Reviewer ’s report  
Title: The Knowledge and Perceptions  of the First Year Medic al Students of an International 
University on Family Planning and Emergency Contraception in Nicosia (TRNC)  
 
Version: 2 Date: 03 Oct 2017  
 
Reviewer: Julie Hernandez  
 
Reviewer's report:  
General comments  
 
 The reviewer would like to tha nk the authors and the journal for the opportunity to 
review this manuscript, which could contribute to the growing base of evidence regarding 
knowledge, perception and behaviors regarding Emergency Contraception in low and middle -
income countries.  
 
Howeve r, the reviewer does not believe the manuscript in its current forms meets the academic 
standards required for publication in this journal without major revisions. The study 
methodology cannot support some of the stated objectives and implications presente d in the 
discussion section, and it suffers from a number of biases in the definition of key concepts that 
are problematic for generalizing its findings.  
 
If the scope of the research is revised and some essential clarifications on the methodology 
(particularly regarding the survey instrument used and the validity of the results it yielded) are 
provided, this paper could echo findings from similar studies co nducted among university 
students in low and middle -income contexts.  
 
In addition, the reviewer recommends the revised manuscript to be reviewed by a professional 
English editor to remove grammar mistakes and improperly constructed sentences.  
We also enco urage a stricter use of the universally used technical terms and language for all FP 
methods, services and indicators terminology.  
Title and Abstract  
Review title to indicate study location  
Parameters and constraints of FP programs and access are widel y different among countries and 
it would help the readers to situate this study in the global health context.  
 
Review WHO and ICEC guidelines on Emergency Contraception. It is a post -coital method of 
contraception that is not limited to sexual assault / fo rced sexual intercourse, but can be used 
after any occurrence of unprotected sex.  
 
Both WHO and ICEC have discontinued the use of the expression "day -after" or "morning after" 
pill and refer to the method as "Emergency Contraception" or "Emergency contrac eptive pills" 
(ECP) to reflect the period during which ECP can be successfully used, which is up to 120 hours 
/ 5 days and not only "the morning after". We encourage the authors to review recent WHO 
guidelines and publications available on ICEC website to ensure they use accurate language 
when describing EC mechanisms of actions, recommendations for use and possible side -effects.  
 
Objectives  Replace "multinational" by "international"  
 
Age 16 to 27 is a wide bracket (considering the amount of knowledge tha t can be accumulated 
by individuals in this decade of their life). In abstract and manuscript, please indicate how it was 
determined. Also, indicate is age was a discriminant variable for any of the study findings.  
 
Background  
The background section nee ds to be refocused on the family planning environment in the Turkish 
Republic of Northern Cyprus (TRNC). It should include the most recently available data on key 
FP indicators for TRNC (or, if not available, for countries with similar socio -demographic 
context in the region) and present the policy landscape surrounding access to FP methods in 
general and Emergency Contraception in general.  
 
 
 
Specific recommendations and suggestions are available below:  
* p.4 - l.1 "Contraceptive prevalence rate" is the tech nical indicator (rather than 
"contraceptive use rate"  
* p.4 - l. 19 What do you mean by "consultancy" of FP services  
* p.4 - l.29 Consider removing the sentence "Humankind […] for ages." since it does not add 
much to the argument.  
* p.4 - l.31 and followin g Since BMC is a publication specialized in women health issues and 
targets an audience of specialists, it may not be necessary to go through a full history of FP 
methods;  
* p.4 - l.44 Replace "breast feeding" by "lactational amenorrhea"  
* p.4 - l.46 What country DHS are you quoting numbers from?  
* p.5 - l.20 Replace "unsuccessful contraception" by "contraceptive failure"  
* p.5 - l.20 The statement "EC should not be used as a method of Family Planning" goes 
against WHO guidelines, ICEC rec ommendation, as well as programmatic efforts of a 
number of international organizations to increase access to FP services and reduce maternal 
mortality. Country policies and regulations might differ on that point but it needs to be 
clearly stated in the ba ckground if this is the case.  
* p.5 - l.20 "Yuzpe et allies" Do you mean "Yuzpe et al." ?  
* p.5-6 Review paragraphs on different EC regimen and specify which ones are legal and 
registered in TRNC  
* p.6 - l.26-27 Review objective of the study. It is not to  increase knowledge but 
to evaluate knowledge levels. Findings from the study may lead to programmatic decisions 
that will increase knowledge.  
 
Methods  
* p. 6 l. 34 -35 Do not repeat objectives in methods section  
* p. 6. l. 4549  How large were the sample  for each country? How representative of the 
general populations were those students? Reformulate to avoid overreaching.  
* p.6 l. 57 -58 Review sentence that starts with "The total group…" using active voice.  
* p.6 l. 59  Why were only 191 students out of 2 29 in the program "accessed"?  
* p.7 l.1  How were confidentiality and anonymity assured (rather than "reassured")? Did 
the students understand that their responses were confidential? How was desirability bias 
limited in data collection procedures?  
* p.7 l. 41 Reformulate "the status of current regular sexual interaction"  
* p.7-8 The "Definitions" need to be worked into either background or method section. 
Please, note that these definitions, while not inaccurate, reflect some of the position of 
researchers. "Unwanted pregnancies" might be superfluous here. Stronger use of scientific 
literature on those topics might support less biased evaluation of the indicators studied here.  
 
Results  
Data on dependent variables are typically presented before results of ind ependent variables 
analysis. Even if demographic breakdown were not always statistically significant, the readers 
would need some basic presentation of the gender, age and nationality distributions among 
survey participants.  
 
The questions asked were over all more focused on student's perceptions of FP and EC (i.e. 
hypotheticals) rather than actual behaviors since only a small number were even aware of EC, 
and even fewer had ever used the method. The reviewer recommend adjusting the paper's title 
and object ives statement accordingly.  
 
* p.8. l.22  Replace "socio -demographic features" by "socio -demographic characteristics"  
* p.8 l.33  Use "the pursuit" instead of "the conduction" of medical studies  
 
"The best known modern methods were cervical cap, IUD and comb ined patch." These are 
unusual methods for middle and low -income countries preference and use. Please, add a note in 
either background or discussion section regarding policies and programmatic decision that may 
explain why.  
 
* p.8-9 Clearly state the overall level of method awareness for EC before going into 
details regarding indications and side -effects knowledge.  
* p.9 l.10  "Unintended pregnancies" cannot be an indication for using EC (EC is ineffective 
in case of pregnanci es). Consider removing.  
* p.9 l.14  Consider replacing "expressed EC as a method" by "stated / declared that EC is a 
method…"  
* p.9 l.30  Consider using "side effects" rather than "adverse reactions"  
* p.9 l. 43  Replace "curettage" by "abortion"  
* p.10. l.6-9  Repeated statement about source of information from previous paragraphs. 
Please, consolidate.  
* p.10 l.22  Review sentence that starts by "The state of being informed..."  
* p.10 l.27 and following  Replace "curettage" by "abortion"  
* Statement "The i nformation that [abortion] is not an FP method" needs to be nuanced.  
* P.10 l.50 - 56 Consolidate results to clarify main take -away.  
 
Discussion  
 The discussion section should not repeat results from above paragraphs but state policy, 
programmatic, and /  or research implications inferred from results section. The reviewer 
recommends that the discussion in its present form be entirely revised accordingly.  
 
  The discussion extrapolates on general populations from the students' countries of 
origins. This st udy was conducted on a very small sample of highly educated (in the medical 
field no less) international students whose views are very unlikely to be representative of the 
knowledge, perceptions and behaviors of their fellow citizens.  
 
 p.11 l.26 The sent ence "The fact that sexual life starts earlier in African countries" is a 
completely unsupported statement. Since almost no findings related to FP / EC were found to 
have significant differences based on country of origins of the students, the reviewer sug gests 
dropping these results in order to avoid gross generalizations.  
 
 Comparing this research discrete results to findings from single studies using different 
methodologies and study population in vastly different national contexts is not sufficient to 
support policy, programmatic or research implications.  
 Reformulate the last paragraph  Need for additional information is a common finding of 
EC awareness studies, however the authors need to explain what initiatives and barriers currently 
exist in TNRC  for the implementation of such recommendations.  
 
Limitations  
 
 Title of the section should read "Study limitations" or just "Limitations"  
 
 p.14 l.25  Replace "equivocal" by "biased"  
  
 Note that results from the study cannot even be generalized to first year students since 
study participants were recruited from an international program.  
 
 The list of abbreviation seems superfluous. Write the full name at first occurrence in the 
manuscri pt, with the acronym in parenthesis, then use acronym in the rest of the paper.  
 
Declaration  
 
 Review Guidelines to the authors for this section  
 p.15 l.40  Correct typo "Consent for publication"  
 
The reviewer suggests adding the survey instrument used duri ng the study to clarify the 
questions asked (e.g. were all of those close or open -ended questions?) in order for the readers to 
better appreciate the data that was exactly measured by this study.  
Tables  
 
 Table 1 l.59  Correct typo "Kenya"  
  
 Table 2 l.24  Reformulate and clarify "State of being informed"  
 Table 2   There is a formatting issue with the "Knowledge of Modern 
Methods section"  
 Table 2   Why doesn't EC appear among modern methods?  
 
 Table 3   How was knowledge of "day -after pill" (correct typo / us e "EC 
Pill") determined to be "Correct", "Incorrect" or "Insufficient"?  
 
 Table 6 l.40  How was "Current regular sex life" defined and measured?  
 
 Table 7   How were "correct knowledge of FP methods" and "Correct 
knowledge of EC" integrated in a single meas urement? Were they weighted?  
 
In the result section and tables, the distinction between countries based on continental location 
("Africa", "Asia", "Europe") might not be the most appropriate, especially for a study taking 
place in TNRC where regional influ ences and trends are extremely complex. Perhaps distinction 
by income levels or current FP indicators for the students different countries of origin might be 
more relevant.  
 
 Table 8 l.9  Typo "Table 8"  
 Table 8. l. 27 -30 What does "in the vicinity" mean?  
 
Are the methods appropriate and well described?  
If not, please specify what is required in your comments to the authors.  
Yes 
Does the work include the necessary controls?  
If not, please specify which controls are required in your comments  to the authors.  
No 
 
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 manus cript or would you recommend an 
additional statistical revi ew? 
If an additional statistical review is recommended, please speci fy what aspects require further 
assessment in your comments to the editors.  
I recommend additional statistical review  
Quality of written English  
Please indicate the quality of language in the man uscript:  
Not suitable for publication unless extensively edited  
Declaration of competing interests  
Please complete a declaration of competing interests, considering the following questions:  
1. Have you in the past five years received reimbursements, fees, funding, or salary from an  
organisation that may in any way gain or lose financial ly from the publication of this 
manuscript, either now or in the future?  
2. Do you hold any stocks or shares in an organisation t hat may in any way gain or lose 
financially f rom the publication of this manuscript, either now or in the future?  
3. Do you hold or are you currently applying for any patents  relating to the content of the 
manuscript?  
4. Have you received reimbursements, fees, funding, or salary from an organization that 
holds or has applied for patents relating to the content of the manuscript?  
5. Do you have any other financial competing interests?  
6. Do you have any non -financial com peting interests in relation to this paper?  
If you can answer no to all of the above, write 'I declare that I have no competing interests' 
below. If your reply is yes to any, please give details below.  
 
I declare that I have no competing interests  
 
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