Reviewer's report
Title:To predict factors associated with Breast Self-Examination behavior in a
sample of Iranian women: An Application of Health Belief Model
Version: 2Date:2 March 2009
Reviewer: Paul Norman
Reviewer's report:
The manuscript reports an interesting study applying the Health Belief Model
(HBM) to the prediction of breast self-examination among Iranian women. The
manuscript is likely to make a positive contribution to the literature given that are
no other HBM studies on BSE in Iran. In addition, the relatively large sample and
the use of Champion’s HBM scale are positive features of the study.
Nevertheless, there are a number of ways in which the manuscript could be
improved especially regarding the description of the BSE measures and the data
analysis where a logistic regression analysis is likely to be more appropriate.
Major Compulsory Revisions:
1. The manuscript would benefit from thorough copy editing by a native English
speaker.
2. Page 4. More information is needed on the BSE measures. How many
questions were asked? What was the wording of these questions and what were
the response categories? Such information is needed to be able to interpret the
results.
3. Page 5. It is necessary for the reader to know what the response options to the
BSE questions were to be able to fully interpret the results (see point 6). The
results for each BSE question need to be reported.
4. Page 5. Given that the authors have compared women who do versus do not
perform BSE (Table 1), I was surprised that they didn’t then report a logistic
regression analysis to examine the independent contributions of the HBM
variables to the prediction of BSE performance. This analysis should also control
for the effects of any sociodemographic variables that are associated with BSE
performance. The regression analysis should employ a hierarchical (or direct
entry) procedure whereby any sociodemographic variables that are associated
with BSE performance are entered in block 1, followed by all of the HBM
variables in block 2.
5. Page 5. The use of stepwise regression analysis should be avoided as it is
atheoretical. The ability of the HBM to explain variance in BSE should be
considered as a whole followed by an examination the unique contribution of
each construct. All of the HBM variables should be entered into the regression
model (after first controlling for the effects of sociodemographic variables that are
associated with BSE). In addition, the frequency measure (which forms the DV in
the current analysis) is likely to be highly skewed, given that most women didn’t
perform BSE. As a result, the use of a linear regression analysis might be
inappropriate. A logistic regression analysis using performance versus
non-performance as the DV might be more appropriate (see previous point). If
the linear regression analysis is retained, then it would be necessary to report the
correlations between the HBM variables and BSE performance.
6. The practical implications of the results need to be expanded. How would one
increase self-efficacy. The authors should refer to Bandura’s work on the sources
of self-efficacy.
Minor Essential Revisions:
1. The title could be more concise – e.g., An application of health belief model to
the prediction of breast self-examination in Iranian women
2. The abstract is clear, but (i) there’s no need to include information on the
response choices and (ii) the R-square value from the regression analysis should
be reported.
3. Page 3. More information could be provided on the nature of the (random)
selection procedure.
4. Page 4. The description of the HBM should be deleted from the method
section as it is already described in the introduction.
5. Table 1. Include details of the n’s for each group. Report the t values in the
table.
6. Page 4. It would be useful to include example items of the HBM measures.
7. Page 4. It is questionable whether it is necessary to include a data analysis
section.
8. Page 6. The results of the study should be compared more closely with other
Iranian (or Asian) studies than with studies that have examined migrant ethnic
groups.
9. Page 6. Is there any evidence for the conclusion that the low rate of BSE is
due to low perceived susceptibility? Perceived susceptibility failed to
distinguished between the two groups in Table 1.
10. Page 6. How do the ratings of the perceived seriousness of BSE compare to
those reported in other studies?
Level of interest: An article of importance in its field
Quality of written English: Not suitable for publication unless extensively edited
Statistical review: Yes, and I have assessed the statistics in my report.
Declaration of competing interests:
I declare that I have no competing interests