Reviewer ’s report  
 
Title: Path analysis of skin cancer preventive behaviors in rural women based on protection 
motivation theory  
 
Version: 1 Date: 29 Jan 2020  
 
Reviewer: Dana Bovbjerg  
 
Reviewer's report:  
 
The authors have been somewhat responsive to the previous review, but several major 
weaknesses have not yet been adequately addressed.  
 
1. Throughout the text there continue to be problems with English grammar, syntax, and usage 
that make the authors' mea ning more difficult, if not impossible, to follow. These need to be 
corrected in order to improve communication with the readers of this journal. Some examples, 
but by no means all, are listed below along with some specific questions about meaning and 
sugg estions for improvement. The problems first arise in the Abstract.  
 
1.1 Page 2, Lines 11 -12: The first sentence of the Background section would be clearer if 
changed to read "Determining the factors that affect the adoption of preventive behaviors that 
can reduce the risk of skin cancer is an important first step for designing interventions promoting 
these behaviors."  
 
1.2 Page 2, Lines 12 -15: In the second sentence of the Background section, the authors' meaning 
in their use of the phrase "...preventive beh aviors' path of skin cancer..." is not clear. What is a 
"path of skin cancer" and how can preventive behaviors be in that path? Because of the 
confusing English, the authors' objective in the study is not clear for the readers of this journal.  
 
1.2 Page 2,  Line 23: The authors should replace the phrase, "dressed up," here and elsewhere in 
the text with a more specific and less potentially confusing brief description (e.g., "wore sun -
blocking clothing"). In American English usage "dressed up" has a different  meaning, as it refers 
to "...wearing special clothes, in order to look more formal than usual or in order to disguise..." 
[https://www.collinsdictionary.com/us/dictionary/english/dressed -up].  
 
2. A scientific rationale is still 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 relevant 
would be citations to epi demiological data from Iran.  
 
3. The text (Page 4, Lines 18 -20) needs to provide a description and citation for the source of the 
list of "...all cities in the west of Iran" from which the city of Nahavand was randomly selected 
for investigation.  
 
4. A strong scientific rationale for using a list of all CITIES in the west of Iran for selecting a 
place to study the behavior of RURAL women still needs to be provided; (emphases added). The 
authors specifically indicate (Page 4, Line 26): "A rural area is a geographic one that is located 
OUTSIDE towns and cities" (emphasis added). That statement appears to be logically 
incompatible with the selection of the CITY of Nahavand (emphasis added) as the site from 
which the study sample was drawn.  
 
5. The auth ors have not addressed a concern about potential selection bias. Since the second 
level of randomized identification of potential study participants made use of documentation 
available from health centers located in the villages whose residents were studie d, 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 for a full population sampling? 
Or, is the documentation limited to a subset of individuals in the village (e.g., those who have 
attended a health center), which could introduce sampling bias. If the latter, this potential bias 
should be menti oned as a limitation of the study in the Discussion and the possible impact on the 
study findings considered.  
 
6. A related issue raised in the previous review has also not been addressed. The number of 
women randomized to receive contact information abou t 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. The 
230 women represent a respond ing subsample of the randomized potential participant pool to 
whom contact information was sent. The responding subset likely differs from the larger 
randomized pool (e.g., participants in research studies generally have higher levels of education 
than the  populations from which they were drawn). If this information is not available, its 
absence should be noted as a limitation of the study in the Discussion.  
 
7. Citations to the relevant literature are still needed for some statements that the authors prese nt 
as "facts" in the text. In a particularly blatant example, the authors assert (Page 7, Lines 56 -57): 
"The role of fear appeals in producing behavior change is a proven fact." But, they provide no 
citations (e.g., to one or more systematic reviews or met a-analyses) to support that claim.  
 
Are the methods appropriate and well described?  
If not, please specify what is required in your comments to the authors.  
 
No 
 
Does the work inc lude 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 t o assess any statistics in the manus cript or would you recommend an 
additional statistical review?  
If an additional statistical review is recommended, please speci fy what aspects require further 
assessment in your comments to the editors.  
 
I am able to asse ss the statistics  
 
Quality of written English  
Please indicate the quality of language in the manuscript:  
 
Not suitable for publication unless extensively edited  
 
Declaration of competing interests  
Please complete a declaration of competing interests, consider ing the following questions:  
 
1.  Have you in the past five years received reimbursements, f ees, 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 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 declare that I have no competing i nterests.  
 
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