Title: Does women's empowerment and their socioeconomic condition affect the uptake of
breast cancer screening? Findings from NFHS-5, India
Version: 4 Date: 14 Oct 2022
Reviewer's report:
I am satisfied with the answer of the authors concerning the screening programs in India. It was a
major concern to me, but with the improved manuscript I now understand that these programmes
do not systematically invite all the target population for screening (by sending invitation letters
for example) and, indeed, as the authors noted in the manuscript, screening participation is
mainly “opportunistic” across all of India.
Overall, the content added in yellow highlights is ok. However, there are some issues with the
writing. Again, this needs to be revised by someone with advanced English level writing skills,
or a language editor. See my comments below here.
The sentence “The roll out of the programs was in phased manner  from 2016 onwards” needs
to be revised.
The sentence “Unlike the screening invites  and letters that are sent to the eligible population in
High Income Countries  (HICs), NPCDCS in India, focuses  on health promotion, education and
improving cancer awareness to encourage people to seek screening for breast, cervix and oral
cavity cancers” also needs to be revised. Some of my comments: “screening invites” is informal,
it should be “screening invitations, “High Income Countries” does not need to be capitalized,
the comma “,” after “India” is wrong.
The sentence “Mapping of screening coverage across states within a setting of government run
screening programs, can  allow assessment of utilization of these services” also needs to be
revised. The comma “,” after “programs” is wrong. Moreover, there is a double space at the end
of the next sentence.
The sentence “These survey report files  from NFHS 5, do  not give distinct information…”
needs to be revised. The comma “,” after NFHS 5 is wrong. I believe the word “files” is not
needed. Please check throughout the whole document and consistently write everywhere either
“NFHS 5” or “NFHS-5”.
The sentence “This highlights  lack of women empowerment and decision making, which may
lead to low health seeking among women” needs to be revised.
The sentence “Screening programs were implemented in all states at the same time and
contribution of some of the large-scale research  programs could have added to higher screening
uptake in some of the states” needs to be revised. Why “research programs”?
IN THE CONCLUSION:
First sentence needs to be revised, the comma “,” after “(WES)” is wrong.
Third sentence: maybe it should be revised as “individual level factors like awareness about
breast cancer symptoms, cultural factors and cancer stigma” ?
ADDITIONAL WRITING ISSUES:
Please check for consistency and use either “socio-economic status” or “socioeconomic status”
everywhere. No capital letter is needed in “Socio-economic status” (e.g. Figure 1 title, methods
p.8) if it is not the first word of a sentence.
“Breast cancer screening” (p.11 and 12, sub-headings) does not need to be capitalised if it is not
the first word of a sentence.
Please revise “populationbased” in: Afshar N, English DR, Blakely T, Thursfield V, Farrugia
H, Giles GG, et al. Differences in cancer survival by area-level socio-economic disadvantage:
A populationbased study using cancer registry data. PLoS One. 2020;15(1):1–13.
Please check all reference carefully as well.
Please revise “with very few centers catering to specialized cancer care”, according to the
dictionary “catering” is “the job of providing food and drinks for people”
ADDITIONAL COMMENTS:
IN THE ABSTRACT:
“This study indicates that improving literacy and financial independence in women may
moderately improve their participation in cancer screening programs ” -> I believe it should
be “improve their participation in cancer screening” (the study does not assess the effect of
literacy and financial independence in screening programmes specifically, but cancer screening
participation in general)
IN THE INTRODUCTION:
References 12 and 13 (Jolidon 2022 and Willems et al. 2020) are not in the right paragraph, these
relate to the issue of gender inequality and cancer screening participation and should be placed
in next paragraph (“Lack of autonomy among…”), and this paragraph should say something
like “gender inequality may affect preventive healthcare participation (and/or cancer screening
participation)” for example, using these 2 references to support this. Please note that references
13 and 16 are duplicated and should be fixed (reference list).
INRODUCTION AND METHODS
I see a contradiction between sentences added (yellow highlights from authors) in the
introduction and methods. It is stated in methods “Government of India had issued operational
guidelines for cancer screening and rolled out the screening”, here the reader may that the
government is implementing screening through programmes. However, as it is stated in the
introduction “ NPCDCS in India, focuses on health promotion, education and improving
cancer awareness to encourage people to seek screening for breast, cervix and oral cavity
cancers”. According to this sentence, the government is not really involved in implementing
(or rolling out) screening. If “rolled out the screening” is used in the methods, then the
reader may understand that the government carries out screening through programmes, while
the introduction argues that the government just “encourages” and “creates awareness” on
screening. In sum, “rolled out the screening” here sounds like a strong intervention of the
government (through programmes) in implementing screening, while the authors argued in their
response letter (and in the modified introduction) that the government programmes’ role was
only minor…
IN THE DISCUSSION:
Reference 24 at end of the first sentence, first paragraph, is not necessary.
In the first paragraph, please replace “increase” by “higher” (the study design does not allow
to infer an “increase” over time).
Please reconsider the statement “A multicenter study from Qatar, a high income country,
highlighted better screening practices among women whose husbands had higher income and
higher education levels.” Why would husbands’ higher income and education be beneficial to
women and their empowerment? This can be criticised. I would rather argue something like in
Willems et al. 2020 that women with higher education level have higher mammography uptake,
or women who live in more gender equal contexts have higher mammography uptake.
Please add the reference at the end of this sentence “A systematic review including Indian studies
on breast cancer screening showed that women had low cancer awareness irrespective of the
SES and education”, not at the end of the next sentence.