Reviewer's report
Title:Development and psychometric testing of a new instrument to measure
factors influencing on women' behaviors toward breast cancer prevention
(ASSISTS)
Version:3Date:2 December 2015
Reviewer: Penny Wright
Reviewer's report:
Major Compulsory Revisions
Overall the authors have described a classical approach to questionnaire
development, have used tests appropriately and reported their findings. My main
concerns about the paper, which I think will need to be revised, are in its
structure, context/referencing and the fact they seem to be using data collected
for a previously published study but have not acknowledged this within the
manuscript.
1. Context and Referencing
The referencing should be better. I looked in some detail at the first few
references and had a number of concerns:
Reference 1: Why did the authors chose to cite an article on incidence and
mortality in Hispanics and Latinos in USA when they refer to a global public
health problem? I suggest they go to the IARC website and get the global picture:
http://www.uicc.org/iarc-release-latest-world-cancer-statistics
Reference 2: This reference is quoted as reporting that breast cancer comprises
21.4% of all cancers and Iranian women get breast cancer about a decade
earlier than women from developed countries. When I looked at reference 2
(Noroozi; Tahmasebi) I found this fact was actually included in the introduction of
this paper and was citing a different papers by Lamyian et al 2007 and Harirchi et
al 2004. Please do not state facts which are derived from ‘secondary references’.
Not only is it misleading but also does not give credit to the originators of the data
quoted.
Reference 3: I have not looked at reference 3 but the percentage quoted of 23%
of women under the age of 40 being affected by (being diagnosed with?) breast
cancer seems highly unlikely.If this is not what they meant the sentence needs to
be rephrased. I suggest the authors look at a recent paper: Jazayeri et al. 2015.
Incidence of primary breast cancer in Iran: Ten-year national cancer registry data
report. CANCER EPIDEMIOLOGY: 39 (4).
Reference 4: I question whether this should be referenced here. It seems to be
reporting findings from the same study as reported in Phase one of this
manuscript. See methods section.
I did not look at all the references in this detail but did read through the others
and wondered if they were the most relevant – for example are references 13
(Diabetic self-management in USA) & 14 (Vaccination uptake ) the most relevant
for breast cancer preventative behaviours regarding health related behaviours;
are 15 (children with disability and chronic illness)and 16 (school based play
activity in adolescent girls) the most relevant for breast cancer preventative
behaviours regarding self-efficacy and ability to change behaviour?
I also had a quick scan through the literature to see what else had been
published regarding Iranian women and breast cancer prevention / screening. I
was surprised to find a number of recent articles some of which I would have
thought of relevance to this work. A comment on how this work may relate to the
articles based around the Health Beliefs Model and its Scale would have added
depth to the manuscript. There are also interesting references on uptake and
reasons for screening in Iran which would be useful background, e.g.:
1. Akhtari-Zavare M et al. 2014. Knowledge of Breast Cancer and Breast
Self-Examination Practice among Iranian Women in Hamedan, Iran. ASIAN
PACIFIC JOURNAL OF CANCER PREVENTION.15: 6531-6534.
2. Sepandi M et al. 2014.Breast Cancer Risk Factors in Women Participating in a
Breast Screening Program: a Study on 11,850 Iranian Females ASIAN PACIFIC
JOURNAL OF CANCER PREVENTION . 15: 8499-8502
3. Harirchi I et al. 2012. Literacy and Breast Cancer Prevention: a
Population-Based Study from Iran. ASIAN PACIFIC JOURNAL OF CANCER
PREVENTION. 13: 3927-3930.
4. Hajian-Tilaki K et al. 2014. Health belief model and practice of breast
self-examination and breast cancer screening in Iranian women. BREAST
CANCER. 21: 429-434.
5. Shiryazdi SM et al. 2014 Health Beliefs and Breast Cancer Screening
Behaviors among Iranian Female Health Workers. ASIAN PACIFIC JOURNAL
OF CANCER PREVENTION. 15: 9817-9822.
6. Fouladi N et al. 2013. Beliefs and Behaviors of Breast Cancer Screening in
Women Referring to Health Care Centers in Northwest Iran According to the
Champion Health Belief Model Scale. ASIAN PACIFIC JOURNAL OF CANCER
PREVENTION. 14: 6857-6862.
7. Taymoori P et al. 2014. Facilitator Psychological Constructs for Mammography
Screening among Iranian Women. ASIAN PACIFIC JOURNAL OF CANCER
PREVENTION. 15: 7309-7316.
8. Taymoori P and Berry T. 2009. The Validity and Reliability of Champion's
Health Belief Model Scale for Breast Cancer Screening Behaviors Among Iranian
Women. CANCER NURSING. 32: 465-472.
I think the introduction and discussion could be informed better by more relevant
referencing and this should be addressed by the authors.
2. Methods and results - structuring
It would help reading the paper if Phase 1 and Phase 2 were separated into their
own sections of methods and results. The Phase 2 work is based on Phase 1
results so it would make navigation easier. The first paragraph of what is now
called methods should go at the end of the introduction, after the aim.
Phase 1 Item generation and scale development
Methods and results were a little muddled together. They should be more clearly
signposted. The aim of Phase 1 should be clearly explained right at the start of
the section followed by the method including ethical approval, recruitment,
interviewing etc., then the analysis plan followed by the results. Results for
Phase 1 should include reference to Table 2 in the text, which describes the
sample. This will mean reordering the Table numbers.
Phase 2: Psychometric testing
I think this section could be cut in to two sections as I assume that the Construct
validity and Reliability testing were only undertaken on the items left in the pool
after the Content and Face validity tests were complete and an amended
questionnaire produced? To make things easier to follow, I suggest starting with
the sections on face validity and content validity methods followed by their
results. Then go on to describe your other studies based on the questionnaire
items and response format agreed following these ‘tests’. Clearly provide the
number of items still included at the end of each stage.
3. Methods - lack of acknowledgement and reference to the previous published
study
I was surprised not to see reference to the qualitative paper (Citation 4) in the
methods section as, from reading it and from Phase 1 of this paper, it looks like it
is referring to the same study. I think it is OK to use data collected from a
qualitative study to generate items as long as this is clearly explained in any
publications coming from the same work. So, is this a secondary analysis of the
author’s 2014 paper of which the aim is clearly stated “to explore Iranian
women’s experiences of breast cancer – preventative behaviors, and provide
more insight on the topic? There is no mention in the primary publication (citation
4) that the data would be used for item generation. In this paper the aim of the
qualitative interviews/focus groups was to ‘generate items’. If it is the same study,
I think it should be stated clearly that this paper reports secondary analysis of the
qualitative data collected in the 2014 published study, and this is a study
limitation which should be discussed. By citing the earlier paper the authors could
cut down quite a bit on the methods section.
4. Methods - study process
There is no clear picture of the methods used to collect the data for the remaining
studies (EFA, CFA, test-retest). Only by looking at Table 2 did I get clearer
understanding of the fact that there were three separate studies undertaken for
the remaining psychometric evaluation. Describe the aim of each and then the
method followed for each sample to recruit, collect and collate study data,
statistical analyses undertaken, and then present the results. In some places
results were presented in the methods section (e.g. reference to Figure 1 at the
bottom of the section exploratory factor analysis methods section).
5. Sample size for CFA
Confirmatory factor analysis: there was no explanation of how the sample size of
130 was reached. A general rule of thumb recommends a minimum of 200 cases
but some recent publications have suggested other ways to estimate an
adequate sample size (e.g. Wolf et al Educ Psychol Meas. 2013 Dec; 76(6):
913–934.). Please provide detail of what approach was taken and whether it was
deemed to be adequate.
Minor Essential Revisions
1. Spelling: Principal Components Analysis - not Principle
2.There was repetition in places within the results of the methods already
described in the methods section (e.g. Under results construct validity –
exploratory factor analysis. It has already been stated the Kaiser-Meyer Oklin
and Bartlett’s tests had been done) . Just provide the result. It will make the
paper a more succinct read.
2. I am so impressed by the researchers who have English as a second
language write manuscripts in English. This paper is understandable but there
are quite a few places where the English reads a little oddly e.g.
Introduction third sentence:
“Breast cancer is the first common cancer diagnosed in Iranian women
containing 21.4% of all the cancers between women.”
Introduction first sentence second paragraph:
“Due to the unknown of the main causes of breast cancer,….”
I think it would benefit the paper greatly if the authors were able to ask someone
who has better English to proof the paper for them and make the minor
corrections where the English is not quite right.
Discretionary Revisions
Exploratory factor analysis: Although the authors cite 4-10 cases per item
(reference 24), it is probably more usual rule of thumb to have 5 as an absolute
minimum, with 10 being acceptable and more than this even better. The smaller
the case per item ratio, the greater the danger of over-fitting the data. If 49 items
were included in the exploratory factor analysis, the sample size just meets
minimal criteria. Maybe mention in limitations – would want to rerun in a larger
sample from a wider group of women.
Level of interest: An article whose findings are important to those with closely
related research interests
Quality of written English: Needs some language corrections before being
published
Statistical review: Yes, and I have assessed the statistics in my report.
Declaration of competing interests:
I declare that I have no competing interests