Title: Women empowerment and Health insurance utilisation in Rwanda: a nationwide cross-
sectional survey
Version: 1 Date: 04 Jul 2022
Reviewer:  Jean Damascene Makuza
Reviewer's report:
Thank you to the authors to produce this article. This present article assesses the association of
different components of women’s empowerment with health insurance utilization using DHS
Rwanda 2020, by analyzing data using a cross-sectional study design. This study has found that
all components of women’s empowerment were negatively associated with health insurance
utilization. This study has the strength of being novel and using a representative sample yielding
an external validity. However, due to many gaps presented in the following sentences, the
internal validity of this study is questionable. From the abstract to the conclusion, there is no
linkage between different parts of the study components. Let us give details of these gaps in
the following.
In abstract,
1) Research questions and objectives are not aligned conceptually. I intended to hear how
women’s empowerment is contributing to the reduction of poverty and then reducing barriers to
health care by enabling people to pay for health insurance and helping them to get health care.
Authors should show this link otherwise readers could not link easily the two.
2)  In methods, it is known that DHS is using multistage sampling strategies, and it was not
necessary to show it in the abstract as appropriate methods used by authors. I suggest showing
the brief definition of exposure and outcome and how participants for this sub-analysis were
selected.
3) In the result, it could be better to show a picture of the study population by briefly summarizing
their main socio-demographic characteristics of them. I recommend also showing how those
women empowerment components are associated with the utilization of health insurance as well
as showing the direction of their association. Better not to talk a lot about other factors, which
they did not explain which variables are associated with them.
4) The conclusion is not connected to the findings, so the authors need to rectify them and try to
link them. This is an example of exposure to media shown to have a negative association with
health insurance utilization in results and then in conclusion they recommend it.
Introduction
Arguments used to explain why this research question was chosen and study rationale are not
strong, I recommend making them stronger by adding comparisons and numbers as shown in
the following sentences:
Does inequity in access to care more common among women discussed exist globally or in
some parts like in developing countries or SSA? The author needs to be precise. How about in
men? In addition, what is the difference between men and women? This could explain why you
considered only women and their empowerment.
CBHI is used by most of the population compared to other health insurance types. Try to show
the numbers that explain this difference.
Methods
In the study sampling and participants, one inclusion criterion of age between 15-49 years old
which is the same as for the whole DHS was shown, do not you have any other inclusion criteria,
if yes, you have to describe them in this area. I did not see also exclusion criteria please show
them too.
In this study, the authors did not show the study design; I recommend they could show it.
In variables, it is good that the authors presented the dependent variables, but there is a need
to define these variables and their types as well as their codes as it was done for the main
explanatory variables.
In the main explanatory variable, the authors said they used the sensitivity analysis by excluding
those with missing responses, which mislead the results, I will recommend them to use missing
imputation as sensitivity analysis.
In other explanatory variables, it is good that the authors defined determinants of the outcome but
they did not show which could be considered as confounders, if possible they can show which of
them are confounders and which could be mediators and not eligible to be included in the model.
In the statistical analysis, the authors considered a p-value of 0.25 as a significant value while
we know that the significant value could be equal to or less than 0.05. This value of 0.25 could
be considered as the cut-off value for considering a variable in the multivariable analysis.
The first model in the multivariable analysis does not make sense as the whole exposure variables
as they are not confounders of the relationship between each of them and the outcome or
determinants of the outcome. I recommend to them to delete the first model and consider only
model 2 and if possible consider each exposure in its model, so conduct 4 multivariable models.
Results
Descriptive analysis results were well presented but, it will be better to also present median and
IQR or mean and SD in quantitative variables like age.
Analytical results and tables and their interpretations need to be totally revised due to the
following comments:
- Some interpretations of the  results were wrong like “Women’s sexual empowerment was not
a significant factor” while looking in table 3 the AOR in model 2, 95%CI for those coded as
high in sexual empowerment was (0.616-0.984) which is significant.
- Most of the results from Tables 3 and 4 which were not significantly associated with
the outcomes were presented as statistically significant (see examples for medium codes for
exposure to masse media, decision making, and economic empowerment.
- Other social-demographic factors found to be significantly associated with health insurance
took a big place, which lead to the table 2 fallacy while they are not essential for presented
objectives.
- Results for sensitivity analysis in table 4 need to be revised according to recommended
sensitivity analysis recommended.
Discussion
The author’s results interpretation is wrong or does not show the direction of the association,
according to the results all variables on women empowerment showed a negative association
with health insurance utilization while the authors showed only the exposure to media.
Conclusions
Recommendations from the authors do not reflect totally on the study findings as they only talk
about media exposure while all components of women empowerment were negatively associated
with health insurance utilization.  We recommend the authors consider all study objectives while
formulating conclusions and recommendations.