PONE-D-19-20459

Assessment of Knowledge And Practice Of Breast Self-Examination Among Reproductive Age Women in Akatsi South District of Volta Region of Ghana.

PLOS ONE

Dear Dr. ADAM,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

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Abstract:

• Background- replace “(district or township name)” with the actual location information
• Methods- the software used for data analysis are probably the least important details to include. Instead include information on which variables were measured and the statistical analysis. The abstract says that women aged 15-45 were included but the rest of the paper indicates that women aged 15-49 were included.
• Conclusion- Your text states that breast self-examination is key to early detection, effective treatment and cure of breast cancer. This wording is too strong and I suggest tempering it to say instead that it is A key strategy.

Introduction:

• The first two sentences of the introduction are unclear and should be clarified.
• The introduction is too long and repetitive and should be shortened and streamlined.
• In the paragraph that starts “Because of poor access…” the sentence “Korle Bu Teaching Hospital…” clarify if these hospitals are in Ghana. In the next sentence, clarify that Volta is in Ghana. In the last sentence clarify whether the five regions you refer to are in Ghana.
• Remove the heading in the introduction section “Awareness of breast self-examination and breast cancer”
• Resource is misspelled as resourse
• Statement “Breast self-examination is critical in resource limited settings as a strategy to reducing mortality due to late reporting and diagnosis” requires a reference
• Statement “Breast selfexam (BSE), or regularly examining your breasts on your own, can be an important way to find a breast cancer early, when it's more likely to be treated successfully.” requires a reference
• Statement “Breast selfexamination as a screening tool for breast cancer in developing countries is advocated in view of its cost-effectiveness.” requires a reference
• The research objective “The objectives of the study were therefore, to examine awareness and knowledge of breast selfexamination as well as the practice of breast self-examination among rural women in Akatsi South District of Volta Religion of Ghana” does not totally match the results you present. Please rewrite your objective to reflect the fact that you are exploring which characteristics are associated with knowledge and BSE

Methods:

• Your methods section is missing quite a bit of information.  Please add:
  • Information about the setting. The district will, of course, not be familiar to readers outside Ghana. What type of setting is this? Rural? Urban? How populated?
  • Please justify why you chose to include women ages 15-49 in your study
  • Please justify why you included only women who had resided in the study area for 5 years or more
  • Please explain what variables are measured in this study (marital status, religion, etc) and justify why each is included. For example, is there existing evidence that religious affiliation is associated or might be associated with your two main variables in this setting?
    • Please enumerate whether the questions asked were open ended or multiple choice. For example, was the question about risk factors for breast cancer open ended, where women had to write in answers or verbally respond without any cues? Or did they choose from a list?
    • You refer to “good” knowledge and “poor” knowledge in your results. Please provide a justification for labeling knowledge good or poor.
  • Explain what statistical analysis you performed

Results:

• The sentence “These socio-demographic variables were crucial in understanding the responses of the participants and the findings in this study.” should be moved to the discussion as it is a commentary on your findings.
• The sentence “To measure awareness of breast cancer among the participants, two questions were included in the questionnaire asking whether or not they had heard of breast cancer as a disease and whether or not they considered breast cancer as a common disease among women in Ghana.” belongs in the methods.
• I suggest changing the phrase “refusal to breast feed” to “did not breast feed” in the following sentence since some women might not have given birth and some women may have been unable to physically breast feed. “Fifty-two people each mentioned family history and refusal to breastfeed as risk factors for breast cancer and that constituted 12% each.”
• Not all of your readers will be experts on breast cancer. You should explicitly state whether the responses given by participants (e.g. list one symptom of breast cancer) were correct.
• Avoid the word “influence” in your results because this implies a causal association. (“After the knowledge of breast cancer was determined above as to either good or poor knowledge, it was important to find out the demographic characteristics of respondents that may have influenced their level of knowledge.”) Also, this sentence really belongs in the methods.
• Please revise the title for Table 2 so that it is more informative and clearly and specifically describes the information in the table
• This sentence belongs in the methods: “Even though those who reported not practicing BSE gave various reasons for not practicing, we wanted to statistically find out the predictors of BSE in this sample and so a chi square (X 2 ) test of significance was performed.”

Discussion:

• Please explain what you mean by “market” women
• Please provide an explanation of why age may relate to BSE. You do provide some references. Has there been any discussion or do you have any ideas about why this relationship exists?
• Limitations and strengths need to be added to your discussion section
• Applications of your research findings should be suggested

General comments:

• Data are plural. Please adjust the text throughout.
• Avoid using the language “increase” and “decrease” throughout and instead say “higher” or “lower.” The words increase and decrease imply a longitudinal association across time. You are describing cross-sectional associations.

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We would appreciate receiving your revised manuscript by Nov 10 2019 11:59PM. When you are ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

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Please include the following items when submitting your revised manuscript:

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Please note while forming your response, if your article is accepted, you may have the opportunity to make the peer review history publicly available. The record will include editor decision letters (with reviews) and your responses to reviewer comments. If eligible, we will contact you to opt in or out.

We look forward to receiving your revised manuscript.

Kind regards,

Carmella August

Academic Editor

PLOS ONE

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Yes

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2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

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Reviewer #1: No

Reviewer #2: Yes

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Reviewer #1: Yes

Reviewer #2: Yes

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5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Introduction

Authors should refer to GLOBOCAN 2012 as reference 1. As the manuscript Ghartey et al refers to Ghanaian specific breast cancer distribution.

The section on BSE of the introduction is repetitive and verbose. It would serve the authors to reduce the length and be more concise.

Methods

Need to be listed in methods:

A summary of the questions asked, which language or languages (s) etc. Were the questions on scales, yes/no, categorical. What variables were collected from study participants. Where were the study participants identified?

Results,

Is the entire region rural or are there more urban centers within the region? Can the authors analyze based on this category.

Reviewer #2: This is a timely article. The topic is good and the data connect to the discussion at hand. It is appreciated that the significant and non-significant findings are presented. Edits would include using past tense throughout and clarifying some of the statements. I have uploaded a scanned copy of my comments.

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Reviewer #1: No

Reviewer #2: No

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files to be viewed.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email us at figures@plos.org. Please note that Supporting Information files do not need this step.

PONE-D-19-20459R1

Assessment of Knowledge And Practice Of Breast Self-Examination Among Reproductive Age Women in Akatsi South District of Volta Region of Ghana.

PLOS ONE

Dear Dr. ADAM,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

We would appreciate receiving your revised manuscript by Dec 29 2019 11:59PM. When you are ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter.

To enhance the reproducibility of your results, we recommend that if applicable you deposit your laboratory protocols in protocols.io, where a protocol can be assigned its own identifier (DOI) such that it can be cited independently in the future. For instructions see: http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols

Please include the following items when submitting your revised manuscript:

• A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). This letter should be uploaded as separate file and labeled 'Response to Reviewers'.
• A marked-up copy of your manuscript that highlights changes made to the original version. This file should be uploaded as separate file and labeled 'Revised Manuscript with Track Changes'.
• An unmarked version of your revised paper without tracked changes. This file should be uploaded as separate file and labeled 'Manuscript'.

Please note while forming your response, if your article is accepted, you may have the opportunity to make the peer review history publicly available. The record will include editor decision letters (with reviews) and your responses to reviewer comments. If eligible, we will contact you to opt in or out.

We look forward to receiving your revised manuscript.

Kind regards,

Carmella August

Academic Editor

PLOS ONE

Additional Editor Comments (if provided):

Thank you for responding to my comments on the first version of your paper. The paper is much improved. I have listed my additional concerns below, please respond and PLEASE INDICATE LINE NUMBERS WHERE YOU MADE CHANGES so that I can easily find your changes. Thank you.

My comments:

1. I asked you to change the conclusion in your abstract to "a key strategy" and you changed it to "key strategy." Please add the "a" so it reads "a key strategy."

2. Your methods is one large paragraph. Please split the text into multiple paragraphs.

3. I cannot find the revised text that you mention in your response #10 in the introduction about BSE, or regularly examining your breasts on your own... Can you please provide line numbers so that I can easily find where you made this change?

4. For your response #18 in the results section of your response to me, I can't find where you made this change. Please respond and include line numbers to make it easy for me to find this change.

Reviewer 1 comments:

1. Please respond to reviewer 1's comments asking about analyzing your data based on geography.

Reviewer 2 comments:

Please review and apply edits made by reviewer 2 in the scanned file provided.

Thank you.

Ella August

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files to be viewed.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email us at figures@plos.org. Please note that Supporting Information files do not need this step.

Assessment of Knowledge And Practice Of Breast Self-Examination Among Reproductive Age Women in Akatsi South District of Volta Region of Ghana.

PONE-D-19-20459R2

Dear Dr. ADAM,

We are pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it complies with all outstanding technical requirements.

Within one week, you will receive an e-mail containing information on the amendments required prior to publication. When all required modifications have been addressed, you will receive a formal acceptance letter and your manuscript will proceed to our production department and be scheduled for publication.

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With kind regards,

Carmella August

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments: