Reviewer ’s report  
 
Title:  Effect of structured training programme on the knowledge and behaviors of breast and 
cervical cancer screening among the female tea chers in Turkey  
 
Version: 1 Date: 22 Nov 2016 
 
Reviewer:  Cameron  Hurst  
 
Reviewer’s report:  
 
The aim of this research is to measure and enhanc e females teachers' knowledge, attitudes and 
practice (KAP) regarding breast self examination (BSE) and cervical screening behaviour (CSB), 
and to trial an intervention to gauge improvement in the above (in the teachers) and to examine 
the effect of the in tervention in female teachers passing on their (presumably) enhanced KAP in 
BSE and CSB to promote better practice in their female students.  
 
I would like to start by saying that I think this research is important, and (in some aspects) I think 
the authors  have done a good job. My main criticism however, are methodological (see below), 
and without these issues being addressed, I can't see how the authors support the claims they 
make.  
 
 
Major comments:  
 
The authors provide no evidence of validity of the instru ments they use. Besides their belief that 
these instruments measure what they say they measure, there is no psychometric validation 
whatsoever. With some of the instruments (e.g. Breast self examination) this is not a problem. 
Women either BSE, or they don 't. However, with instruments that relate to knowledge or 
attitude, the authors only provide partial evidence of content validity (via a literature search). 
They do not use expert panels to refine their item pool (for a more thorough content validation). 
Furthermore, there is no attempt to provide evidence of construct or criterion validity. I think this 
is a major limitation of the research and needs to be addressed before the work can be published. 
Finally, there is no measure of the reliability (test -retest, internal consistency etc).  
 
The authors employ the Friedman test, a classical non -parametric test that can be used in a 
simple longitudinal study such as this. If the sample is small (as is the case here) AND the data 
are not normal, then this would s eem to be one of the only choices we have. However, rank -
based tests such as the Friedman are notoriously underpowered. Did the authors actually check 
the normality of the data within the times. Using parametric methods (e.g. Linear mixed 
modelling) would have given the authors much more scope to examine other risk factors, 
confounders and even effect modifiers (Friedman can't really do this). Most parametric methods 
are very robust and minor assumptions (unequal variances or a small departure from normalit y) 
really don't worry them.  
 
Even if the Friedman is appropriate, where did the minimal clinical difference of 0.05 come 
from. Does this mean that you consider a difference of 0.05 in the average rank (remember 
Friedman is a rank -based test) to be scientif ically important in terms of improved Breast and 
cervical cancer KAP? It seems arbitrary to me. This needs justification.  
 
 
Minor comments:  
 
METHODS:  
 
Study design: "quasi -experimental and longitudinal designs". Do you mean a quasi -experimental, 
longitud inal design?  
 
"The pre -test and post -test were compare via pseudonyms." What do the authors mean by this?  
 
 
RESULTS:  
 
A p-value can never be zero (it is literally impossible). Don't confuse bad practice in certain 
statistical packages (e.g. SPSS which trunca tes the p -value) with a p -value of 0. I suggest using 
p<0.001 (or even p<0.05). I suggest you do this in both the text and Tables 2 -4. 
 
Avoid sentences with numbers. I know it is a silly rule, but there it is. Trying starting the 
sentence with "In total,…."  
 
Results: Para 1. The percentages you present 48.6, 41.7, 33.3 and 16.7 do not sum to 100%. I 
found this a little confusing. You will  need to clarify.  
 
 
DISCUSSION:  
 
In the limitations section, I think the authors have been unnecessarily harsh on themselves. This 
is not an epidemiological study, it is a trial. Yes, the sample should be (more or less) 
representative, but they are making no statements about incidence, prevalence and or risk factors 
in the general population. My feeling is that if there intervention works with their particular 
sample, then this would be sufficient evidence to consider deploying it in a larger (and even 
broader sample). The authors should remember, that intervention was designed exactly for the 
population (female teachers) from which there sample was drawn.  
 
However, there are other limitations that the authors don't mention.  
 
Their sample was quite small. No w this will usually lead to an underpowered study. Given that 
they found differences however, they demonstrate a significant difference.  
 
Their study was conducted in a single province. What effect might this have on their external 
validity.  
Are the methods appropriate and well described?  
If not, please specify what is required in your comments to the authors.  
 
No 
 
Does the work include the necessary controls?  
If not, please specify which controls are required in your comments to the authors.  
 
Yes 
 
Are the conclusions drawn adequately supported by the data shown?  
If not, please explain in your comments to the authors.  
 
No 
 
Are you able to assess any statistics in the manuscript or would you recommend an 
additional statistical review?  
If an additional statistical review is recommended, please specify what aspects require further 
assessment in your comments to the edito rs. 
 
I am able to assess the statistics  
 
Quality of written English  
Please indicate the quality of language in the manuscript:  
 
Needs some language corrections before being published  
 
Declaration of competing interests  
Please complete a declaration of competing interests, considering the following questions:  
 
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