Reviewer ’s report  
 
Title: Path analysis of skin cancer preventive behaviors in rural women based on protection 
motivation theory  
 
Version: 0 Date: 21 Nov 2019  
 
Reviewer: Dana Bovbjerg  
 
Reviewer's report:  
 
Strengths of the manuscript include:  
 
* The important topic. A better understanding of factors affecting preventative behaviors 
for skin cancer could help guide improved intervention strategies.  
 
* A high -risk study population: The investigators cite evidence that skin cancer is the 
most common cancer in Iranian men and the second most common in Iranian women.  
 
* A population -based randomized cluster sampling approach was used to identify 
potential participan ts: Four villages with a population &gt; 1000 were randomly 
selected and then within each village (using documentation at health centers in the 
villages) women were selected for potential participation by a random sampling 
method.  
 
* A theory -based approach  to identifying predictors of preventative behaviors for skin 
cancer to include in the study assessments and statistical analysis.   
 
 
Major weaknesses of the manuscript include:  
 
* Throughout the text. Challenges in English grammar, syntax, and usage make t he 
authors' meaning more difficult to follow throughout the manuscript. I strongly 
recommend careful proof reading and editing for content by someone with expertise in 
English.  
 
* Introduction.  
 
o The scientific rationale for limiting the study to women is  not clear, 
particularly since skin cancer is even more common among men in Iran.  
 
o The scientific rationale for developing an entirely new questionnaire to assess 
key concepts in protection motivation theory needs to be provided, along with 
a brief secti on describing strengths and weakness of existing measures.   
 
o A scientific rationale is needed for including each of the 8 behaviors (e.g., 
wearing sun glasses) assessed as the primary outcomes of the study. Citations 
to the literature should be provided that link each of these behaviors to 
increased risk of skin cancer. Particularly important would be citations to data 
from Iran.   
 
o If this study is part of a larger program of research, the overall research effort 
should be described in a brief paragraph  and the present study put into context 
of prior publications and planned future publications.   
 
* Methods. More detail is needed.   
 
 o A geopolitical definition of the "west of Iran" needs to be provided.  
 
o To allow comparison with the literature, an oper ational definition of "rural" 
needs to be provided along with one or more citations to support that 
definition generally, as well as specifically in Iran.  
 
o The definition of a "village" in Iran should be provided. The rationale for 
limiting potential par ticipants to individuals living in "villages" with 
populations &gt;1000 (with no stated upper bound of population size), also 
needs to be provided. On its face, eliminating villages of &lt;1000 would 
seem at odds with the stated focus of the study on a rur al population and 
failing to have an upper bound raises questions about how "rural" the study 
sample was. Demographic and other characteristics of the four randomly 
selected "villages" should be briefly described. If not precluded for some 
reason, which sh ould be described, the manuscript should include the names 
of the villages.   
 
o Since the second level of randomized identification of potential study 
participants made use of documentation available from health centers located 
in the villages, more detail  is needed regarding the health centers and the 
documentation. Most critically, are all inhabitants of each village that would 
meet the other inclusion criteria (e.g., women, age &gt;19 years) documented 
in the health center records, as would be required f or a full population 
sampling? Or, is the documentation limited to a subset of individuals in the 
village, which could introduce sampling bias. If the latter, this potential bias 
should be mentioned as a limitation of the study in the Discussion and the 
possible impact on the study findings considered.   
 
o The description of the potential participants (first sentence of the Methods) 
also indicates that they were "…most of the time working in front of sun" but 
it is not clear how that is operationally define d, or if it was a selection 
criterion for recruitment. Were potential participants required to be employed 
outside the home in a job that required working in the sun (and thus high risk 
for melanoma due to sun exposure)? If these were eligibly criteria, th en how 
that exposure was defined and assessed needs to be detailed. If they were not 
eligibility criteria, then they should not be mentioned in the sentence.  
 
o The number of women randomized to receive contact information about 
potential participation should be presented along with the percentage actually 
agreeing to participate. The Abstract should also mention that larger number 
since the 230 were NOT randomly selected as is currently stated. They 
represent a subsample of the randomized potential participant pool, which 
likely differs from the larger randomized pool (e.g., participants in research 
studies generally have higher levels of education).  
 
o The approa ch taken to provide a quantitative summary descriptor for the 8 
"skin cancer preventing behaviors" for the analyses (e.g., Table 3, Figure 1) 
needs to be described and justified.  
 
o There is mention of "training sessions" but no indication of their purpose  or 
content is provided.   
 
o More detail is needed regarding the development and validation of the new 
questionnaire, along with some consideration of overlap in the methods here 
with previously peer -reviewed and validated measures in the literature that 
focus on protection motivation theory. Among other things currently lacking 
is any description of the source of the items/questions used in the study and 
any process for winnowing down the number of items. Any overlap among 
the members of the three sets of individuals who provided input on the 
questionnaire during development should be described and noted as a 
weakness of the study in the Discussion section.  
 
* Results.  
 
o The confusing statement in the Results about the study participants that "most 
of them were housekeeping (87%)" appears at odds with eligibility requiring 
outdoor work, (whether paid or unpaid) and seems to suggest that the study 
sample was not at particularly high risk due to occupational sun exposure. In 
addition, the high percentage of wo men with housekeeping jobs raises 
questions about possible sampling bias in the study participants. Is this high 
percentage expected based on the populations in the villages randomly 
sampled for the study? Clarification is needed.  
 
o The "researcher -made q uestionnaire" is a result of the study and should be 
provided in an appendix (or as online only supplementary material) along 
with an English translation.  
 
 o The tables should include horizontal lines to demarcate different variables.  
 
o Footnotes are needed  to define all abbreviations/acronyms used in each table 
and the figure.  
 
* Discussion.  
 
 o Citations to the relevant literature are needed for all statements of fact.   
 
 o A paragraph should be added detailing strengths and weaknesses of the study.  
 
o Other d irectly relevant papers in the literature addressing skin cancer 
risk/prevention behaviors should be discussed. For example: Skin Cancer 
Preventive Behaviors in Iranian Farmers: Applying Protection Motivation 
Theory. Moeini B, Ezati E, Barati M, Rezapur -Shahkolai F, Mohammad 
Gholi Mezerji N, Afshari M. Workplace Health Saf. 2019 May;67(5):231 -
240. doi: 10.1177/2165079918796850. Epub 2018 Oct 10. PMID: 30305002  
 
Are the methods app ropriate and well described?  
If not, please specify what is required in your comments to the authors.  
 
No 
 
Does the work include the necessary controls?  
If not, please specify which controls are required in your comments to the authors.  
 
Yes 
 
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 review?  
If an additional s tatistical 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 manuscript:  
 
Not su itable 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 sal ary 
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 from the publica tion 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 competing interests in relation to this paper?  
 
If you can answer no to all of the above, write 'I dec lare that I have  no competing interests' 
below. If your reply is yes to any, please give details below.  
 
I declare that I have not competing interests.  
 
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