Title: What is the role of attitudinal barriers on cervical cancer screening non-attendance?
Findings from a cross-sectional study with migrant women in Portugal
Version: 1 Date: 13 Sep 2022
Reviewer's report:
I appreciated the opportunity to review the manuscript titled “What is the role of attitudinal
barriers on cervical cancer screening non-attendance? Findings from a cross-sectional study
with migrant women in Portugal.” I thought the research aim  was worthwhile. However, I
had a couple of concerns that prevented from me discerning whether this research purpose was
sufficiently accomplished.
Here are a few comments/ suggestions for the authors to consider:
1. Many readers may not be familiar with the CCS prevention campaign system in Portugal, so
it would be helpful if the authors could provide some background information on it, especially
regarding HPV testing. More information is also needed about the health care system in Portugal,
where a woman can be screened and at what cost, the care of an undocumented patient etc. This
information is crucial to better understand the health care pathway of the migrant women, their
barriers to CCS (e.g. low socioeconomic status). The introduction needs more information on
the CCS participation rate among the general population and the migrant women in Portugal.
The proportion of migrant women in Portugal is also missing.
2. BMI was found to be a factor associated with CCS non-attendance among migrant women
(Crampe-Casnabet, 2019). This factor is missing in Introduction section.
3. I think it is important to distinguish your study from the Marlow's one and show what you
will add.
4. I wonder why women aged 20-24 years were included to the study. Were them excluded from
analysis?
5. I am uncomfortable with the definition of a migrant in our study. A woman who was born
in Portugal but who has moved in France and finally returned to Portugal can she not consider
herself a migrant by your definition?
6. Information is missing on how many women did not achieve the questionnaire, if women was
able to answer several times (duplicate data).
7. Information is missing on how the variables “Agreement with the items” were created from
the 5-point Likert scale (from 5 categories to 2).
8. Information is missing about the eligibility criteria to CCS according the official guidelines in
Portugal (e.g. no sexual intercourse, hysterectomy etc.) and whether they have been considered
in your study. If not, this must be discussed.
9. I suggest to reorganize the results section with one paragraph for each attitudinal barrier
(description of the crude and adjusted models at the same time).
10. I don’t understand why the supplementary data is not included as a Table 3 in the paper. I
think it should be. Regarding this table, there were several mistakes in numbers: for “I’m not
sexually active…” and distribution of the Agree/Disagree according to age, marital status and
for “I’ve had a bad…” and age.
11. I really appreciated the discussion section but I think that several points are missing.
a. The comparison with the Marlow study is incomplete. We really need to better understand
the differences between the two studies and what your study adds.
b. Comparison between the CCS participation rates you found and the rates in other studies is
needed.
c. Another potential explanation for the socioeconomic distribution of your data is that a
significant part of migrant women has moved for studies.
d. Discussion on HPV testing is missing, especially regarding HPV self-sampling, which can be
a solution for some women, e.g. those who lack the time to make an appointment etc.
e. Discussion on BMI is missing while it is an important factor that could explain some of the
differences observed according to the continent of birth (additional file 1).
f. Perceived health is also an important factor that could explain in part why some women
intended to go for a smear test but do not get around it (competing demand). This is not discussed
in your paper.