Title: Quality of Life, Insomnia, Attitudes and Beliefs in Women Undergoing Chemotherapy
for Breast Cancer: A Cross-Sectional Study in Amol city Northern Iran
Version: 1 Date: 07 Apr 2025
Reviewer:  Amirmohammad Dahouri
Reviewer's report:
General comments:
Your findings are timely and valuable, particularly given the significance of addressing the
quality of life and insomnia among women undergoing chemotherapy for breast cancer. These
patients often face diverse and complex experiences that negatively impact their physical and
psychological well-being. Understanding their attitudes and beliefs—as well as the associations
among these variables—is essential for developing targeted interventions.
I have carefully reviewed your manuscript and provided specific comments and suggestions
below, which I hope will help improve the overall clarity, rigor, and quality of your work.
Abstract section:
1. In the Methods section of the abstract, there is no mention of how the normality of the data
was assessed. This issue also persists in the corresponding section of the main manuscript. I
recommend that you address this in both the abstract and the main Methods section. Given your
sample size, it would be appropriate to report skewness and kurtosis indices and to utilize visual
tools (e.g., histograms or Q-Q plots) to evaluate the normal distribution of the data.
2. While you have referred to the instruments used in the study, it remains unclear whether the
validity and reliability of these questionnaires were confirmed in the current context. Please
clarify whether the psychometric properties were re-evaluated for your study sample, and if so,
specify the methods used to assess them.
3. In the Background section of the abstract, you identify insomnia, attitudes, and beliefs as
your primary variables. However, in the Results section, the description implies that quality of
life (QOL) is the primary variable influencing the others. This discrepancy should be resolved.
Please ensure consistency between your stated objectives and the presentation of your findings,
aligning them with the conceptual framework and literature review.
4. For improved indexing and alignment with the journal’s guidelines, I recommend revising
your keywords using standardized MeSH terms (Medical Subject Headings).
Introduction section:
1. The logical flow between paragraphs appears to be inconsistent. For improved clarity and
coherence, I recommend reviewing the transitions between paragraphs to ensure a smooth
progression of ideas. Readers should be able to follow the development of your argument
from general background information to the specific aims of your study. To enhance the
structure and scientific rigor of your introduction, I strongly encourage the use of the funnel
structure, beginning broadly with the topic background, narrowing down to the literature gap,
and concluding with the study objective.
2. In the final sentence of the last paragraph, you state that “the study provides culturally
relevant insights.” However, this claim may mislead readers, as no cross-cultural comparison
was conducted. Moreover, its placement shifts the reader’s focus away from the central aim
of the study. I recommend removing this sentence and, instead, more clearly articulating the
specific knowledge gap your study seeks to address. Expanding on this point would strengthen
the rationale for your research.
3. Overall, consider incorporating statistical data and findings from previous studies to
underscore the significance and necessity of your research topic. Additionally, use the existing
literature to better clarify the theoretical positioning of your variables, particularly which of the
three (insomnia, attitudes/beliefs, or quality of life) should be treated as the primary variables
based on conceptual precedence.
Method section:
1. In the subsection titled “Study Design”, I recommend expanding the content to include
essential details such as the study population, research setting, sampling method, and remove the
inclusion and exclusion criteria an add under the other subsection. Presenting this information
in a clear and organized manner, possibly as a distinct subsection, will enhance the transparency
and replicability of your study.
2. I have a question regarding the determination of sample size. Given that your study
investigates associations among variables, it would have been more methodologically
appropriate to use a sample size calculation based on correlation analysis. Furthermore, it is
unclear why only one variable (insomnia) was used as the basis for calculating the sample size.
Please clarify this rationale or consider revising the explanation.
3. Among the demographic variables you assessed, I believe that the time interval since the
last chemotherapy session could be a relevant factor influencing your outcomes. Based on both
existing literature and clinical experience, this variable may significantly affect symptoms such
as fatigue, sleep disturbances, and emotional well-being. If this data was collected, I suggest
including it in your analysis. If not, please mention this omission as a limitation in your study.
4. In the subsection related to “Data Collection Procedure”, you mention that the study received
ethical approval. For enhanced transparency, I recommend including the ethical approval code
in this section, as you added in Declarations section.
5. You note that a “elf-administered” questionnaire was used for data collection. Accordingly,
individuals who are illiterate would likely be unable to complete the questionnaire
independently. Please clarify whether such individuals were excluded, or describe the assistance
provided to help them complete the forms. This should also be reflected in your exclusion criteria
or data collection procedure.
6. There appears to be a discrepancy in the reported sample size. While the calculated sample size
is 460, you mention that 468 participants were studied, yet only 384 individuals are reported as
having completed the questionnaires. This inconsistency should be clarified to avoid confusion.
Please clearly state the number of participants approached, included, excluded, and ultimately
analyzed.
7. In the “Statistical Analysis” section, please explain the procedures used to assess the normality
of your data, as previously recommended in the Abstract comments. Additionally, all statistical
tests applied in the Results section should be fully introduced and explained in the Statistical
Analysis section to maintain consistency and prevent unexpected findings from appearing
without context.
Results section:
1. According to the reported findings, 77 participants were identified as illiterate. However,
earlier in the Methods section, it was stated that the questionnaires were self-administered.
This raises a concern regarding how these illiterate participants were able to complete the
questionnaires. Please clarify the procedure that was followed in such cases, whether assistance
was provided, or if an alternative method of administration was used. This clarification is
essential to ensure consistency between the methodology and the reported results.
Discussion section:
1. It is advisable to avoid including numerical parameters in the Discussion section, as this
section should primarily focus on the interpretation and implications of your findings. Please
remove any numerical data from this section and instead focus on explaining the results in the
context of the broader literature.
2. In the first one or two paragraphs of the Discussion, please clearly highlight the key findings
of your study. Following this, you can discuss the reasons for the similarities and differences
between your findings and those of other studies. This will help contextualize your results and
offer insight into why your findings align or diverge from existing research.
3. It would be beneficial to integrate a hypothetical framework to better support and explain your
study’s findings. This theoretical perspective will provide a stronger foundation for interpreting
your results and allow you to position your findings within the broader academic discourse.
4. While you have provided valuable insights, the end of discussion section mainly focuses on
the limitations of your study. I suggest balancing this by also highlighting the strengths of your
study, such as its methodological rigor, sample size, or relevance to the field. Acknowledging
both the strengths and limitations will present a more well-rounded view of your work.
References section:
1. Upon reviewing the references list, I noticed that some of the cited sources are relatively
outdated, especially in relation to cancer studies. Given the rapid advancements in this field, I
recommend replacing the older references with more recent and relevant studies.