Reviewer ’s report  
 
Title: Path analysis of skin cancer preventive behaviors in rural women based on protection 
motivation theory  
 
Version: 3 Date: 19 Apr 2020  
 
Reviewer: Dana Bovbjerg  
 
Reviewer's report:  
 
The authors have been somewhat responsive to my comments in the previous review and made 
several changes in the manuscript. In so doing however, a new concern has arisen that needs to 
be addressed (see Concer n 2, below). I now have two concerns with the revised manuscript as 
submitted.  
 
 
Concern 1: I continue to be concerned that problems with the English language throughout the 
text will substantially reduce the impact of the publication of this manuscript. I appreciate that 
English is a highly challenging language, and strongly encourage  the authors to hire one of the 
many commercial scientific editing services that can be found on the web to do a thorough proof 
reading and editing of their manuscript.   
 
 
Concern 2: In the previous review, I noted the need for a citation at the end of a s entence in the 
Discussion. That sentence was as follows: "A study on high school female students in Yazd city 
of Iran indicated that the most performed protective method was using sunscreen."  
 
The authors have now added a citation, but not at the end of th e sentence for which I requested it. 
In the revised manuscript this section of the Discussion now includes a citation in the sentence 
after the one that I requested a citation for. The text thus seems to imply that this one citation 
applies to all three se ntences in the section. The three sentences in the revised section of the 
Discussion in the manuscript are as follows:  
 
A study on high school female students in Yazd city of Iran indicated that the most performed 
protective method was using sunscreen. Als o, they have used all other protecting behaviors more 
than rural women (27). This indicates that rural women due to lower knowledge, attitude and 
behavior, have used skin cancer protective behaviors lower than high school students.  
 
 
2.1 If by putting the c itation at the end of the second sentence above, the authors mean to 
indicate that the cited paper also provides support for the other two sentences, it would be clearer 
to put the new citation at the end of each of the three sentences. These separate cita tions should 
be made so that the reader will know for sure where to find support for the separate assertions the 
authors have made in each sentence.  
 
2.2 I have now read the English abstract provided in the newly cited published paper (inserted 
below). Th e rest of the text is not in English, so I cannot read it. However, based on what is in 
the published English abstract, I now have several new concerns that need to be addressed.   
 
2.21) The English abstract of the now cited (#27) paper does not indicate that the participants 
were high school students. If citation #27 applies to the first sentence of the three from the 
Discussion of the submitted manuscript that I inserted above, that sentence should be changed to 
indicate that the participants were univer sity students, as is explicitly stated in the published 
abstract.  
 
2.22) The English abstract of the now cited (#27) paper makes no mention of inclusion of a 
sample of rural women in the study. Either this second sentence should be cut, or the authors 
need  to provide a citation to a published study that included rural women and explicitly 
compared their use of protective behaviors to university students, or better - matched groups of 
representative urban and rural women that did not include confounding with  educational levels, 
age, and socioeconomic status.   
 
2.23) The third sentence in the section above also does not appear to be supported by the cited 
paper based on the information in the published English abstract: a) there is no mention of rural 
women be ing included in the study; b) high school students were not included in the study; c) 
there is no mention of results of any comparison between rural women and the students in the 
study; d) there is no mention of any results from the study that would suppor t a causal 
relationship ("due to") between "lower knowledge, attitude and behavior" and "skin cancer 
protective behaviors." Either a citation should be provided that includes all these elements 
asserted in the sentence or the sentence should be cut.   
 
27. Nadrian H, Rahaee Z, Mazloomy Mahmoodabad SS, Bahrevar V, KHajeh Z, Najafi S, et al.  
 
Effects of educational intervention on promoting skin cancer preventive behaviors and its  
 
predisposing factors among female students in Yazd city: An application of some PRECEDE 
Model  constructs. Razi Journal of Medical Sciences. 2014;21(126):55 -64. 
 
 
Abstract Background: Skin cancer is the third prevalent cause of mortality and morbidity and the 
second widespread cancer based on organ involvement in Yazd province. This stud y aimed to 
assess the effects of educational intervention on promoting skin cancer preventive behaviors of 
female students based on of some PRECEDE Model constructs. Methods: Semi - experimental 
interventional study with 75 sample size in each group perform ing random sampling from Yazd 
universities was implemented. Validity and reliability of researcher made scales were approved. 
Questionnaires filled by participants and data were analyzed. Based on problem and weakness of 
preventive skin cancer and its pred isposing factors adoption analysis was distinguished and 
educational intervention planned and performed. Educational strategy was compromised face to 
face and group discussion. After three months follow up, data using descriptive and inferential 
statistics  were analyzed. Significance level was set less than 0.05. Results: Before intervention, 
predisposing factors was in the moderate level (%56.6) [Knowledge in moderate (%51.6), 
attitude relatively good (%66.1)] and preventive behavior adoption was poor (%48 ). Knowledge 
with attitude and practice, also attitude with practice had direct significant correlation. 
Knowledge and attitude as predisposing factor accounted for 25.1% of the variation of skin 
cancer preventive behavior changes with the attitude as the strongest predictor. Conclusion: 
Based on more attitude power in predicting skin cancer preventing behavior, more attention to 
attitude changes in order to prevent skin cancer epidemic is suggested. It seems that The 
PRECEDE model is the effective model in  planning interventional programs to promote skin 
cancer preventive behaviors.  
 
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 manus cript or would you recommend an 
additional statistical review?  
If an addition al statistical review is recommended, please speci fy what aspects require further 
assessment in your comments to the editors.  
 
I am able to assess the statistics  
 
Quality of written English  
Please indicate the quality of language in the manuscript:  
 
Needs some language corrections before being published  
 
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 from the p ublication 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 re ceived 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 declare that I have no competing interests.  
 
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