Reviewer ’s report  
 
Title: Barriers to essential surgical care experienced by women in the two northernmost regions 
of Ghana: A cross -sectional survey  
 
 
Version: 0 Date: 25 Dec 2015  
 
 
Reviewer: Laura  Harris  
 
 
Reviewer's report:  
 
This is a solid, well written paper that addresses an important and interesting topic. I think that it 
could fit well as a publication in BMC Women's Health, provided that the issues below are 
addressed.   
 
The main issue that I see with this paper is the juxtaposit ion between its current discussion of 
index performance, and its conclusion that "women had greater barriers to surgical care". While 
the difference between the scaled scores of men and women is statistically significant, the 
magnitude is a half point on a  10-point index, and no statistical assessment or validation of the 
index has been presented. It is hard to know what that half point really means, and to what extent 
the results are an artifact of the index's construction. In my opinion, the magnitude of the 
difference combined with the lack of validation is not enough to justify the conclusion that 
women face greater barriers for surgery than do men - i.e., despite the statistical significance, the 
difference may or may not be substantively meaningful.  
 
I see a few ways forward. One would be to downplay the results found from the index, and to 
instead focus on the specific barriers that were greater among women. The paper already has a 
good discussion of specific barriers, and I think that this discussion  could be emphasized. 
Another approach would be to strengthen the case for the index and to (briefly!) give more 
information about its statistical performance. This could involve:  
 
- Making more of a case for the need to develop a index to answer the study question  
- Performing a confirmatory factor analysis to determine whether the sub -indices hang 
`together statistically as well as conceptually.  
 
- Reporting index statistics like internal consistency (Cronbach's alpha) for the overall 
index and for the sub -indices.  
 
- Performing a validation test - perhaps assessing whether the length of the time before 
seeking surgical care was correlated with a lower score on the index (although this may 
be complicated by the fact that men and women sought treatment for dif ferent surgical 
procedures). (On a similar note, what do you make of the fact that none of the a -priori 
vulnerable sub -populations have significantly higher adjusted odds of having a barrier to 
care index in the lower quartile (Table 3)?)  
 
- On a related note, I appreciated the discussion of the origin of questions for the index and 
the modified Delphi process for refining them; this gave me more confidence in the 
index.  
 
The strongest approach may be a combination of these two strategies. I have also noted other 
more minor issues in the comments below.  
 
This paper presents important research - as the authors note, a recent systematic review included 
no articles on barriers to surgery among women in LMIC. I hope to see the results published.  
 
- Major Compulsory Revisions  
 
1. Intro, line 114: Please further define essential surgical care.  
 
2. Intro, line 116: Please include a bit more about the Grimes review, because it forms the 
starting point for your survey tool - e.g. was it systematic? Ho w recently was it published?  
 
3. Intro, line 135: Please explain how your survey assessed community -level barriers.  
 
4. Intro, line 136: It seems as though the survey was developed specifically to assess differences 
between men and women. Please clarify in  this sentence whether this was the main intent of 
developing the survey, or the intent only of this particular analysis.  
 
5. Methods, line 160: When reading the draft, I was confused about whether the survey asked 
about barriers to surgical care outside of the context of surgical missions, or whether surgical 
missions were included in the question. I suggest clarifying by incorporating the actual text of 
the question in this section: "Which of the following reasons for not having surgery for your 
problem sooner apply to you?"  
  
6. Methods, line 161: The index only lists four items for accessibility, but the text of the 
manuscript says there are 9 items. Please address this discrepancy.  
 
7. Methods, line 215: Did you perform metrics on the index as a whole , such as factor analysis, 
Cronbach's alpha? Did the three dimensions of accessibility, acceptability, and affordability hang 
together statistically, in addition to conceptually? Please briefly discuss them, if so, and see the 
general comment above.  
 
8. Re sults, line 301: in the paragraph on "Female -specific barriers not captured by the tool", 
please indicate how many qualitative responses mentioned each barrier noted, if it is possible to 
do so.  
 
9. Discussion, first few paragraphs: The discussion at pres ent focuses on the differences found 
between genders. Please also mention the ways that genders were not found to be different (i.e. 
no significant difference of odds of being in the lowest quartile, same affordability sub -index).  
 
11. Discussion, line 38 1: As the paper discussed, the survey was administered to a specific 
population that chose to access surgery at this point, and thus were able to surmount the barriers 
to surgery in this context. I would appreciate more discussion of how the survey results  should 
be interpreted - particularly how the specific sub -indices of affordability, accessibility, and 
acceptability might be affected. For example, more women indicated that lack of privacy was a 
barrier - how private was the care at the study sites?  
 
- Minor Essential Revisions  
 
12. Abstract, line 81. "Women might be vulnerable to certain barriers to care that are not 
significan t obstacles for others in developing countries." This reads awkwardly to me - which 
groups are being compared? And, the survey did not assess how significant the barriers were. I 
suggest this rephrase: "Women in developing countries may experience certain ba rriers to care 
more frequently than men." Or something similar.  
 
13. Intro, line 116. When defining unmet need for essential surgical care, please state that the 
person in need of the surgery/consultation must not be able to access this surgery/consultatio n (if 
this is indeed the case). In addition, I found the opening paragraph of the introduction to be a bit 
difficult to parse, and would suggest breaking it into shorter sentences.  
 
14. Methods, line 192. The patients that presented for care → The patients  who presented for 
evaluation  
 
15. Methods, line 196. All patients that presented for surgery → All patients who presented for 
surgery  
 
16. Results, line 264: Please specify the 10ths place (after the decimal) in the dimension scores 
for accessibility, to have the same number of significant figures as in the other scores.  
 
17. Results, line 278: Please clarify the differences in the paragraphs "factors contributing to low 
dimension scores" and "Specific barriers to care", or consider combining them into one  
paragraph.  
 
18. Results, line 251: The upper end of IQR for travel time is noted as 24 hours here, but in line 
228, the upper limit of travel time is 8 hours. Please address this discrepancy.  
 
19. Discussion, line 335: Please change to "women were more l ikely to report"  
 
20. Discussion, line 399: Saying "gender -specific" seems too strong - men also experience these 
barriers. Please rephrase.  
 
- Discretionary Revisions  
 
21. General: I understand that this is a paper about gender differences in barriers to surgical care, 
but I would have appreciated more discussion about how the gendered differences in barriers 
related to the overall barriers experienced. For example, were the specific barriers that were 
mentioned as contributing to the index score differenc es also the barriers that were most 
commonly mentioned overall, or were others more commonly mentioned overall? The devil's 
advocate position would be - why focus on gender differences if they are not showing up among 
the most commonly mentioned barriers. Discussing the overall picture of barriers could address 
this argument.  
 
22. General: I found it confusing that a lower score on the barriers index signified a higher level 
of barriers. I would suggest either changing the scoring so that 10 = the highest barriers, or 
renaming the index accessibility of surgery.  
 
23. General: I suggest revisiting the usage of the terms female and woman in the article text. The 
term female (and male) has the potential to be dehumanizing when used as a noun to describe a 
person.  Further, sometimes female is used and sometimes woman is used. I would suggest 
making the terminology consistent, and suggest using men/women as nouns rather than 
males/females, even though this is not the terminology used in the survey tool.  
 
24. Di scussion, 324: This point seems useful to bring up in the introduction instead, as it makes a 
case for the originality your research.  
 
Are the methods appropriate and well described?  
If not, please specif y what is required in your comments to the authors.  
 
Yes 
 
Does the work include 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.  
 
Unable to assess  
 
Are you able to assess any statistics in the manuscript or would you recommend an  
additional statistical review?  
If an additional statistical review is recommended, please specify what aspects requ ire further  
assessment in your comments to the editors.  
 
I am able to assess the statistics  
 
Quality of written English  
Please indicate the quality of language in the manuscript:  
 
Needs some language corrections before being published  
 
Declaration of competing interests  
Please complete a declaration of competing interest s, considering the following questions:  
 
1. Have you in the past five years received reimbursements, fees, funding, or salary from 
an organisation that may in any way gain or lose financially from the publication of this  
manuscript, either now or in the fut ure? 
 
2. Do you hold any stocks or shares in an organisation that 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 cont ent 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 hav e 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 compet ing interests  
 
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