Title: The Effectiveness of Educational Intervention based on the Health Action Model )HAM)
in Improving Breast Cancer Screening Behaviors
Version: 1 Date: 25 Nov 2022
Reviewer's report:
Title: The Effectiveness of Educational Intervention-based on the Health Action Model (HAM)
in Improving Breast Cancer Screening Behaviors
While the study has an interesting topic, I am surprised by its weaknesses in methods, structure,
results and discussion. Indeed, the English grammar construct of the manuscripts needs to be
reviewed for simplicity and clarity. Frankly speaking, I am not very glad about the draft as
I am not convinced about few arguments [mainly based on inadequate/undesirable methods
and analyses]. Let the esteemed editor decides the future course. I am recommending ‘Major
Revision’ in case the editor advises to rescue this article.
Since this is  an experimental study design, the authors should include adequate details of
required sample size estimation and other important items of CONSORT guidelines {like Item
8a # Random Sequence generation (if not done, explain why), Allocation concealment (Item
9), Blinding (Item 11a)} but are not found. Please refer to the “CONSORT checklist 2010:
Structured summary of trial design, methods, results, and conclusions” to improve the writing
of this study.
Abstract:
In the background of the abstract, please note the importance of educational interventions and its
effectiveness in terms of the theory of HAM in Improving Breast Cancer Screening Behaviors as
a successful framework. In addition, this part lacks the research gap. The methods of this section
are also very poor and too long. Unfortunately, it lacks some important information such as the
sampling method, study participants for experimental and control group, formal analysis and
when the study started and ended. The results of this part should be reported accurately with the
mean of structures and statistical significance (and statistical tests). Finally, as the background
and results are poorly presented, this results in taking a good conclusion.
Background:
Please summarize the background. It is very long. In this section, first, the importance of
educational interventions in terms of HAM should be discussed using what has been already
known. Then, the readers need to know the role of the educational intervention and HAM and
their impact on behavioral change among cancer patients. The importance of educating mothers
should be emphasized. Then the theory of HAM should be expressed as a successful framework
for implementing and evaluating such interventions. Finally, the importance of educational
intervention and mothers' behavioral changes should be concluded based on the appropriate
theoretical framework and the lack of studies in this field, and then the purpose of the study
should be stated.
Methods:
While the methods section must be convincing, sounds scientifically and academically, this is
one of the weakest parts of this study. First of all, the subheadings are disorganized.
For example
1. The subheading ‘Type of study and participants’ should be “study design and participants’
2. Participants were not appropriately defined; inclusion and exclusion criteria
3. There is a lack of the description of the study settings
Sampling:
Please describe the sampling process completely. What was the type of allocation and
randomization? Write the formula for calculating the sample size by inserting numbers.
Authors stated that they used multi-stage sampling, please, how many samples or clusters did
you include in this study? How many participants for each group? How many participants for
control and experimental group?
The following information about the limitation to data collection could be in limitation section
“During the sampling for the study, there were few visitors to comprehensive health service
centers due to the COVID-19 pandemic »
The section of ethics statement should be placed at the end of the methods (after analysis).
Educational intervention
Please talk about the educational program briefly in the text of the method section. The
details of the educational intervention should be presented in detail in a table. Includes each
session, learning objectives, modified construct, content, time, teaching methods and materials,
instructor, learner assignment, etc.
Instrument: Please provide an example item of behavior and behavioral intention.
Please edit the text related to the validity and reliability of the questionnaire. Face and content
validity should be reported quantitatively and qualitatively. Please report the impact score,
content validity index, and content validity ratio as a range.
Then the reliability of the questionnaire in terms of stability and internal consistency and the
number of samples to be presented.
Data collection: This subheading is too long and needs to be revised. Also, this part has the
problem of study materials, which are not clear. In addition, the authors said that the study
materials have four sections; these sections are not well clarified. Indeed, some variables are
mixing. It is not possible that menauposal can be in demographic characteristic.
In the second paragraph of data collection and tools, the authors said “A total of 16 items
for knowledge and six items for behavior…” How did they find the items? Are they from
standardized instruments? What are their psychometric properties? In the same paragraph, the
authors said “Therefore, the first version of the tool was prepared in four sections….” Are these
items from which instrument?
Moreover, the authors indicated that they assessed “content validity index and ratio’
Confirmatory factor analysis, and internal consistency”, why did you assess this kind of
statistical analyses? Are they helping you to respond to the study objectives? Finally, the authors
did not indicate us how they performed them and which are their statistical parameters. They
did not indicate us the results in the results.
Please, all statistical analyses must be stated in the analysis part and the results in the results
section.
It would helpful to identify if any of the tools used to measure the outcomes were validated.
The authors said, “The external reliability of the questionnaire was measured using the test-
retest method” what is this contributing to your study objectives?
Data analysis:
The subheading of analysis is very poor and was not well presented. Please, all statistical
analyses must come to respond to the research questions.
To assess the contribution of education interventions comparing the interventional group
and control group you are expected to use {for comparison of means from non-Gaussian
distributions} Wilcoxon’s Signed-Ranked test [for within group comparison] in place of paired
‘t’ test {for Unpaired Case i.e. for between-groups comparison use Mann-Whitney ‘U’ test
instead of two independent samples ‘t’ test}. In this context, please read the following [which
is pasted from one standard textbook on.
Results:
Overall, the analyses done are not proper. For example, what is the purpose and interpretation of
(values in) table 1-3? Is the method/technic/test used capable/desirable/indicated for the purpose/
aim in mind? Between-groups comparison is not done [directly] anywhere. Separate ‘p’-values
for experimental/intervention group & control group and then drawing/making comparative
statement is not correct.
The authors examined the impact of the interventions using the pre-intervention, 3 months after
an intervention and then long term impact (in 6 months); which statistical used for assessing to
compare the groups and to assess the impact of the interventions?
How can you say that the intervention has significant impact on behavioral changes or
effectiveness with these analyses comparing means of the three groups?
Discussion:
The discussion section needs to be strengthened. Please present the results in terms of
constructs (knowledge, attitude towards behavior, subjective norms, perceived behavioral
control, intention, and behavior) respectively. In each result, the reason for the modification
and effectiveness of the theory structure should be interpreted. How did the educational
intervention affect that structure? Compare consistent and inconsistent studies with the mention
of interpretation.
Conclusion
Based on the results and methods issues, I am sure whether the conclusions are correct.
The strengths and limitations should be placed before the conclusions.