Reviewer ’s report  
 
Title:  Using the theory of planned behavior and self -identity to explore women's decision -
making and intention to switch from combined oral contraceptive pill (COC) to long -acting 
reversible contraceptive (LARC)  
 
Version: 0 Date: 31 May 2018 
 
Reviewer:  Brianna  Magnusson  
 
Reviewer’s report:  
 
Overall, I find the method ology to be solid.  I do think adding a few more details to the 
manuscript will improve understandability for the reader.  I've outlined some suggestions below.  
 
1. In the abstract and methodology sections, you state that the survey was conducted at a 
southern university (or similar language).  Due to the international audience of this 
journal, please specify that it is a university in the southeast United States (or something 
of that ilk).  In other places you should clarify for example, the US. FDA etc.  
 
2. In the first paragraph of the background you have three separate sentences that include a 
clause, "despite…".  Varying sentence structure could be beneficial.  
 
3. Line 61 - "Nearly half of all pregnancies are unintended, with higher rates among at -risk 
groups." Two comments, please state this is nearly half of pregnancies in the U.S. and it 
would be useful if you provide some additional details on "at -risk groups" (minorities, 
low-income etc.).  
 
4. Line 62 - "Unintended pregnancies are often accompanied by challenges, as well as 
multiple reproductive issues." I know this is a well documented topic, but some 
additional details on challenges and reproductive issues may be beneficial to the reader.  
 
5. Given your focus on college -aged women, including (or perhaps focusing on) 
information about their risk of unintended pregnancy and gaps in contraceptive use would 
improve the background, which at present is fairly generic.  
 
6. Line 146 you describe the  186 women in the analysis as women who meet the "paradox 
of inertia criteria". In your methodology you describe these women as current COC users 
who are aware of LARCs. But on page 3 (background) you describe the paradox of 
inertia as not just being aware  of LARCs but understanding the benefits, acknowledging 
LARCs are superior and understanding disadvantage of COCs in comparison to LARC 
and still using COCs.  I'm not sure it's accurate to consider the 186 women in your 
sample as meeting the paradox of ine rtia criteria.  I don't think this invalidates your study, 
but you should remove this language regarding paradox of inertia from your methodology 
or if I misunderstand clarify how your respondents really do meet the paradox of inertia.  
 
7. In Table 1, it w ould be very useful if you added numbers to your questions, particularly 
as this would assist readers in understanding your subsequent tables in which only 
numbers are presented.  
 
8. In Table 1, please provide as a footnote the range (1 -7) for items so tha t the means can be 
easily interpreted.  
 
9. Given that the question stems are provided in table 1, I would recommend citing table 1 
in your measures section so that people can easily follow along there.  Doing this, I 
believe allows you to drop the sample q uestions from the text.  
 
10. For all of the TPB and self -identify measures:  
 
a. Please provide a statement such as …higher values on the attitudes items indicate 
attitudes that are more supportive of LARCs (or whatever is true).   
 
b. I *think* the TPB const ructs are all oriented toward LARC use, but am I correctly 
understanding that self -identify is measuring the degree to which a women felt 
that taking the pill was part of her self -identity?  Does this then mean that we 
would expect reduced intention with h igher self -identity scores?  If this is true, it 
would help to clarify this and the expectations in the text.  
 
c. I see no mention of any reverse coding of items.  It looks like most questions are 
oriented in the same direction, but in the Self -Identity se ction "I see myself as 
responsible enough to take the pill every day…"  More agreement on this question 
seems to be oriented differently toward COCs rather than IUDs. Did you reverse 
code this question?  
 
d. On that same question it seems like "I'm responsib le enough" and "IUDs aren't for 
women like me" seem like they should be two different questions. I realize you 
can't redo the study, but is there any precedent for this question?  
 
11. Many of your TPB and self -identity items seems to have neutral (about 4)  values.  Is 
there any significance in this?  What do you make of this?  
 
12. Please review your results of the TPB constructs. Overall I would appreciate some help 
interpreting these descriptive results.  
 
a. For example Line 214: "Obtaining and IUD/implant  was found to be easy versus 
frightening or painful." I'm not sure how to interpret this.  These are all semantic 
differential scale are you just saying that the group mean was over 4 (the center) 
towards easy, but scored closer to frightening and painful than their opposites?  
 
b. Similarly, Line 215 "Choosing and IUD/implant was seen as less harmful or 
inconvenient than unhealthy." My interpretation of the numbers is that women 
seem to think that having an IUD would be beneficial and convenient but were 
more neutral on health.  Maybe this is just me, but I'm struggling to figure out 
how to make something meaningful of these results.  What do your descriptive 
results tell me about women's attitudes, subjective norms, perceived behavioral 
control, intention a nd self -identity?  
 
13. I have only published a few papers with SEM, so this may be my ignorance. Is it 
necessary to provide the skewness and kurtosis statistics in Table 1?  You state in the text 
that they meet the assumptions of SEM.  I suspect this is wha t is primarily of concern to 
readers.  Removing these 4 columns from Table 1, simplifies the table and in my opinion 
focuses on what is more important.  If you feel they are vital, perhaps a supplementary 
table would be better?  
 
14. Please add strengths and  limitations to the discussion.  
 
15. Line 266 "COC users indicated sexual partner would support LARC use more than their 
mothers or friends, suggesting partners influence contraceptive choice…" Possibly.  But 
there is at least some research to suggest that  men don't feel like women's choices about 
contraception methods or breastfeeding etc. are their choices to make.  So are women 
perceiving their partners would be active supports or is this really that that partner would 
say, "yeah whatever you want".  I d on't know the answer, but both seem possible to me.  
 
16. It may be useful to add specific research questions and hypotheses to the text.  What do 
you expect the relationship between attitudes, norms, control and self -identity with 
LARC intention to be?  
 
17. I'm not clear on the relationship between self -identify and the sense of permanence with 
LARCs (Line 289 -302).  I agree that the shift to a longer -acting method may make some 
women uncomfortable with them.  Particularly if they concerns about finding new 
providers as they move out of college into jobs etc. But how does this connect to COCs 
are part of how I see myself?  Perhaps I'm not understanding fully the idea of self -
identify related to COC use.  
 
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.  
 
Yes 
 
Are the conclusions drawn adequately supported by the data shown?  
If not, please explain in your comments to the authors.  
 
Yes 
Are you able to assess any statistics in the manuscript or would you recommend an 
additional statistical review?  
If an additional statistical review is recommended, please specify 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:  
 
Acceptable  
 
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 financially from the publication of this 
manuscript, either now or in t he future?  
 
2. Do you hold any stocks or shares in an organisation that may in any way gain or lose 
financially from 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 competing 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 delcare that I have no competing interests  
 
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