Title: Knowledge, Attitudes, and Practices of Lebanese Women toward the Use of Oral
Contraceptive Pills
Version: 3 Date: 04 Sep 2024
Reviewer's report:
Again, the authors have significantly improved the quality of their paper. I do request they
consider the following before I can accept this manuscript for publication.
Abstract
There is far too much detail about each of the factors associated with higher knowledge
scores. Background could explain what is meant by “Lebanese women” – reproductive aged?
sexually active? contraceptors? A convenience sample of Lebanese women shopping in local
pharmacies? In the Results section of the abstract, right after age, the authors should report the
percentage of the subjects who had ever used OCPs. There is an exaggeration in the Conclusions
section that needs tempering – not all these steps are “vital”. In fact, is there any evidence from
this study or others that the interventions recommended are effective in increasing knowledge
of your target population? Are women not told by their doctors about OCPs? If they are, what
is meant by “integration of OCP education into routine health care services”?
The point I hope the authors want to make is that women need to have correct information about
their contraceptive choices, especially in the context of patient-centered decision making. I wish
they would just state it that way.
Background
The long review of contraceptive options is really not necessary for this reading audience. I
would urge the authors not to perpetrate the misconception that there is only one pill (“the pill”).
Women abandon use of oral contraceptives because they do not know that different formulations
with different impacts are available.
The most recent estimate of first year OCP failure in typical use is 7% (see CT 22nd edition).
Are rates in the Middle Eastern countries not very similar? It seems 52-61% is a close clustering.
Much of the discussion of factors associated with OCP use in different Middle Eastern countries
really belongs in the Discussion, not in such detail in the Introduction.
The importance of the role of pharmacists in contraceptive counseling is well outlined. Does
this mean that healthcare providers do not discuss contraception? Who places IUDs, etc?
Perhaps the discussion of earlier studies in Lebanon could be significantly shortened for the
Introduction and elaborated upon in the Discussion section.
How close do the results of this survey come to the goal of representing all Lebanese women?
If the authors assumed a 50% rate of correct answers and obtained a 36.9% correct answer
rate, what does that say about the study design? Is it underpowered? Apparently, the authors
administered the survey to 10 women in a semi Beta testing. Why weren’t their answers used to
estimate a rate of correct responses? Should this not be addressed as a limitation in the discussion
and cause the authors to modulate the strength of their recommendation?
As in the abstract, the authors should report the percent of subjects with any pill experience and
the percent of current users early in the results section. Was any information collected about
what percent of those surveyed was at risk for pregnancy? If it was only a small subset, that
should also be mentioned as a limitation of the study.
The Methods section should not report results, such as the response rate, the numbers of subjects
unprotected, etc. That information belongs in the Results Section. I note it is there too, so the
authors should delete the duplication in the Methods Section.
Table 2 should also report numbers and % of women with prior and current OCP use.
In Table 3 and corresponding text: I do not understand why the authors insist on listing as “side
effects” (not even “possible side effects”) problems that placebo-controlled, double-blind studies
have disproved. Are OCPs used in Lebanon for EC? Haven’t dedicated products for EC replaced
the use of some types of OCPs for EC? Why not remove this finding?
Table 4 – The text describing this table is very misleading. It sounds as if the authors believe that
OCPs are both the safest and most effective method. If they are trying to show the misinformation
people harbor, then they should point out that 97.1% agreed to some degree that  OCPs were
the most effective contraceptive method when it clearly is not. Was such misinformation greater
among ever pill users or never pill users?
Pattern of pill use
Since only slightly over 50% of pill users were taking them for contraception, the missed pill
rules need to be reported by use. It may not be as important for those who are using pills to
know how to catch up than it is for those trying to prevent pregnancy. Did the pill users have
higher rates of correct answers – (33.19 + 17.6%)? How many of the users had discontinued?
What does 37.1% and 25.7% mean?
From Table 5, I would assume that up to 47% (133/284) of the study population was not at risk
for pregnancy. This should be highlighted in the Results section and discussed in the Discussion.
Were the knowledge scores of those not at risk different from those who should have knowledge
so they could make informed choices?
There should be some comment that most of the factors identified by each of the analyses
were not modifiable. However, this work could be used in reverse to identify those who might
be in greater need for appropriate education when they were making informed choices about
contraception. This might be a point to make in the conclusion.
In the Discussion and the Conclusion, references should be supplied to support the
appropriateness and utility of the interventions the authors recommend in achieving their goals.
I hope my more detailed comments may help the authors. I would be happy to review any
revisions the authors decide to submit that address my concerns.