Title: Knowledge, Attitudes, and Practices of Lebanese Women toward the Use of Oral
Contraceptive Pills
Version: 2 Date: 11 Jul 2024
Reviewer's report:
I beleive that the authors have worked hard to address the reviewers' comments. A few minor
listed below could further aid the reader in appreciating the findings of this paper.
Unify the use of oral contraceptive pills in the document. They are sometimes referred to as oral
contraception, OC, OCP, oral OCP, …
Background:
• Some discrepancies in fonts example “incorrect utilization” in 2nd paragraph
• Paragraph 2 “OCP’s, often known as …” is mostly about the benefits of OCP except for the
last sentence which seems out of place
• In paragraph 3, the sentence “the significant determinants of contraceptive use …” is not saying
the same thing as the sentence before it although they are both referring to the same study.
• The last paragraph on page 5 is about the role of pharmacists which is beyond the scope of this
study. This needs to be reformulated to justify use of pharmacies as a setting for the study.
• Were previous studies in Lebanon limited in geographical scope?’
Methods
• Oversampling by 25% not 29%. Is this based on any reference?
• The sample is representative of the geographic distribution of women aged 18-49 in Lebanon
• There is some overlap with the categorization of profession as healthcare professionals could
be included in workers or non-workers depending on whether or not they are actually working.
I suggest you use unemployed, non-medical employment and medical employment to be clearer
• For the knowledge score, is source of knowledge included in the score?
• Are all the items in the attitude score in the same direction? Did you reverse the coding in the
calculation of the scores? This should be clarified.
• Did you test for multicollinearity in the multivariable analysis?
Results
• Descriptive:
o Why do we have data on number of children from 242 women only?
o It is interesting to highlight the proportion of women who do not know about side effects and
possibility of pregnancy while using OCP. Are these users or non-users?
o The knowledge score is generally low. Maybe differentiating between users and non-users
would provide useful information.
o For the source of OCP information, there is a difference between getting information about
OCP use and receiving instruction on how to use the pill. How was the question asked?
o What does it mean to have an overall positive attitude about oral OCPs?
o The table presenting attitude scores should be presented in reverse order as 1 = totally disagree
and 5 = totally agree. Also, since this results in a scale, I would suggest adding the means and
standard deviations for each item in the table and ordering them by decreasing mean.
o Since the attitude score varies from 6 to 36 (not 35) it is difficult to report it as 25.8 out of
36; rather you could revert back to the original scale by dividing by the number of items which
gives a 4.3 so somewhere between agree and totally agree.
o It is not clear if the information on practice for missed pills is actual practice or intention.
• Inferential
o In Table 6, for age, footnote that this is determined through correlation rather putting r in
brackets. It is confusing.
o There are variables missing in table 7 (education for knowledge and region for attitude). Some
categories are also missing. I suggest that you work on the format of this table as it is not clear.
o In the methods section, reporting for the multiple linear regressions includes unstandardized
coefficients and 95% confidence intervals, yet you report standardized coefficients and p-values
as well.
o You report standardized coefficients but do not interpret them.
o For the OCP use, bivariate results are only described relative to income although there are
several variables significant at the bivariate level
o Assuming that AOR in table 8 are adjusted OR based on the logistic regression,you should
mention this in the footnote and probably present the unadjusted ones as well in the table. Also,
if this is the case, why was attitude kept in the logistic regression?
o I suggest replacing correlation by association when reporting or discussing the relation between
OCP use and age.
Discussion
• For the statement: “In terms of information sources for OCP users, it was found that over a
quarter of users obtained information from social media platforms, family members, neighbours,
colleagues, and friends”, your results suggest that it is actually under a quarter, close to 22%.
I think that exploring the difference in knowledge between users and non-users is interesting
and should be capitalized on for later use in awareness interventions, however, it is only clearly
described for the question of sources in this paper. I suggest reformulating the paragraph to
highlight this distinction.
• In the statement: “Furthermore, our study identified several sociodemographic factors
influencing knowledge and attitudes towards OCPs”, knowledge and attitudes are not
sociodemographic factors. Rephrase to avoid confusion.