Barriers to and Enablers of Preventive Sexual and Reproductive Health Care Among Women Seeking Asylum in Melbourne, Victoria: A Qualitative Study

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

"Multiple levels of disadvantage: Barriers to and enablers of accessing preventive sexual and reproductive health care for women seeking asylum in Melbourne, Victoria: A qualitative study"

This manuscript addresses an important and timely topic: the multilevel barriers and enablers affecting access to preventive sexual and reproductive health (SRH) care among women seeking asylum in Australia. Using a socioecological framework and a qualitative approach, the authors provide rich and insightful findings that deepen understanding of the complex interplay of individual, interpersonal, community, and policy factors affecting healthcare access. The manuscript is generally well-written, grounded in relevant literature, and makes a valuable contribution to the field. However, there are a few areas where further clarification, refinement, or elaboration would strengthen the paper.

Major Comments:

1. Justification of Sample Size:

While qualitative research often relies on saturation, the manuscript would benefit from a clearer justification of the chosen sample size (n=12).

Please consider stating whether thematic saturation was formally assessed and how it was determined.

1. Conceptual Framework Usage:

The use of McLeroy’s socioecological model is appropriate. However, the framework could be more explicitly integrated into the presentation and discussion of results.

Suggest visually aligning themes in the Results section with the model’s levels for clarity.

1. Participant Demographics:

The demographic tables are detailed, but the narrative summary could better contextualize how certain characteristics (e.g., time in detention, length of stay in Australia, country of origin) may have influenced SRH access.

1. Depth of Analysis on SRH Knowledge Gaps:

There is substantial evidence on limited awareness and misinformation (especially on HPV and contraception). Consider discussing whether these knowledge gaps reflect failings in health system communication or broader cultural/language access issues.

1. Discussion of Strengths and Limitations:

The limitations section is transparent, but could include further reflection on:

The potential influence of interpreters on data collection.

The possible response bias (e.g., women connected to services may differ from more isolated individuals).

How findings may differ by visa type (e.g., bridging vs community detention).

1. Implications for Practice:

The study could benefit from clearer translation of findings into practical implications for frontline healthcare providers.

How might GPs or community health workers adjust their practice based on these findings?

 

Minor Comments:

• Grammar and Formatting:
• A light copyedit is needed for grammar and punctuation, especially in participant quotations.
• For example: Line 120: “patriciate” → “participate”; Line 144: “Interpreters” → “interpreters”.
• References:
• Reference formatting is inconsistent in some places (e.g., spacing, punctuation).
• Also consider adding more recent literature (from 2023–2025) where relevant.

 

Recommendation:

Major Revision

This is an important, well-conducted qualitative study that offers new insights into a vulnerable population’s access to care. With the suggested refinements, the manuscript will make a valuable contribution to the literature on refugee and asylum-seeker health.

Author Response

Please see the attachment.

Responses to Reviewer 1 Round 1

 

Comments for the Author

 

Reviewer 1

 

This manuscript addresses an important and timely topic: the multilevel barriers and enablers affecting access to preventive sexual and reproductive health (SRH) care among women seeking asylum in Australia. Using a socioecological framework and a qualitative approach, the authors provide rich and insightful findings that deepen understanding of the complex interplay of individual, interpersonal, community, and policy factors affecting healthcare access. The manuscript is generally well-written, grounded in relevant literature, and makes a valuable contribution to the field. However, there are a few areas where further clarification, refinement, or elaboration would strengthen the paper.

 

Major Comments:

 

R1 Comment 1

Justification of Sample Size:

While qualitative research often relies on saturation, the manuscript would benefit from a clearer justification of the chosen sample size (n=12).

Response 1

We appreciate the reviewer’s insightful comment. We have revised the methods section and added the following:

 

“Women seeking asylum in Australia constitute a highly marginalised and hard-to-reach population. Consequently, pragmatic considerations and ethical sensitivity informed the final sample size. Considerable efforts were made to engage this group through trusted community networks, service providers, and advocacy organisations. Despite these challenges, twelve women consented to participate, which represents a meaningful and diverse sample given the significant barriers to access, including transience, distrust of institutions and authority, and concerns about confidentiality impacting their visa status.” (Line 151-158)

 

R1 Comment 2

Please consider stating whether thematic saturation was formally assessed and how it was determined.

 

Response 2

We have provided some additional information on assessment of thematic saturation in the data collection procedure section”

 

“Data collection and analysis occurred concurrently. Interviews were conducted until thematic saturation was reached, that is, when no new themes or insights emerged from the data. After approximately eight interviews, recurrent patterns were evident, and sub-sequent interviews confirmed these existing themes. Saturation was assessed informally through ongoing team discussions and review of coded transcripts, consistent with established qualitative research practices” (Line 211-216)

 

R1 Comment 3

Conceptual Framework Usage:

The use of McLeroy’s socioecological model is appropriate. However, the framework could be more explicitly integrated into the presentation and discussion of results. Suggest visually aligning themes in the Results section with the model’s levels for clarity.

 

Response 3

We thank the reviewer for highlighting this important point. The levels of the framework, along with the associated themes and subthemes, are presented in Figure 1 (the coding tree). These themes have been aligned and correspond with the headings in the Results and Discussion sections to ensure clarity and consistency in the presentation of findings.

 

However, we agree that there is a need for visually clarifying model’s levels in the Results and Discussion sections. To this end we have increased the font size and bolded the levels of the framework. We have also increased the font size and underlined the themes and subthemes for clarity.

 

R1 Comment 4

Participant Demographics:

The demographic tables are detailed, but the narrative summary could better contextualize how certain characteristics (e.g., time in detention, length of stay in Australia, country of origin) may have influenced SRH access.

 

Response 4

These are important points, thank you for raising them. We appreciate your interest in contextualising how certain these characteristics influenced SRH access. While the focus of this study was on broader barriers to and enablers of accessing preventive SRH care, we acknowledge that exploring how time in detention, length of stay in Australia, country of origin characteristics may have influenced SRH access could provide valuable insights

 

These specific points were beyond the scope of our current analysis. However, we agree that they represent an important area for further investigation. In response to the reviewers comments we have sought to address this later in the future research section.

 

“Future studies might examine the extent to which specific sociodemographic and experiential factors, such as duration of immigration detention, length of residence in Australia, and country of origin, shape access to SRH services among women seeking asylum.  Research might explore how periods of detention constrain opportunities to engage with preventive SRH care, or exacerbate psychosocial stressors that influence healthcare-seeking behaviours. Similarly, shorter durations of residence in Australia may be associated with limited familiarity with Australia’s healthcare system, restricted knowledge of available services, and reduced social support networks, thereby creating additional barriers to SRH access. Further research is needed to explore cultural norms and practices pertaining specifically to countries of origin for women seeking asylum to help understand barriers to and enablers of SRH access. Investigating the interplay of these factors could inform the development of targeted interventions and policies aimed at enhancing SRH equity for women seeking asylum.” (Line 779-791)

 

R1 Comment 5

Depth of Analysis on SRH Knowledge Gaps:

There is substantial evidence on limited awareness and misinformation (especially on HPV and contraception). Consider discussing whether these knowledge gaps reflect failings in health system communication or broader cultural/language access issues.

              

               Response 5       

We agree with you and we acknowledge the broader cultural/language access issues. The women in this study did suggest that experiences of broader cultural challenges spouse and family dynamics impacted access to preventive SRH care. We have elaborated further on the community level factors of spouse and family dynamics by including the following text in the discussion section.

 

“Women reported negotiating health decisions within unequal power dynamics, where prioritising household stability or avoiding conflict with partners took precedence over their own health needs… “

 

….”In several cases, familial pressure to conform to cultural or religious norms around fertility and modesty discouraged open discussion of SRH needs or attendance at preventive services.” (Lines 657-663)

 

… “For women seeking asylum, the intersection of these cultural dynamics with structural barriers outline below in policy-level factors creates additional layers of disadvantage.”   (Lines 678-680)

 

The importance of failings in health system communication are acknowledged in the policy-level factors which highlight experiences of structural disadvantage, including insecure visa status, ineligibility for Medicare, perceived financial cost, and limited access to appointments that collectively undermined their ability to prioritise preventive SRH care.

 

Comments 6 to 8

Discussion of Strengths and Limitations:

 

The limitations section is transparent, but could include further reflection on:

 

We agree with you and have added the following points to the limitations section.

 

The potential influence of interpreters on data collection.

 

Responses 6

“Conducting research with participants who have limited English proficiency and diverse cultural backgrounds presents methodological challenges, particularly in ensuring that the meanings of participants’ responses are accurately captured. This process carries an inherent risk of misinterpretation or loss of contextual nuance during translation and interpretation. To minimise this risk, any ambiguity or uncertainty that arose during the interviews was immediately clarified with the interpreter, and post-interview debriefing sessions were conducted to discuss and resolve potential misunderstandings or culturally specific expressions.” (Lines 750-758)

 

The possible response bias (e.g., women connected to services may differ from more isolated individuals).

 

Response 7

“Although multiple recruitment strategies were employed, including outreach through services, professional networks, and word of mouth, these approaches may not have effectively reached women who were truly ‘hard to reach,’ such as those not engaged with ser-vices or social networks. Most women learned about the study through a service provider or community leader, indicating some level of connection with local organisations. Broader and more sustained community outreach efforts may have facilitated participation from women beyond those already linked to health or community services.” (Line 742-749)

 

How findings may differ by visa type (e.g., bridging vs community detention).

 

Response 8

“Information on visa type was not specifically collected from women; therefore, distinctions between different visa categories could not be systematically examined. However, during the interviews and subsequent thematic analysis, it became apparent that visa status itself functioned as a barrier to care. Participants described how the uncertainty and restrictions associated with asylum-seeking visas influenced their access to, and engagement with, SRH services.” (Line 770-775)

 

We have commented on the importance of exploring how specific visa types may shape healthcare experiences and outcomes among women seeking asylum.

 

“Future research might explore the effectiveness of culturally tailored, family-inclusive, and policy-sensitive interventions to improve preventive SRH care access among women seeking asylum, particularly across different visa categories.” (Line 775-778)

 

 R1 Comment 9

Implications for Practice:

The study could benefit from clearer translation of findings into practical implications for frontline healthcare providers.

 

How might GPs or community health workers adjust their practice based on these findings?

 

Response 9

We thank the reviewer for highlighting the need to translate our findings into actionable strategies for frontline healthcare providers. Based on our findings, GPs, nurses, and community health workers can adjust practice in several practical ways to improve preventive SRH care for women seeking asylum. We have expanded our strategies with the following points

 

“GPs might incorporate routine SRH discussions during appointments, provide written or translated resources and use trained female interpreters when needed” (Line 793-794)

 

“encourage GPs and nurses to implement follow-up care and call reminders ensuring women receive continuity of care and reduce fragmentation” (Line 793-794)

 

“….screening for psychosocial needs and …. (Line 793-794)

 

R1 Comment 10

Minor Comments:

 

Grammar and Formatting:

A light copyedit is needed for grammar and punctuation, especially in participant quotations.

For example: Line 120: “patriciate” → “participate”; Line 144: “Interpreters” → “interpreters”.

References:

Reference formatting is inconsistent in some places (e.g., spacing, punctuation).

Also consider adding more recent literature (from 2023–2025) where relevant.

 

Response 10

We appreciate the reviewer’s suggestion to incorporate more recent literature (2023–2025) where applicable. In response, we have integrated the most current studies available and removed older references that are not essential. However, due to the limited volume of recent research in this specific area, some older references remain. These were retained only when no recent studies provided comparable insights or when foundational data were essential for contextual understanding. We have revised the referencing formatting to be more consistent and undertaken a edited to improve grammar and punctuation.

 

Author Response File: Author Response.pdf

Reviewer 2 Report

Comments and Suggestions for Authors

Title:  Multiple levels of disadvantage: Barriers to and enablers of accessing preventive sexual and reproductive health care for women seeking asylum in Melbourne, Victoria: A qualitative study

From what I can read through, the manuscript addresses an important and timely issue: barriers to and enablers of preventive sexual and reproductive health (SRH) care for women seeking asylum in Australia. I think the qualitative design, socioecological framework, and thematic analysis employed are appropriate and could yield valuable insights. However, I have some comments that I believe could help strengthen the manuscript.

 

Title

First, I think the title is descriptive but very long (“Multiple levels of disadvantage: Barriers to and enablers of accessing preventive sexual and reproductive health care for women seeking asylum in Melbourne, Victoria: A qualitative study”).
I will suggest, you shorten and sharpen the title while retaining the key elements. For example:
“Barriers and Enablers to Preventive Sexual and Reproductive Health Care among Asylum-Seeking Women in Melbourne: A Qualitative Study”

 

Abstract

You abstract, currently reads like a mini-results section with excessive detail. I will suggest, you clearly separate background, aim, methods, results, and conclusion in abstract presentation. This can be employed in writing the abstract without sub-heading if the journal does not allow sub-heading in abstract. Also, please focus on the most important barriers/enablers rather than listing all.

 

1. Introduction

On you Page 2-3, lines 93–96.  The aim of the study is clearly stated, but the rationale could be better positioned in the introduction. Currently, from what I see the introduction is long and descriptive, but the gap in existing knowledge and the originality of this study are less prominent. I will suggest, you end the introduction with a concise paragraph highlighting the novelty (e.g., very limited research on asylum-seeking women in Melbourne; focus on preventive SRH; qualitative lens with socioecological model).

 

2. Materials and Methods

See page 4, lines 108–121: Recruitment through NGOs may have excluded more isolated or marginalized women, potentially introducing bias. What do you think? While this is briefly acknowledged in the limitations, I think it deserves clearer discussion earlier. I will suggest you explicitly discuss recruitment limitations in the methods section, not only in the discussion.

Also, please consider whether convenience sampling undermines transferability of findings.

On Page 4, line 119–120: You said “Data collection continued until sufficient information…” – This phrase is vague. I will suggest, you clarify whether data saturation or information power guided sample size decisions, citing appropriate references where applicable.

 

On Page 4, lines 154–167: I see that thematic analysis is well-described, but reflexivity of the researchers is missing. Since this is a qualitative study, the positionality of the interviewer (ND) and how it may have influenced interviews should be briefly described. I will suggest you add a paragraph on reflexivity (e.g., professional background, assumptions, steps taken to minimize bias). Also, rigour/trustworthiness. No mentioning of steps such as triangulation, member checking, or audit trail. I will suggest you add explicit details on credibility, dependability, transferability, and confirmability. For your reference on Rigour/Trustworthiness, and Reflexivity, see this study by Itoro published in 2025 ‘It’s Not a Weakness’: Lived Experiences, Support Systems, and Emotional Wellbeing in Caesarean Birth among Postpartum Women in Nigeria https://sjhresearchafrica.org/index.php/public-html/article/view/1994 . I think it this study will you on these aspects.

 

3. Results

I can see that while participant quotes enrich the findings, some themes (e.g., policy-level barriers, community isolation) are supported by very few quotations. For example, page 12, lines 392–399: Only one or two quotes illustrate social isolation, which may weaken the credibility of this theme. I will suggest you provide more diverse participant voices to balance the presentation or justify why limited quotations were included.

4. Discussion

I see that the discussion is strong but occasionally repetitive. For example, I see on Page 14, lines 487–497, reiteration of cultural taboos without deeper theoretical framing.

Also on page 15, lines 541–562: Spouse and family dynamics described, but little connection is made to gender theories or intersectionality. I will suggest you move beyond descriptive comparisons with prior studies to a more critical analysis, for e.g., situating findings within intersectionality or feminist health frameworks.

 

5. Policy Implications

Here, while Medicare ineligibility is discussed, I see that the recommendations in Table 3 are relatively general. I will suggest you strengthen policy recommendations with concrete examples (e.g., extend state-funded community health programs (mention the exact programs or examples if applicable); train GPs in trauma-informed care, and be specific if applicable).

 

6. Limitations

I see that limitations are acknowledged but could be more comprehensive. For example:

Possible response bias given sensitive SRH topics. Influence of interpreters on meaning transfer. Overrepresentation of certain countries of origin. I will suggest you expand this section to provide a fuller reflection of methodological constraints.

 

Additional Minor Comments I can see are:

Page 2, line 67: Typo: “a numbered of high-income country settings” should be “a number of high-income country settings.”

Inconsistent referencing style (e.g., “Stirling- Cameron 2024”). Please see and correct it, and also check for others.

Author Response

Please see the attachment.

Recommendation:

 

Major Revision

 

This is an important, well-conducted qualitative study that offers new insights into a vulnerable population’s access to care. With the suggested refinements, the manuscript will make a valuable contribution to the literature on refugee and asylum-seeker health.

 

Reviewer 2

 

Title:  Multiple levels of disadvantage: Barriers to and enablers of accessing preventive sexual and reproductive health care for women seeking asylum in Melbourne, Victoria: A qualitative study

 

From what I can read through, the manuscript addresses an important and timely issue: barriers to and enablers of preventive sexual and reproductive health (SRH) care for women seeking asylum in Australia. I think the qualitative design, socioecological framework, and thematic analysis employed are appropriate and could yield valuable insights. However, I have some comments that I believe could help strengthen the manuscript.

 

Title

R 2 Comment 1

First, I think the title is descriptive but very long (“Multiple levels of disadvantage: Barriers to and enablers of accessing preventive sexual and reproductive health care for women seeking asylum in Melbourne, Victoria: A qualitative study”).

I will suggest, you shorten and sharpen the title while retaining the key elements. For example:

“Barriers and Enablers to Preventive Sexual and Reproductive Health Care among Asylum-Seeking Women in Melbourne: A Qualitative Study”

 

Response 1

We agree with you and have shortened the title to “Barriers to and Enablers of Preventive Sexual and Reproductive Health Care among Asylum-Seeking Women in Melbourne: A Qualitative Study”. (Lines 1-5)

 

Abstract

R2 Comment 2

Your abstract, currently reads like a mini-results section with excessive detail. I will suggest, you clearly separate background, aim, methods, results, and conclusion in abstract presentation. This can be employed in writing the abstract without sub-heading if the journal does not allow sub-heading in abstract. Also, please focus on the most important barriers/enablers rather than listing all.

Response 2

We have rewritten the abstract more clearly and concisely and focused on the most important barriers/enablers rather than listing all in line with your suggestions. Here is the revised version (Line 12-25)

 

“Women seeking asylum experience markedly poorer health outcomes than refugees, other migrants, and host populations, with sexual and reproductive health (SRH) needs that are complex and multidimensional. This qualitative study explored the barriers to and enablers of accessing preventive SRH care among women seeking asylum in Australia. Between March 2022 and September 2023, semi-structured interviews were conducted with twelve women from eight countries. Using a socioecological framework, analysis revealed that access to preventive SRH care is shaped by intersecting factors at individual, inter-personal, community, and policy levels. Key barriers included limited knowledge of preventive care, psychosocial and financial constraints, fragmented health services, and restrictive immigration policies. Enabling factors included culturally concordant care, continuity with trusted general practitioners, and supportive community and social relationships. The findings underscore how structural and relational factors intersect to influence SRH access and highlight the need for coordinated, multi-level strategies to promote equitable SRH care for women seeking asylum in Australia.” (Line 12-25)

 

 

Introduction

R2 Comment 3

On you Page 2-3, lines 93–96.  The aim of the study is clearly stated, but the rationale could be better positioned in the introduction. Currently, from what I see the introduction is long and descriptive, but the gap in existing knowledge and the originality of this study are less prominent. I will suggest, you end the introduction with a concise paragraph highlighting the novelty (e.g., very limited research on asylum-seeking women in Melbourne; focus on preventive SRH; qualitative lens with socioecological model).

 

Response 3

Thank you for raising this important point. We have revised the introduction and included the following text

 

“Despite the growing attention to the health needs of refugees, there remains

limited research focusing specifically on women seeking asylum in Australia, their access to preventive SRH care or their views on the barriers to and enablers of care. This study addresses this gap by exploring the experiences of women seeking asylum through a qualitative lens, using the socioecological model to capture influences at multiple levels. By examining these perspectives, the study provides novel insights into barriers to and enablers of preventive SRH care and aims to inform strategies for improving access and health equity for this underserved population.” (Line 109-116)

 

Materials and Methods

R2 Comment 4

See page 4, lines 108–121: Recruitment through NGOs may have excluded more isolated or marginalized women, potentially introducing bias. What do you think? While this is briefly acknowledged in the limitations, I think it deserves clearer discussion earlier. I will suggest you explicitly discuss recruitment limitations in the methods section, not only in the discussion.

 

Also, please consider whether convenience sampling undermines transferability of findings.

 

Response 4

Thank you for making this helpful suggestion. We agree with you and have added the following text to the participants and recruitment section in the methods.

 

We have also addressed the comment about the whether convenience sampling undermines transferability of findings in the limitations section of the discussion.

               

“Multiple recruitment strategies were used, including outreach through services, professional networks, and word of mouth. Consequently, women were likely informed of the study via a service provider or community leader. These methods may have missed women who were truly ‘hard to reach,’ such as those not connected to services or social networks.” (Line 135-139)

 

“The use of a convenience sample may limit the representativeness and contextual diversity of participants, thereby reducing the transferability of findings to other settings or populations. This limitation was mitigated through the inclusion of women from diverse of countries of origin, across a wide age range all with markedly different immigration experiences….” (Line 758-762)

 

R2 Comment 5

On Page 4, line 119–120: You said “Data collection continued until sufficient information…” – This phrase is vague. I will suggest, you clarify whether data saturation or information power guided sample size decisions, citing appropriate references where applicable.

 

Response 5

We have provided some additional information on assessment of thematic saturation in the data collection procedure section.

 

“Data collection and analysis occurred concurrently. Interviews were conducted until thematic saturation was reached, that is, when no new themes or insights emerged from the data. After approximately eight interviews, recurrent patterns were evident, and sub-sequent interviews confirmed these existing themes. Saturation was assessed informally through ongoing team discussions and review of coded transcripts, consistent with established qualitative research practices” (Line 210-215)

 

We have also removed the sentence “Data collection continued until sufficient information to address the research question had been gathered,” and replaced it with the text above.

 

R2 Comment 6

On Page 4, lines 154–167: I see that thematic analysis is well-described, but reflexivity of the researchers is missing. Since this is a qualitative study, the positionality of the interviewer (ND) and how it may have influenced interviews should be briefly described. I will suggest you add a paragraph on reflexivity (e.g., professional background, assumptions, steps taken to minimize bias).

Response 6

We agree with your comment. We have included two brief paragraphs on the positionality of the interviewer and how it may have influenced interviews in the following text

 

“Reflexivity involves critically examining how a researcher’s social, cultural, and professional contexts shape the research process. The first authors extensive experience in refugee health, both internationally and within Australia, has significantly influenced her motivation and approach to this study. As a Registered Nurse with over thirty years of experience across tertiary hospitals and primary healthcare settings, she has developed a deep understanding of health disparities affecting vulnerable populations. She has undertaken humanitarian aid postings with the International Committee of the Red Cross, in Tanzania, Myanmar, and Banda Aceh, Indonesia, together with extensive work and travel in low- and middle-income countries, which has further informed this perspective.

 

The first authors professional and humanitarian background may have influenced the interview process in several ways. Her extensive experience working with refugee populations likely facilitated rapport and trust with women, enabling open and in-depth discussions. At the same time, her familiarity with refugee health challenges may have shaped the direction of questioning and interpretation of participants’ narratives. To address this, she engaged in ongoing reflexive practice, maintaining awareness of her assumptions and striving to ensure that participants’ voices and perspectives remained central to the analysis.” (Line 180-197)

 

R2 Comment 7

Also, rigour/trustworthiness. No mentioning of steps such as triangulation, member checking, or audit trail. I will suggest you add explicit details on credibility, dependability, transferability, and confirmability. For your reference on Rigour/Trustworthiness, and Reflexivity, see this study by Itoro published in 2025 ‘It’s Not a Weakness’: Lived Experiences, Support Systems, and Emotional Wellbeing in Caesarean Birth among Postpartum Women in Nigeria https://sjhresearchafrica.org/index.php/public-html/article/view/1994 . I think it this study will you on these aspects.

 

Response 7

Thank you for raising these important points and for your suggested reference. We agree with you and have added an additional section “Rigor and trustworthiness” in the methods.

 

“Several strategies were employed to enhance the rigour of this study and ensure credibility, dependability, confirmability, and transferability of the findings. Credibility was supported through prolonged engagement with women, informal member checking during interviews, and regular supervisory discussions to ensure interpretations reflected womens’ perspectives. Dependability was enhanced by maintaining a detailed audit trail of recruitment procedures, analytical decisions, and coding processes, enabling transparency and consistency throughout the study. Confirmability was achieved through reflexive journaling to monitor potential researcher bias, combined with peer review with JF and KH of coding and theme development to ensure findings were grounded in womens’ accounts. Transferability was promoted by providing rich descriptions of womens’ contexts and experiences, including their diverse countries of origin, age ranges, and migration histories, allowing readers to assess the relevance of findings to other settings.” (Line 217-229)

 

Results

R2 Comment 8

I can see that while participant quotes enrich the findings, some themes (e.g., policy-level barriers, community isolation) are supported by very few quotations. For example, page 12, lines 392–399: Only one or two quotes illustrate social isolation, which may weaken the credibility of this theme. I will suggest you provide more diverse participant voices to balance the presentation or justify why limited quotations were included.

               

Response 8

We agree with your observations here. We have added quotes supporting the theme of social isolation.

 

“Most women described social isolation and lack of community support as limiting their access to SRH information and their ability to navigate services.

“…I came over here when I was only 19 years old…I didn’t come with my parents. If they were here I could have asked my mother… so, I didn't know what to ask or what to go for. I wouldn’t know [why women don’t do screening] because the women from my community… that I know are much older than me, I’m much younger and I would be reluctant to ask them about whether they would like to do it [cervical screening] or why they are not doing it.”“(Vijitha, 28) (Line 481-488)

 

When women were asked about contraception specifically, this was a typical response

“Nobody talks openly about this. I don’t have much friends. We can talk because if I ask the doctor he will tell me but no talk to anyone. I don’t know anyone” (Maria, 36) (Line 489-492)

 

We have added quotes supporting the policy level barriers.

 

““Well I didn’t have a Medicare for one year and I was given Medicare only 2 months ago. As I’m on a bridging visa as we are still on a bridging visa so the department of immigration is quite strict and the Medicare used to be valid for one or two years. But they are valid for only 6 months at the moment.” (Sarah, 34) (Line 515-518)

 

Discussion         

R2 Comment 9

I see that the discussion is strong but occasionally repetitive. For example, I see on Page 14, lines 487–497, reiteration of cultural taboos without deeper theoretical framing.

 

Response 9

Thank you for suggesting this. We agree with you and have included a sentence providing d theoretical deeper framing

 

“From a theoretical perspective, these cultural taboos can be understood through the lens of feminist and intersectional perspectives, which highlight how patriarchal structures and intersecting cultural identities shape women’s agency and constrain conversations about sexual and reproductive health.” (Line 585-589)

R2 Comment 10

Also on page 15, lines 541–562: Spouse and family dynamics described, but little connection is made to gender theories or intersectionality. I will suggest you move beyond descriptive comparisons with prior studies to a more critical analysis, for e.g., situating findings within intersectionality or feminist health frameworks.

                Response 10

                We agree with you and have added the following text in the discussion section

 

“From an intersectional feminist perspective, these findings highlight how gendered power relations within families intersect with cultural and social structures to shape women’s health agency. Patriarchal norms that position men as decision-makers over women’s bodies are further compounded by intersecting factors such as migration status, socioeconomic dependence, and cultural identity, which can intensify women’s vulnerability to reproductive health inequities. Within this framework, limited autonomy is not merely an individual constraint but a reflection of broader structural power imbalances that define who has authority in reproductive decision-making.” (Line 648-656)

 

Policy Implications

R2 Comment 10

Here, while Medicare ineligibility is discussed, I see that the recommendations in Table 3 are relatively general. I will suggest you strengthen policy recommendations with concrete examples (e.g., extend state-funded community health programs (mention the exact programs or examples if applicable); train GPs in trauma-informed care, and be specific if applicable).

               

Response 10

Thank you for this suggested addition strengthen policy recommendations. We have added more concrete examples to Table 3.

 

                “provide specific training for GPs and nurses in trauma-informed care” (Line 792)

 

“expand and enhance state-funded community health programs specifically for asylum seekers such as the Asylum Seeker Resource Centre and Victoria’s Refugee Health Program” (Line 792)

 

Limitations

R2 Comment 11

I see that limitations are acknowledged but could be more comprehensive. For example:

 

Possible response bias given sensitive SRH topics. Influence of interpreters on meaning transfer. Overrepresentation of certain countries of origin. I will suggest you expand this section to provide a fuller reflection of methodological constraints.

 

Response 11

These are important points, thank you for raising them. We thank the reviewer for highlighting the concern of potential overrepresentation of certain countries of origin. While recruitment from this hard-to-reach group presented challenges, we were fortunate to include 12 women from eight different countries, which we believe offers a reasonably diverse range of perspectives.

 

We agree with you and have included information on influence of interpreters on meaning transfer and the possibility of response bias given sensitive SRH topic.

 

“Conducting research with participants who have limited English proficiency and diverse cultural backgrounds presents methodological challenges, particularly in ensuring that the meanings of participants’ responses are accurately captured. This process carries an inherent risk of misinterpretation or loss of contextual nuance during translation and interpretation. To minimise this risk, any ambiguity or uncertainty that arose during the interviews was immediately clarified with the interpreter, and post-interview debriefing sessions were conducted to discuss and resolve potential misunderstandings or culturally specific expressions.

 

“While women appeared comfortable and open when discussing sensitive SRH topics, it is important to acknowledge that those who chose to participate may have been more willing to engage in such discussions. This self-selection introduces a potential risk of response bias, as the experiences of women who were less forthcoming or hesitant to discuss SRH may not be fully captured. Nevertheless, the candidness observed during interviews suggests that response bias due to the sensitivity of the topics was unlikely to have significantly influenced the findings.” (Line 749-768)

 

R2 Comment 12 and 13

Additional Minor Comments I can see are:

Page 2, line 67: Typo: “a numbered of high-income country settings” should be “a number of high-income country settings.”

Inconsistent referencing style (e.g., “Stirling- Cameron 2024”). Please see and correct it, and also check for others.

 

Response 12/13

We have a corrected these errors.

Author Response File: Author Response.pdf

Reviewer 3 Report

Comments and Suggestions for Authors

Thank you for the opportunity to review this paper. It is well written, methodologically sound, and covers an important health issue for asylum seeker women. 

Introduction: Very good. I thought it could be a bit clearer how PTSD can impact women seeking SRH care. Also, the gap in the literature could be clearer leading into the research aim. It could be clearer what this research adds that is not already known. 

Materials and methods

Clear, well-reasoned and sound research methodology. You mentioned convenience sampling and continuing recruitment until you had enough data to answer the research question. Were there any elements of purposive sampling in there as well. The diversity of participants is a strength of this paper and could be highlighted more. Did you aim for this in your recruitment and sampling? I applaud your detail in the methodology. I think it supports the credibility of the research.  

Results

Line 173 – Did 12 women agree or 14 agreed and only 12 were interviewed? This could be a little clearer so we know why 2 were not included in the interviews.

Table 2. Are these pseudonyms? If they are, please say so. If not, are the demographics provided sufficient to potentially identify some of them? For example, there are not many people from Togo in Australia.  Perhaps change country of origin to region of origin (e.g., West Africa, South East Asia etc), this will still convey the diversity that is a strength of this paper without potentially identifying anyone.

The coding tree is nice and clear and helps to orient the reader. However, in the results I sometimes got a little lost with the numbering. That might be a journal expectation. For example. 3.3 was individual level but Lack of knowledge, a theme under individual level was 1.1. For some reason that threw me. Perhaps even changing to 1a, 1b etc for the themes might help to keep those numbering systems distinct.

Line 401 Heading 5.2 Religious norms and expectations shared by the religious community. The paragraph under that did not really seem to support the heading.

Line 440 seems to have a typo.

Discussion: Integrates well with the literature.

Line 536 ref is author-date but probably should be #8.

Line 562 appears to have a typo

Table 3. I like this table because it is a useful summary of recommendations for people working in the field. I would recommend more referencing to support. I also recommend left aligning the text. And the first point under Interpersonal change to ‘encourage GPs to consider…’ in line with structure of other points

Conclusion: Good. Perhaps a little more on how this has added to the literature. Was it the focus on asylum seekers, the use of an ecological model in this space or something else?

Overall a very well conducted and well-structured piece of research.

Author Response

Please see the attachment.

Reviewer 3

 

Thank you for the opportunity to review this paper. It is well written, methodologically sound, and covers an important health issue for asylum seeker women.

 

Introduction:

R3 Comment 1

Very good. I thought it could be a bit clearer how PTSD can impact women seeking SRH care. Also, the gap in the literature could be clearer leading into the research aim. It could be clearer what this research adds that is not already known.

 

Response 1

Thank you for raising this important point. We have revised the introduction and included the following text identifying the gap in the literature and what this research adds.

 

“Despite the growing attention to the health needs of refugees, there remains

limited research focusing specifically on women seeking asylum in Australia, their access to preventive SRH care or their views on the barriers to and enablers of care. This study addresses this gap by exploring the experiences of women seeking asylum through a qualitative lens, using the socioecological model to capture influences at multiple levels. By examining these perspectives, the study provides novel insights into barriers to and enablers of preventive SRH care and aims to inform strategies for improving access and health equity for this underserved population.” (Line 109-116)

 

Thank you for your interest in how PTSD can impact women seeking. We have included the following sentence in the introduction

 

“Substantial evidence exists that asylum seekers are at higher risk of post‐traumatic stress disorder (PTSD) due both to experiences in their country of origin and during transit” (Line 87-89)

 

Materials and methods

R3 Comment 2

Clear, well-reasoned and sound research methodology. You mentioned convenience sampling and continuing recruitment until you had enough data to answer the research question. Were there any elements of purposive sampling in there as well. The diversity of participants is a strength of this paper and could be highlighted more. Did you aim for this in your recruitment and sampling? I applaud your detail in the methodology. I think it supports the credibility of the research. 

 

Response 3

Thank you for your observations. Given the pragmatic considerations, ethical sensitivity and challenges accessing this hard-to-reach group we were not able to include any elements of purposive sampling. However, while a convenience sample was used, by focusing on accessing and contacting a wide range of community organisations and NGOs, we employed a deliberate recruitment strategy aimed at achieving diversity in participants’ backgrounds and experiences.

 

We have included a comment on how the diversity of participants is a strength of this paper.

 

“This limitation was mitigated through the inclusion of women from diverse of countries of origin, across a wide age range all with markedly different immigration experiences and consider the diversity of women is a strength of this study.” (Line 759-761)

 

Results

R3 Comment 4

Line 173 – Did 12 women agree or 14 agreed and only 12 were interviewed? This could be a little clearer so we know why 2 were not included in the interviews.

               

Response 4

We have added the following line in the results section

 

“Two women declined to be interviewed.” (Line 249-250)

 

R3 Comment 5

Table 2. Are these pseudonyms? If they are, please say so. If not, are the demographics provided sufficient to potentially identify some of them? For example, there are not many people from Togo in Australia.  Perhaps change country of origin to region of origin (e.g., West Africa, South East Asia etc), this will still convey the diversity that is a strength of this paper without potentially identifying anyone.

 

                Response 5

Pseudonyms were not used in this study. Women agreed to using their own first names.  We agree with your observation that this could potentially identify some of them and we have changed the country of origin to region of origin in Table 2

 

R3 Comment 6

The coding tree is nice and clear and helps to orient the reader. However, in the results I sometimes got a little lost with the numbering. That might be a journal expectation. For example. 3.3 was individual level but Lack of knowledge, a theme under individual level was 1.1. For some reason that threw me. Perhaps even changing to 1a, 1b etc for the themes might help to keep those numbering systems distinct.

 

Response 6

Thank you for pointing this out. We agree that there is a need for visually clarifying model’s levels in the Results section. To this end we have increased the font size and bolded the levels of the framework. We have also increased the font size and underlined the themes and subthemes for clarity.

 

R3 Comment 7

Line 401 Heading 5.2 Religious norms and expectations shared by the religious community. The paragraph under that did not really seem to support the heading.

 

Response 7

Thank you for this observation. We have now included relevant text and supporting quotes under the heading 5.2 Religious norms and expectations shared by the religious community.

 

“A few women openly reported how religious norms and expectations impacted their health seeking behaviour and access to SRH care. For example, in relation to contraception some women commented;

“In my country there are some religious beliefs, it’s a Catholic country and the catholic church say you have to have the kids that God send to you so its another thing more common in the countryside.” (Maya, 43) and then this “In my culture they said it is not good to use contraception, that children are a gift from God, that its not good to stop your-self from getting pregnant when you are given the chance to have children.” (Afiji, 35)” (Line 495-502)

 

Line 440 seems to have a typo.

This error has been corrected

 

Discussion: Integrates well with the literature.

 

Line 536 ref is author-date but probably should be #8.

This error has been corrected (Line 638)

 

Line 562 appears to have a typo

This error has been corrected (Line 677)

 

R3 Comment 8

Table 3. I like this table because it is a useful summary of recommendations for people working in the field. I would recommend more referencing to support. I also recommend left aligning the text. And the first point under Interpersonal change to ‘encourage GPs to consider…’ in line with structure of other points

 

Response 8

We have aligned Table 3 to the left and add the text ‘encourage GPs to consider..’ in the first line under interpersonal (Line 792)

 

R3 Comment 9

Conclusion: Good. Perhaps a little more on how this has added to the literature. Was it the focus on asylum seekers, the use of an ecological model in this space or something else?

 

Response 9

We have included reference on why we focused on asylum seekers and the use of an ecological model in the later section of the introduction.

 

“Despite the growing attention to the health needs of refugees, there remains

limited research focusing specifically on women seeking asylum in Australia, their access to preventive SRH care or their views on the barriers to and enablers of care. This study addresses this gap by exploring the experiences of women seeking asylum through a qualitative lens, using the socioecological model to capture influences at multiple levels. By examining these perspectives, the study provides novel insights into barriers to and enablers of preventive SRH care and aims to inform strategies for improving access and health equity for this underserved population.” (Line 109-116)

 

Overall a very well conducted and well-structured piece of research.

Using a socioecological framework and a qualitative approach, this study provides rich and insightful findings that deepen understanding of the complex interplay of individual, interpersonal, community, and policy factors affecting healthcare access.

Author Response File: Author Response.pdf

Round 2

Reviewer 2 Report

Comments and Suggestions for Authors

The authors have addressed the issues raised during the review process. They should, however, read through the manuscript once more to correct any remaining or residual errors.

 

Author Response

Response to Reviewer:

Thank you very much for your constructive feedback and for taking the time to review our revised manuscript a second time. We appreciate your acknowledgement that the issues raised during the review process have been addressed. In response to your suggestion, we have carefully read through the entire manuscript once more and have corrected any remaining or residual errors to ensure clarity and accuracy throughout.

We are grateful for your thoughtful comments, which have helped us strengthen the quality of our paper.