Title: Knowledge, Attitudes, and Practices of Lebanese Women toward the Use of Oral
Contraceptive Pills
Version: 1 Date: 25 Apr 2024
Reviewer's report:
The authors have made important changes to their manuscript, but they did not make significant
edits to delete at least a third of the word count. I offer more specific comments to help the
authors continue to improve the quality of their draft.
• “Inadequate utilization” of OCP is not what you mean. You mean “incorrect utilization” and
the failure rate in new studies is 7% not 9%.
• The methods section should describe and justify how and why categories of “totally agree and
partially agree” were combined in the analysis.
• I am confused. The sample size was based on an anticipated knowledge percentage of 53.9 from
Barbour’s study. It would be important to use the same questions that Barbour used. However,
it seems that the authors developed their own survey instrument to test subjects’ knowledge
about OCPs. The authors must report what proportion of their study match the questions asked
by Barbour. If the authors asked about topics not covered by Barbour, they should be deleted
and a subanalysis done to evaluate the knowledge of these women compared to those reported
by Barbour.
• Another problem is that it is not clear why women who are not at risk for pregnancy should
have to be educated about oral contraceptives. The inclusion criteria did not require that the
subjects even needed contraception.
• Why would women have to know the increased risk of breast cancer? That risk is only
minimally elevated and does not persist for more than a few years after pill discontinuation.
Long term there is no measurable impact on death from breast cancer when comparing never
users ever used.
I would recommend removing that finding. Similarly, there is no evidence to demonstrate in
healthy pill users, lipid changes have any adverse clinical impacts. Why should women have to
know about clinically insignificant metabolic changes with pill use?
• After all the new text added in this version about the role of pharmacists in educating women
about OCPs, it is interesting how little they contributed to women’s information. Why not
highlight that in the findings? Did you have data about pharmacists as a separate category?
• Why did the authors not ask about what method the subject used, if she were at risk for
pregnancy? Are we sure they were not already using more effective methods than OCPs?
• There are some fact issues the authors report that 38.8% believed OCPs could cause infertility,
but only 12% actually believed that; the rest “partially agreed”. This wording overstates the true
finding. Similarly, the expected failure rate of 6% is very close to actual 7%. Since the authors
apparently did not specify that they were asking about typical failure rates, I would count the
6% estimate as a correct answer.
• Figure 1 is very misleading. It seems to be based on the total population. There should be a
second bar on each row for the answers from the pill users; 78% (85/109) or 60% (85/140) of
pill users relied on health professionals for their information. This very important finding t is
buried in Table 5. The discussion highlighted only the percentages of information sources for
all women, not those who use OCPs.
• How many of the factors associated with OCP used are modifiable? What methods did the
wealthier women use; is there any change they relied on IUDs and injections, which are more
effective?
• One wonders why women need to know all the health benefits of pill use, if they are already
using pills.
• The discussion section is overly repetitive, and much does not relate to clinically significant
findings.
• The conclusions may be misleading. Why focus only on OCP education?
I would be happy to review any other revisions the authors may wish to submit.