Reviewer’s report
Title: 
The Effect of Educational Program Based on Beliefs, Subjective Norms
and Perceived Behavior Control on Doing Pap-smear Test in Sample of Iranian
Women
Version: 
1 
Date: 
20 Mar 2021
Reviewer's report:
With cervical cancer being among the most frequent cancer in women and deaths
are highly preventable, the topic studied is highly relevant. Especially for
countries where cervical testing is still not frequently performed due to personal
beliefs and norms, and thus education programs could considerably improve the
screening participation. Detailed description of the education process adds
additional value. This paper could even stimulate some countries or health
centers to deliver educational programs on cervical cancer. However, the paper
needs considerable improvement before publishing, both in technical proficiency
and in language editing.
The concept and methodology of the study are sound, but the narrative should be
improved to better follow logical flow.
In relation to pap testing for early diagnosis of cervical cancer, we speak about
secondary prevention, which means it does not prevent the cancer (as is the case
with HPV vaccination), but prevents detrimental consequences of the disease.
Authors should correct the text of the manuscript to use the terminology
correctly and accurately.
Use "Pap smear test" 
(without hyphen) consistently allover the text.
Revise the References list, there are several typing mistakes present. 
Introduction:
The introduction is too long. 
Epidemiological data can be much shorter, try to consolidate it and organize it
systematically and hierarchically from global, to LMIC, to Iran. Data for USA is
not relevant for the purpose of this paper.
One sentence with one strong reference is enough to state that cervical cancer is
largely treatable if detected early and treated effectively. Additional references
on this fact are not needed.
Lines 42 and 43: The introduction section can begin directly with cervical
cancer. The first two sentences on cancer 
as such are too general for the topic
considered in the present manuscript. 
Line 45: It is not correct that cervical cancer is the second leading cancer
following breast cancer in the world, and it is not clear what is meant by "leading
cancer" - incidence, mortality or else? 
Line 45: Reference No. 1 does not seem proper. For cancer burden of disease
data, I suggest to use the following reference https://gco.iarc.fr . Preferably, most
recent primary data sources should be used. 
Reference No. 2 is not referred to in the text of the manuscript.
Line 46: Use "gynaecologic cancer" instead of "cancer in their reproductive
organs".
Lines 48 and 51: References No. 4 and No. 5 seem not appropriate, suggest to
use the https://gco.iarc.fr .
Line 51: Instead of "Statistic suggest …" 
use 
"Evidence suggests…".
Line 52: Instead of "leading cancer" use "most common cancer". Delete "among
the most common cancers".
Line 56: Delete "which nearly" 
so it will read 
" … uterus, 30 % of them
occurring in cervix…".
Line 57: Missing reference for sentence beginning with "Nearly one million
women are affected…" It is not clear whether this data refers to the world or any
other region. Please add. 
Line 60: Cervical cancer is preventable through HPV vaccination only. It is
treatable as long as it is detected early and managed effectively. Please correct
the sentence accordingly. Correct the abstract as well.
Lines 62-63: References No. 9 and No. 10 seem not appropriate. Please check
and use the primary data source.
Lines 63-70. Sentences on risk factors not relevant for the purpose of the
manuscript. Can be omitted.
Line 66. Reference No. 11 seems not appropriate. Please check and use it with
correct claim. 
Line 70: References 12 and 13 could be used above in the epidemiology part.
Line 71 and on: References seem not to be used correctly. Please check and
correct. 
Line 73: Sentence can be shortened to read: "Evidence in several countries
suggests that screening programs can reduce cervical cancer mortality rates by
up to 60 %.".
Line 78: Sentence beginning with "Timely diagnosis…" should be moved and
joined into the sentence in Lines 60-61. (…treatable as long as it is detected
early…)
Line 79: Not clear, which country or region the claim refers to. Please add.
Line 81: Add the exact data on take up of Pap test in Iran.
Line 89: Deaths from cervical cancer are preventable by screening and not the
cancer as such. This sentence should be corrected and moved above and
amalgamated within existing text, as in this place it is repetition of what has
already been said before.
Line 95: What exactly do you want to say with "Pap smear test screening is not
easy"? Do you mean easy to perform the test? Or easy to organize national
screening program? Or that it is not pleasant for the patient? Please correct to be
concise in terminology.
Line 96: "…in this regard…" too lay language, please correct. State exactly in
what regard.
Line 96: "…have the highest chance of success.." Not clear to what kind of
success this refers to. Must be written more accurately. Add reference.
Line 101: Correct to be "…the Health Beliefs Model (HBM)…", add reference.
Use the acronym hereafter.
Line 108-109: "…can overcome factors affecting screening participation such as
negative emotions, lack of time etc.". Do not state cost as a factor, as screening
programs should always be reimbursed. Also, pain itself is not inhibiting factor,
but negative emotions related to pain.
Line 109, 129 and 153: Use comma in writing references (20, 21), (21, 26) and
(21, 26), respectively. Consider hereafter.
Lines 109-111: It is not enough to state only that two author have conducted
research. Please put exact results of the studies.
Line 111-112: Use "Planned Behavior Theory (PBT)" and use the acronym
hereafter. Add reference.
Lines 119, 126: "Beliefs" to be written with lower-case b, beliefs.
Line 124: Use comma in writing references (1, 25) and put it at the end of the
sentence.
Line 129: "Pap" instead of "Pop".
Methodology:
Why do authors think this is a quasi-experimental study? It is written in Line 138
that study subject were randomly assigned to either experimental or control
group. Please reconsider and argument.
Line 134: ")150 subjects in the experimental group and 150 subjects in control
group)" can be omitted. It is stated below.
Line 138: Use "… were randomly assigned into either experimental or control
group…" 
Line 145: Add: "Women in experimental group received extensive education on
cervical cancer and Pap-smear testing, while women in control group received no
educational intervention." 
Lines 158-170: This data adds no information value. Instead, publish the
questionnaire as supplementary material. 
Lines 171-172: Explain how validity and reliability were confirmed.
Line 186: Usually, it is used "to manage" or "to control" non-communicable
diseases".
Line 188: Use "…held in eight 50-minute educational sessions, once per week,
…"
Line 193: Delete "and one session was heldper week".
Line 202: Use "Women" instead of "Subjects".
Line 204-205: Delete "Control group received no educational intervention.".
Results:
No major comment, find results reporting sound and well written.
Line 229: Use "found" instead of "fund".
Discussion:
The whole first paragraph of the Discussion section can be meaningfully moved
and integrated into the Introduction section.
Line 249: Pap-smear test is a method for early detection of cervical cancer and
not its prevention. Please correct.
Line 269: Use "practice" instead of "performance". 
Line 314: Instead of "He justified…" use "They justified…"
Line 334: Delete "et al.", as this is a PhD thesis and D. Linton is the sole author.
Use as in the cited source: "…showed direct effect on Pap-smear behavior".
Line 351: Please explain "spouses were abstract forms". Please check the cited
resource again.
Lines 389-390: Revise the sentence "… and subjective norms such as spouse and
health care staff cooperate, the intention and performing the behavior in women
would also enhance." It is not clear and easy to understand.
Lines 391-393: Consider to put "Well-planned, comprehensive and integrated
approach, based on clients' needs and requirements, is the most important
characteristic of successful screening program. It should include health
education and health promotion elements, and interventions of the health care
staff need to be based on these principles". 
Line 394: Delete "so".
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Is the study design appropriate to answer the research question (including the use
of appropriate controls), and are the conclusions supported by the evidence
presented?
Yes
Are the methods sufficiently described to allow the study to be repeated?
Yes
Is the use of statistics and treatment of uncertainties appropriate?
Yes
Is the presentation of the work clear?
Yes
Are the images in this manuscript (including electrophoretic gels and blots) free
from apparent manipulation?
Yes