Reviewer's report
Title:Sexual coercion among married women in Nepal
Version: 1Date:29 April 2010
Reviewer: Chelsea Polis
Reviewer's report:
The authors have selected an important topic that deserves increased attention.
Factors associated with sexual coercion are poorly understood, and this study
contributes to our knowledge regarding the high levels of sexual coercion
experienced by married women in Nepal, which has important human rights and
public health consequences. However, this paper does need considerable
revision before it is acceptable for publication.
Major compulsory revisions
1. All sections: Please be very careful of the terminology insinuating causality
throughout the text. For example, you state that male patriarchal control
“elevates” sexual coercion, that factors “accounted” for high rates of sexual
coercion, and that factors are “predictors” of sexual coercion. Please revise the
text to remove insinuations of causality, since this is cross-sectional data and can
only establish association, not causation.
2. Background: This section requires significant revision. Terminology such as
abuse, violence, sexual coercion, and force are used interchangeably and
without clear definition. The authors do not specify why they chose to focus on
sexual coercion among married women, rather than among all women. There is
no review of previous literature examining the factors previously demonstrated
shown to be associated with sexual coercion, and it is unclear why small
qualitative studies are cited for prevalence estimates. Finally, the last two
sentences of this section have the feel of having been pasted in from a grant
proposal, and seem out of place in a publication.
3. Methods: Description of the sample selection methodology needs greater
detail. What are the “four districts” the authors refer to? How representative of the
population of married women in Nepal do the authors believe this survey data to
be? What groups might have been missed?
4. Methods: The construction of the sexual coercion variable should be more
clearly articulated. It is mentioned under the “Correlates of sexual coercion”
section but should be moved to the methods section.
5. Methods: The definition of sexual coercion seems to vary throughout the text –
sometimes referring to lifetime sexual coercion, sometimes referring to sexual
coercion by the husband. Please be clear and consistent in what this variable
refers to.
6. Methods: Unclear how you classified “high” “medium” or “low” perception of
power relations, or what these categories mean. Similar issue for the patriarchal
control variable.
7. Methods: What does “other” include in terms of the decision making for own
health variable? Should be clarified in tables and text.
8. Methods: How did you decide which variables to collect in the survey, and how
did you select specific variables to include in your multivariate model? What do
you mean that the “least important” variables were removed from the logistic
model? Which ones were removed?
9. Results: There are inconsistencies between the text and tables (for example,
the first paragraph discusses community group involvement which does not
appear in Table 1).
10. Results: Certain bivariate results could be more fully explored in the text. A
few examples: you note that more women were 6 or more years younger than
their husband experienced sexual coercion as compared to women 1-5 years
younger – but fail to note that the group with the highest level of coercion are
women who are the same age as or older than their husband. Commenting on
the fact that the percentages of women in various age categories who have
experienced sexual coercion are similar may be interesting (does this mean
coercion generally happens at a young age? Or that coercion has become more
frequent in younger generations? Or that recall bias makes older women less
prone to report sexual coercion? Or something else?) The lack of significance of
type of marriage is also interesting, and may warrant mention and exploration
within the Nepalese cultural context.
11. Results: Why not show 95% CIs and crude and adjusted ORs?
12. Discussion: Parts of the first paragraph in this section feel redundant – some
of this information has already been presented in the previous section and does
not need to be restated. Other pieces, such as the mention of potential
under-reporting of sensitive issues, are useful and should remain in the paper,
but potentially within a discussion of the limitations of the study.
13. Discussion: Exploration of the meaning of the husband-wife age difference
variable should be revisited. The non-significant finding of same age category
may be due to small sample size, given the results in Table 3, and should be
mentioned. Some of the speculations on reasons for significance of variables
seem tentative and unsubstantiated, and should be supported with references to
the literature.
14. Discussion: The interpretation of the husband occupation variable seems
problematic, because if you controlled for husband’s education in multivariate
analysis, then the effect of occupation should not be confounded by husband’s
education, and therefore should not be used in your explanation.
15. Discussion: Please be careful generalizing about women being busy with
household chores, being tired, and being unwilling to have sex, unless you have
data to back up this assumption.
16. Discussion: The paper needs a section to discuss the limitations of this study.
Minor essential revisions
1. Results: Adjusted OR for husband’s alcohol use is inconsistent between what
is reported in the text and shown in the table.
2. References: Citation style is inconsistent
Discretionary Revisions
1. Methods: Were research participants protected from the possibility of
additional violence if abusive male partners found out that they were involved in a
study regarding sexual violence? Were services extended to sexually abused
women?
2. Tables: Tables 1 and 3 could be combined. It is unclear why certain variables
were not included in Table 1 (i.e., number of children, age differences).
3. Tables: The information in Table 2 does not necessitate a separate table,
since the information is already presented in the text.
Level of interest: An article whose findings are important to those with closely
related research interests
Quality of written English: Not suitable for publication unless extensively edited
Statistical review: Yes, and I have assessed the statistics in my report.
Declaration of competing interests:
I declare that I have no competing interests.