Title: Knowledge, Attitudes, and Practices of Lebanese Women toward the Use of Oral
Contraceptive Pills
Version: 3 Date: 05 Sep 2024
Reviewer's report:
I congratulate the authors on their efforts to address the reviewers comments. I believe that hey
have succeeded for the most part. What remains are mostly editorial/clarification points.
General:
• More than half the references are more than 10 years old and some of the statistics quoted are
from these references. How do you know that this is still the case today? I suggest that you find
a few more recent references or mention this as a gap in knowledge.
• There are still a few cases where you use oral pills, oral OCP, the pills and oral contraception
instead of OCP
Introduction:
• Make cautious use of words like crucial, significant, …
• I suggest reviewing this information “On a global scale, this issue results in significant
unintended pregnancy rates, with approximately nine out of every one hundred women
experiencing unintended pregnancies within the first year of OCP use (8), contributing to about
one million unintended pregnancies annually worldwide (9)” as the references are old and pertain
to data from the United States rather than global data.
• Check reference 10, it does not seem to give the right information.
• In the statement “there is a significant increase in contraceptive use among working women
with a higher level of education, aged 30 years and older, and those having a large number of
children”, what do you mean by a large number of children?
• Qualify working status and education level in “The study identified working status and
education level as significant determinants of contraceptive use (13)”. Same with age in the next
sentence.
• The sentence structure for “This study also investigated women's practices and attitudes
towards general contraceptive methods briefly, not practices and attitudes specific to OCPs” is
not clear.
• How relevant is the statement “Moreover, it is noteworthy that coitus interruptus was reported
as a contraceptive method used by 16% of current contraceptive users in Beirut and 21% in the
Beqaa, based on data from the national Pan Arab Project for Child Development (PAPCHILD)
survey program conducted in 1996 (16)”, given that the reference is from 1996?
Methodology:
• Since knowledge is assessed as a score, you cannot use a proportion of knowledge in your
sample size calculation. You can however use a proportion of use (y/n). Otherwise, you would
need to use an estimate of the standard deviation in your sample size calculations.
• In the statement “We conducted random sampling to select 32 pharmacies from the Order of
Pharmacists in Lebanon” it is better to say that you chose 32 pharmacies at random from a list
of registered pharmacies provided by the Order of Pharmacists in Lebanon. You should include
selection criteria for pharmacies.
• The categorization of employment was corrected in the results but not in the methodology.
Make sure that it is consistent throughout the paper.
• Did you need to make any adjustments for multicollinearity?
Results:
• “South Lebanon and Nabatiyeh (15.3% vs. 9.3%)” might not be a minor variation. There is
oversampling here.
• How did you decide that “these variations are within acceptable margins”?
• There is imbalance in the description of knowledge about risks associated with OCP use
for uterine cancer (9.9%), thrombosis (8.6%), non-contraceptive benefits of contraceptives for
treating acne (7%), use as an emergency contraceptive (3.6%). Why are you implying that 9.9%
for uterine cancer is a good level of knowledge while the rest are low?
• In table 3, no need to report n for OCP usage in first row. If you want to keep it, it should be 384.
• For table 4 maybe start with describing the mean scores and then go into the details.
• In table 4, this statement “The results showed that only a small proportion of women
totally disagreed with the perception of OCPs as the safest (7.8%) and most effective (36.4%)
contraceptive methods”, does not match the corrections or the results in the table.
• Also in table 4, why is a mean of 3.1 for concerns about OCPs causing infertility interpreted
differently from the same mean for perceptions of OCP safety and effectiveness?
• The titles of figure 1 and table 4 are missing the sample size
• In table 5, you are missing 2 people for consultations and blood tests before use and “Why do
you prefer the usage of OCPs for birth control purposes” adds up to more than 100%.
• The multiple linear regression results for knowledge should be table 7.
• Why do you need a multiple linear regression for attitude if only education is significant at the
bivariate level? The interpretation of the results of this regression are wrong.
• Tables 6 and 7 are missing sample sizes
• In table 8, why include p-values for the unadjusted OR but not the AOR? I suggest removing
that column. Also check the p-value for region of residence
• Since OCP is a categorical variable, you should be discussing associations rather than
correlations.
Discussion:
• Can you substantiate this statement: “This outcome was anticipated, as OCPs are a subject of
interest for users who actively seek out information to meet their knowledge needs regarding
the pills”?
• You do not say much about factors associated with attitude in your discussion. How do your
findings compare to the literature?