Title: Factors associated with Female Genital Mutilation/Cutting in Tanzania: Insights from
Tanzania Demographic and Health Survey 2022
Version: 7 Date: 24 Mar 2025
Reviewer's report:
Major comments
1. The justification provided for this study does not sufficiently demonstrate a significant
research gap. Existing literature has already explored factors associated with FGM, and the study
as currently framed does not clearly articulate how it advances beyond what is already known.
To strengthen the justification, the authors should consider addressing key limitations of prior
research. For instance:
- Data Scope: Have previous studies primarily relied on non-representative samples, thereby
limiting generalizability to national or regional populations? If so, does this study overcome that
limitation by using nationally representative data?
- Variable Selection: Are there well-established determinants of FGM that previous studies have
overlooked, which this study accounts for? If so, specifying these novel factors would better
position the study as making a meaningful contribution.
- Methodological Limitations: Did earlier studies primarily use descriptive or bivariate
analyses without adequately adjusting for certain confounders? If this study employs a more
rigorous analytical approach (e.g., multivariable modelling), highlighting this methodological
advancement would strengthen the argument for its significance. One easy way to do this is by
categorizing the independent variables by various levels (I have made suggestions) and running
some sort of multi-level modelling.
Reframing the research gap in these terms—by explicitly identifying what was missing in
previous work and how this study addresses those gaps—would make the justification more
compelling.
2. The findings in some instances are somewhat counterintuitive. For example, one would
expect individuals who support the continuation of FGM to have higher odds of being cut
compared to those who oppose it. This unexpected result raises concerns about the selection and
conceptualization of independent variables in the regression model.
- To strengthen the analysis, the authors should critically evaluate the variables included
and ensure they align with a well-defined conceptual framework. Without a clear theoretical
foundation, the selection of independent variables appears arbitrary, making it challenging to
interpret some of the findings. A more structured approach—grounded in existing theories
or frameworks on FGM decision-making—would enhance the robustness and clarity of the
analysis.
3. The conclusions presented are overly narrow, focusing primarily on few variables (e.g.,
educational attainment) associated with FGM, while overlooking other important factors that
also showed significant relationships. This limited approach weakens the overall interpretation
of the findings and their broader implications. Again, this is where my earlier comment on the
importance of a conceptual framework to guide the analysis and interpretation of results will
be helpful.
To enhance the depth and coherence of the analysis, the authors should consider employing a
conceptual framework to systematically organize the variables at different levels. For instance:
- Individual level (e.g., age, education level, marital status, religion)
- Interpersonal level (e.g., household wealth index, household decision-making power)
- Community level (e.g., support for FGM continuation, media exposure, access to healthcare
services, religious requirements for FGM)
- Societal level (e.g., urban vs. rural residence)
Applying such a framework would not only facilitate a more structured and insightful
interpretation of the findings but also allow for more precise articulation of the study’s
programmatic and policy implications. Otherwise as currently structured, the analysis,
presentation of results and discussion appears fragmented and lacking a clear theoretical
grounding.
Minor comments
Abstract:
- Rather than “The burden is disproportionately high in developing countries”, need to be specific
and say “the practice is disproportionately high in African countries”
- Rather than “bivariable using Chi-square and multivariable logistic regression models were
conducted”, consider “bivariate and multivariate logistic regression analyses were conducted”
- Rather than “determine a significant variable”, consider “determine a statistically significant
association”
- There is no type of FGM called “flesh removed”. Use the WHO categories and maybe put the
“flesh removed” in parenthesis.
- Be consistent in the way you report the aOR. The standard way is to report the aOR in reference
to the control/reference group.
Background:
- The text in the background is too long and winding. There is need to focus on what the study
truly intends to add to the existing scientific literature.
Methods:
- The educational level variable needs to be broken down further for more insightful analysis.
At a minimum, you should have categories: no education, primary, and secondary and beyond
Generally, the authors would benefit from services of a language expert to edit the manuscript.