religious leaders and religious teachers the same group? Two terms are used and I wasn’t
sure if they referred to the same 4 people interviewed.