Reviewer's report
Title:Preliminary development of a scale to measure stigma relating to sexually
transmitted infections among women in a high risk neighbourhood
Version: 1Date:19 May 2008
Reviewer: Carol Kaufman
Reviewer's report:
This manuscript describes the development of a sexually transmitted infection
(STI) stigma scale for women. The authors provide an interesting narrative of the
scale development and results. The paper may be strengthened through address
of the following points:
(Note that the following used outline formatting in Word - please excuse the
less-than-clean translation into text format.)
Major compulsory revisions
1. The authors should be careful about their use of “gendered.” In the abstract,
for example, they note that because women are often judged more harshly on a
moral scale, their experience of sexual stigma is likely to be different then men’s.
I agree with this – but it sets up the paper as a comparative piece when it is not.
Mostly, the authors describe the scale accurately – it is a measure of stigma
developed in a group of women. Please go through the paper to ensure the
accurate and consistent use of this term.
2. Related to this, could the authors explain why they elected to use a
female-only sample to develop the measure? There are at least two significant
limitations to a single-sex population. First, we do not have a basis for
comparison: Does this measure work better for women than for men? Or just as
well for both sexes? Second, if this were to be incorporated in future research,
we would not know how it might perform across both sexes. For female-only
samples, this is not a problem. However, clearly STIs are not limited to women;
women just happen to be the ones more likely to be tested. However, slowly STI
research initiatives are in fact including men. In sum, I find it unfortunate that the
authors elected to use a female-only sample for this scale development.
However, I also realize that repeating the study is not likely an option. In view of
this, can the authors address their rationale for the sample? Also addressing this
in the limitations section would be useful.
3. The authors mention that there are “few scales that examine STI-specific
stigma.” What are they? Please cite references – if they exist, it is important to
know also their relative strengths and weaknesses. The authors do generally list
these, but if they want to make the case their scale is better or makes a
substantial improvement or contribution, they need to provide more evidence.
4. The use of “tribal” to describe “good v. bad” strikes me as introducing more
confusion than clarity to the sub-scale. Although the term may be useful in some
disciplines, for a medically-oriented journal, this term will simply be associated
with indigenous people. I do not believe the authors intend such an association. I
also believe that some other label could be used without losing the meaning of
the construct.
5. Please provide more information on the sample. For example, it would be
useful to know the distribution of the sample by characteristics presented in
Table 3.
6. Why did the authors standardize the scales in Table 3? Since all scales were
already coded 1-10, they were standardized – just on a different, but more easily
interpretable, scale.
Minor essential revisions
1. Abstract:
a. Please define STI.
b. Please define DTES.
c. Neither “DTES” nor “passively recruited” were used in the main text. Please
either follow through in the main text or revise the abstract.
d. Related to this, what is “passively recruited?” I suspect this is different from
passively consented, but no description is provided. The authors should also
include a statement about IRB approval.
2. Main text:
a. Please spell out STIs the first time the acronym is used.
b. Please provide more information on the weekly program from which women
were recruited and the community in which the clinic operates. Specifically, “local
health community clinic” does not describe much about the kind of clinic it is ,
services it offers, or clientele. Further, no description of the type of neighborhood
is provided – including some census-type stats would be useful. Of note, the term
“high risk neighborhood” which appears in the title, is never defined.
c. P10/11: In the discussion the authors state that: “[t]he tribal stigma scale was
not found to be significantly different among participants.” Yet, on the prior page,
the authors list age, ethnicity, and IDU status as being associated with higher
tribal stigma scores. Isn’t this a contradiction?
d. Since the Spearman-Brown Prophesy is usually for evaluating reliability of
different survey lengths, could the authors please describe what this estimate
contributes in the current study where all surveys have the same number of
items?
e. Please clarify the issues of missing data. Are all cases used in this analyses
complete cases (i.e., any participants who did not respond to all 18 stigma items
were dropped?)?
f. Including n’s on Table’s 1 and 3 would be useful.
g. Please include in the conclusions a sentence or two about the future of this
scale (future development, applications, purposes, etc.).
Discretionary revisions
1. Can the authors take the analyses one step further and perform multivariate
analyses? It would be useful to know the relationship of the various
characteristics to the scale after controlling for the others.
2. After such an even-handed treatment of an often incendiary topic, I was
disappointed with the last sentence of the manuscript. While in fact many
policies/programs likely are rooted in stereotypes, terming this an “excuse” will
simply make the proverbial policy-eyes glaze over. I recommend a revision of the
closing sentence.
Level of interest: An article whose findings are important to those with closely
related research interests
Quality of written English: Acceptable
Statistical review: Yes, and I have assessed the statistics in my report.
Declaration of competing interests:
I declare that I have no competing interests.