Title: Knowledge, Attitudes, and Practices of Lebanese Women toward the Use of Oral
Contraceptive Pills
Version: 1 Date: 04 May 2024
Reviewer's report:
The authors have done a concerted effort to address previous reviewer's comments and have
made major revisions to their paper. I beleive that they have succeeded in addressing some of
the important issues. However, there remains a few more items in need of clarification, some
more inportant than others. Below are my suggestions, questions and comments.
1. “Therefore, while OCPs may not require a prescription, the involvement of pharmacists in
the provision of OCPs emphasizes the importance of ensuring that women are well-informed
about their contraceptive options to make informed decisions aligned with their reproductive
health needs and preferences.” This comment makes it sound that the women need to be more
informed because of the pharmacists. I am not sure that I follow the reasoning here. Rephrase?
2. “Although these studies have provided valuable insights into the knowledge and attitudes
of specific Lebanese groups about OCPs, their scope has been constrained. To address
this limitation and achieve a more comprehensive understanding, a broader investigation is
warranted, one that encompasses a wider range of women across all Lebanese governorates.”
Did the authors actually address these gaps in this study?
3. The introduction suggests that the study is mostly about knowledge. The literature review is
exclusively concerned with knowledge, what about attitude and practice?
4.  The determinants of knowledge in the literature are the same in all studies, what is the added
value in this study?
5. “However, excluded from our study were women aged less than 18 and over 49 years
old, women who refused to participate in the study, or those who decided to interrupt their
participation in the study.” These exclusion criteria are not valid as the women are already not
part of the study given the inclusion criteria.
6. The sampling strategy needs to be better explained. What the authors have provided is
somewhat confusing. There are also some inconsistencies in their calculations.
a. It is not clear form the text how many strata the authors have chosen. The table indicates 5 so
it is assumed that they chose 5 (by the way there are 8 governorates in Lebanon so the authors
would need to explain how they combined them).
b. The authors selected proportional to the size of the total population per governorate but that
is not their population of interest since they are only sampling women between 18 and 49.
c. The author’s first level of sampling is pharmacies so maybe they should sample pharmacies
per governorates? How many would they need? How did they determine that they would need
32 pharmacies in all? How did they distribute them within the governorates?
d. Where did the number 15 participants per pharmacy come from? If they have 32 pharmacies,
this will yield a sample of 480 whereas their calculation suggests that they only need 372. If
the sample size was increased to account for non-response, it should be indicated along with
information on the proportion increase and a justification.
e. Did the authors replace the 6 pharmacists who refused? How? If not, how did they redistribute
the number of participants per pharmacy? Would the sample still be considered representative?
What about the 57 who declined? At this point since they are proposing a convenience sample
they would not need to replace them but they should probably indicate that they took the first
15 women who agreed to participate.
f. In table 1 the total required sample size is 384 whereas the calculation suggests that they need
372.
g. Did the authors check whether the final sample is representative of the population of interest?
This was one of the original reviewer’s comments and I do not think that it was adequately
addressed.
7. How was the questionnaire translated? If data is being collected from the general population
wouldn’t have been better to have a questionnaire in Arabic? Were some people excluded due
to language barriers or did the interviewer translate on the spot?
8. Was any attempt made to validate the content of the scores? Why not use existing tools?
9. The 384 questionnaires were administered face-to-face by one person?
10.  In the demographic variables: what does non worker mean? What categories were included
under medical and paramedical? Where is the data on the duration of marriage? These variables
should be included in the literature review.
11. In table 3 the authors should indicate that more than one response was allowed for questions
on benefits, side effects and risks.
12. The authors mention that “Similarly, few participants were aware of their non-contraceptive
use against acne (7%)” but did not highlight that even fewer participants knew of its benefit as an
emergency contraceptive (3.6%). Why are these two items particularly important to highlight?
What about reducing the risk of endometrial and ovarian cancer and protection against acute
pelvic inflammatory disease and ectopic pregnancies. Why is this important and how will it
influence use?
13.  How did the authors differentiate between side effects and risks? Mood swings and weight
gain could be considered as side effects rather than health risks. The risks are not exhaustive
how did the authors decide on which risks to include?
14. The authors quantify knowledge and attitude but do not explain what the results mean. For
example, when they state that “The mean knowledge score was 5.6 (SD = 2.4) out of 18.” What
does this mean in term of knowledge? The same for the statement “The mean attitude score was
25.8 (SD = 2.8) out of 35.”
15. Some proportions in the text need to be better represented. For example, in the statement
“The results showed that although the majority of participating women (75.0%) were in favour
of birth control in general, only a small proportion considered OCPs to be safe (32.0%) and
effective (33.6%).”, we note that 75% is not a the majority but rather three quarters and 32%
and 33% are not a small proportion but rather a third.
16. The statement “the majority of participating women (75.0%) were in favour of birth control
in general” was not considered as part of the attitude scale?
17. Around 85.5% of the women use OCPs for birth control and to regulate their menstrual
cycles. What about the others? Same issue with the word majority.
18 . Remove the quotes from table 5.
19. How many cases of missed pills were there?
20. Were the women allowed to suggest reasons not included in the list of answers provided
when asked about reasons, preferences or behaviors?
21. The multivariable logistic regression analysis to identify factors associated with OCPs use
was not included in the results.
22. “Despite scientific evidence refuting them, certain participants harboured misconceptions
regarding OCPs, encompassing concerns about weight gain, uterine cancer, and the likelihood
of conception.” It is not clear in the text what is considered misconception.