Reviewer's report
Title:Evaluation and factors associated with noncompliance in users of
combined hormonal contraceptive methods: a cross-sectional study. Results
from the MIA study.
Version: 2Date:10 August 2013
Reviewer: Kelli Hall
Reviewer's report:
Overall, the authors did a nice job with this revision and the manuscript is
improved. I have a few more suggestions that should be considered before
publication. I describe these below.
The title is improved. The word “of” should be added after evaluation.
The abstract methods and results are also improved. The last methods sentence
should read “physicians reported their recommendations”
The abstract conclusion section seems long. The longest sentence actually
belongs in the results, not the conclusion and would fix this problem if is moved
to the results to replace the other nondescript results statement about reasons
for noncompliance: “High treatment duration, low level of information on the
contraceptive method, not having a routine for taking treatment, indifference to
becoming pregnant, not interested of the partner, not having a routine method
and difficulties remembering to use the contraceptive method are also factors
associated with noncompliance.”
Introduction/Background:
Overall, the introduction content is much more thorough and helpful. I have a few
more suggestions that might help improve the flow and organization.
Sentence at the bottom of page 4/top of 5 needs to be included in the previous
paragraph. There is also a punctuation error in that paragraph.
I would suggest deleting this sentence, “In most cases, the amount of drug
delivered is lower than with the pill, thus increasing bioavailability [4].” It is not
helpful in the context of the point the authors are trying to make.
The 3 small paragraphs on page 5/bottom of 6 (starting with “studying the
reasons”) should be merged into one.
While the individual paragraphs and content of the background section are
better, the organization of the section still seems awkward. In particular, I would
recommend, the following order which I think might set the stage better for the
public health problem at hand (ie unintended pregnancy, noncompliance) and the
justification that the authors work will fill a gap.
First paragraph “In Europe….”
Second paragraph “combined oral hormonal contraceptives are safe…”
Third paragraph is good.
Fourth paragraph/sentence is small and seems unsupported. The authors could
consider moving the following sentence up to this paragraph on the bottom of
page 4 and it would read something like: “Women’s perceptions influence their
contraceptive decisions. Indeed, poor compliance generates a significant care
burden in terms of user anxiety about preventing pregnancy and more visits to
the gynecologist for advice [12] To support informed contraceptive
decision-making, healthcare professionals should realize that a woman’s view of
a method’s ease of use is more important than perceived efficacy, tolerability,
health benefits, or risks.”
I would suggest deleting the sentence, “Other consequences include work
absenteeism and emotional problems with one’s partner” since it is stated
elsewhere.
Methods:
Overall, the methods section is much more descriptive and precise now. The
paragraph referring to the precision and overlap of the sample is still very
confusing to me. However, I think I finally understand what the authors are trying
to say about differences in sample characteristics between the initial and final
sample. However, what are the characteristics compared – baseline
demographics?
Results:
I feel that the results section could be shortened by condensing the presentation
of some of the descriptive statistics. While the content is somewhat interesting, it
is a little burdensome to read through. Some of it is already presented nicely in
the tables and the rest should be presented in the tables (see my comment
below). Additionally, there are many places in the results where long sentences
do not include any numerical results. Overall, I would condense these
descriptions considerably. The authors already did a nice job with this in the
revision for the multivariable results.
I also feel that some results that the authors state were of interest in this study
are not presented. For example, where is the information about contraceptive
use characteristics collected by the providers or self-reported by the women?
Some of them end up being important in the mutlivariable analysis (e.g. time on
method) so they need to be described.
Also, the significant effect of “time on method” is pointed out in several places but
the ORs is essentially 1. I could not find what the unit of analysis for time actually
is? Years, months, weeks ? Also, what is the level of measurement – continuous,
ordinal? The authors need to define this variable and then interpret the result. If
the unit of analysis is such that the result is not meaningful (e.g. 0.6% higher
odds with every 1 year increase), then I would de-emphasize this finding and just
state that is was controlled for in the multivariable analysis.
In the 2nd discussion section, the authors need to cite the literature of several
other scholars who have found that forgetfulness is an important factor in
adherence (e.g. Potter).
I would suggest moving the next paragraph starting with, “other factors
associated with…” down toward the end of this section (after the provider
–related content). The "other factors" paragraph also needs more elaboration.
Right now, it reads like a long laundry list of many diverse reasons. Many of
these have been widely studied. How do these findings fit into the broader
literature. The authors may consider just picking a few of the most commonly
reported ones and emphasizing those (rather than listing them all). Many of these
could tie into the implications for the provider role in counseling.
Tables:
The tables are nicely done – clear, well organized and informative.
I would suggest adding descriptive information about the reasons for
non-adherence into at least one of the tables or adding a new descriptive table
with reasons for non-adherence by method type.
Level of interest: An article of importance in its field
Quality of written English: Needs some language corrections before being
published
Statistical review: Yes, and I have assessed the statistics in my report.
Declaration of competing interests:
I declare I have no competing interests.