Reviewer’s report
Title: 
Use of community-based interventions to promote Family Planning use
among Pastoralist women in Ethiopia: Cluster randomized controlled trial
Version: 
2 
Date: 
11 Feb 2021
Reviewer's report:
Thank you for the opportunity to review the revised paper, which presents the
results of a cluster RCT evaluating a community-based program to increase FP
use among pastoralists in Afar region, Ethiopia. Overall, the paper is improved
from the last version, but some comments were not meaningfully addressed and
more work is needed on the organization of the paper to improve clarity. My
specific comments are below.
1. Background: My previous comment, "This section includes important
background on the problem, the Ethiopian context, and the male involvement
literature, but it would help to organize it so that there is one main point in each
paragraph. Currently it is somewhat repetitive. For example, paragraph three
starts off discussing the RIF (is this study part of that project?) and low FP use
among pastoralists in Afar (also mentioned in paragraph two) and then goes into
the literature on male involvement" was not fully addressed. The authors deleted
three sentences but did not meaningfully re-organize the Background section,
which I think should be done to improve clarity.
2. Methods: My previous comment, "Please provide more information about the
control group. In the Background you mention that the faema are a long-standing
group, which I assume would have been operating in the control areas. Is it that
these groups were operating, but were not trained on any FP content? In your
intervention description, you also mention that you made health facilities in
intervention areas ready to provide FP methods. Were FP services available in
the control areas? I see in Figure 1 that the control arm received "existing
intervention from the government", and it would be helpful to understand more
about what that entailed" was not fully addressed. Thank you for adding the
description of the control group, but I think you still need to add more for the
reader to understand how comparable they are to the intervention groups. Please
add whether any time of health workers were operating in these communities,
and if so, how they differed from those operating in the intervention
communities. For example, was it just that the HEWs did not receive specialized
training from the project, but they did receive the standard FP training from the
government? Please also add whether there were any differences in the FP
methods available in the control areas compared to the intervention areas.
3. Methods, Study Setting: Thank you for responding to my previous comment,
"It would be helpful to know more about these three districts selected for the
study, e.g. are they representative of Afar as a whole in terms of demographics?
How about in terms of FP and other health service availability?" Can you please
add the information on comparability between the selected districts and Afar as a
whole in the text of the manuscript as well?
4. Methods, Interventions: My previous comment, "It would be helpful to know
more about the process used for developing and testing the FP messages used as
part of the intervention" was not fully addressed. I am hoping you can add to the
manuscript more information about the process you used to develop the FP
messages. It sounds like you might have had an expert group develop them
based on what is known in the literature about barriers and based on your
qualitative key informant interviews. Please also provide more information about
how you tested them. Did you have community health workers share them and
then get feedback from community women? Or was testing what you were
referring to with the statement about the key informant interviews? Please add
this information into the revised manuscript.
5. Methods, Interventions: Your reorganization by intervention arm helped, but it
still is not clear the differences between the two intervention arms. I think you
could easily clarify this by revising "2) Women's Education on FP use arm" to
state how each component is different from the male involvement arm. You have
the three points listed, but this still is not clear. For example, it still isn't clear
how "assistance from HEW" is different between the two arms. In the women's
education arm you say that what makes it different from the male involvement
arm is that "On the assisting the faema leader using HEW and health workers,
they support for female faema leaders to teach the married women in their
clusters", but this is also what you've described in the male involvement section.
The differences between the arms should be clearer to the reader.
6. Discussion: Thank you for your work delving into the similar studies and
discussing how they support your findings. This section would still benefit from
some re-organization. It is currently organized by study (second paragraph is
Vietnam study, third is Kenya study, fourth is Nigeria study, etc.), and it would
help to organize by your main points. For example, you can have a paragraph
about overcoming male opposition to FP use where you support your findings
with relevant points from each of these studies.
7. Conclusion: Thank you for the revision making this more broadly applicable. I
think this section still needs some work to clarify your conclusions based on this
study. It seems like you are recommending both women's education and male
involvement (a combination of your two intervention arms), is that correct? 
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Is the study design appropriate to answer the research question (including the use
of appropriate controls), and are the conclusions supported by the evidence
presented?
Yes
Are the methods sufficiently described to allow the study to be repeated?
Yes
Is the use of statistics and treatment of uncertainties appropriate?
Yes
Is the presentation of the work clear?
No
Are the images in this manuscript (including electrophoretic gels and blots) free
from apparent manipulation?
Yes