Reviewer ’s report  
 
Title: Implications of male circumcision for women in Papua New Guinea: a transformational  
grounded theory study.  
 
Version: 0 Date: 20 Feb 2017  
 
Reviewer: Colleen Fisher  
 
Reviewer's report:  
 
Thank you for the opportunity to review the manuscript.  The manuscript is well written and 
interesting with the issue of HIV prevention  being important in the context of PNG.   
 
 
 
I raise the following issues for modi fication by the authors to improve and clarify aspects of the 
manuscript to enable it to potentially be publication standard.   
 
 
 
 
Background:  
 
As BMC Women's Health attracts an international readership, it would be useful to add some 
detail at line 83 where i t is noted that the 'social and educational status of many women in PNG' 
is low.  How does it relate to similarly developed nations?  Other nations in the region? Etc.  
There is some description of the setting (lines 99 -106) but no description/detail of th e status of 
women in the country is provided at any point, despite it being mentioned throughout (including 
in the findings of the manuscript where education and ability to influence decisions are 
discussed).  Having specific information about the status o f women would contextualise these 
findings for the reader.  
 
 
 
A transformational grounded theory study design is appropriate for the research, but I have the 
following comments:  
 
 
The process of sampling and data analysis is not clearly described r in the manu script.  It is noted 
that in Phase 1 existing qualitative data were theoretically sampled.  What were the dimensions 
that were used to theoretically sample from the data?  How much data were in this sample?  
These data were then analysed (line 116) .  It i s then noted, however, (line 118) that "Chunks of 
data identified during this phase were then analysed by 64 female co -researchers in seven 
interpretive focus groups".  Description of how these 'chunks of data' were identified should be 
included?  The use of the term 'analysed' (line 118) is confusing given that the process of 
'interpretive focus groups has not previously been described.  It would have been useful to 
provide a brief discussion of this and also refer the reader to the publication of the auth ors related 
specifically to the describing 'interpetive focus groups' undertaken for this particular study.  It is 
also unclear who participated in  the "11 semi -structured interviews" (line 121).  What data are 
presented in the manuscript?  Is it the anal ysis undertaken in the interpretive focus groups and 
the 11 semi -structured interviews?  Or does it also include the analysis of the original sample of 
data from the broader study (as described in lines 115 -116). Or does it relate to the 11 semi -
structured  interviews described at line 121?  Or Something else? What was discussed in these 
interviews?  
 
 
Under the heading "Sample" (line 126 -127) it is unclear where this data were sampled from.  Is it 
the same as that described at lines 113 -114?  If so, then the d escription of the samples are very 
different (861 males and 519 females compared to 9 semi structured interviews and 2 focus 
groups).  Clarity and required.  In phase 2 (line 128) it is noted that 66 women and 1 man co -
generated primary data  which were "t heoretically samples at two of the four original sites".  
Which sites are the 'original sites' - those described at line 113? 119? Other? Along what 
characteristics were the participants 'theoretically sampled'?  
 
 
A very brief description of the data analysi s is provided.  Although it is well known that data 
analysis for grounded theory utilised 3 levels of coding, memoing and constant comparative 
analysis, there is no description of how this was operationalised for this particular study.     There 
is no desc ription provided of how the data from the interpretive focus group were analysed (there 
is description that they were transcribed "line 123) but the reader is not provided with any 
information on what analysis was undertaken on these transcripts.  How were  the 'storyboards' 
analysed? Who undertook the analysis?  Was it the same analysts across all phases?   
 
 
Why was the Kelly et al article chosen to be included?  Rationale should be provided.  
 
 
It is apparent that data were collected in the local language, but  were they also collected in 
English?  How were the translations undertaken and what processes were implemented to ensure 
that the context and cultural meaning were retained in the translation?  Who undertook the 
translation?  Who facilitated the interpret ive focus group?  
 
 
Line 307 notes that a participant in an interpretive focus group had an agricultural qualification 
and that "This wamn was deferred to by other women during the group".  What does this mean 
for the integrity of the data within that group - was 'group think' occurring with the other women 
deferring to her?  
 
 
What was the involvement of "one man" (line 128).  What primary data is being referred to here?  
It is noted that the data were 'co -generated'.  Does that mean he was also involved in an 
interpretive focus group?  Or was he interviewed?  Clarity required.  
 
 
In sum, the sections related to methodology require re -writing to provide clarity.  
 
 
The manuscript reports interesting findings, but at many times I was wanting evidence, by way 
of verbat im quotes, to support what was being asserted. Without the quotes it is difficult to 
understand whether what is being presented are findings of this research, or what is known in the 
literature.  If the former, quotes are required, if the latter, reference s are required.   See for 
example:  
 
 
Lines 175 – 184 
 
 
Lines 186 – 193 
 
 
Lines 221 - 231 only includes on very brief quote in the paragraph with the quote at lines 233 - 
236 not really reflecting the text preceding it  
 
 
Lines 250 -254 
 
 
Line 294 -295 
 
 
Line 299 -311 
 
 
Lines 313 -331 - just one quote of substance is provided for an entire category.  Is this sufficient?  
 
 
Lines 356 -367 (just one quote after line 367).  Is this sufficient?  
 
 
Lines 373 – 379 
 
 
Lines 390 -391 
 
It would be useful to provide a description of what the codes given to participants stand for (eg, 
DWU SSI 20; NBPOL IFG 2; PAU 22I 4).  
 
 
At various stages in the findings, the category 'Acting on Choices (as noted in the model) is 
referred to as 'Acting on Options"  
 
 
Line 408 - a category "Increasing Choices" is m entioned, yet there is no category labelled this in 
the model  
 
 
There is a lot of repetition throughout.  The following are examples, but a full edit is required to 
ensure repetition is removed:  
 
 
Line 213 - repetition from line 189  
 
 
Line 256 - repetition fro m previous paragraph  
 
 
Line 263 -268 
 
 
Lines 292 -293 - repetition from 244  
 
 
Line 333 - repetition from 301  
 
 
Lines 399 -402 and "stopped" by whom?  
 
 
I found the section that brings into discussion the social determinants of health to be very 
superficial particularly  that linking the oppression, to systemic power, discrimination and 
structural power.  (For example what is meant by "The theoretical concept of the social 
determinant of Peace/Oppression)?  And what "areas for action (line 438) are highlighted?  
There are  some very large statements made about social structure and social organisation in a 
country based on a small qualitative study, specifically researching male circumcision.  Critical 
theory and social determinants of health  are very large bodies of l lite rature (very theoretical in 
the case of the former) and a deeper engagement is required to give them justice and to provide a 
well considered argument for the linking of the various power structures described.  
 
 
It is noted that "Peace is one of the conditi ons of health originally identified in the Ottawa 
Charter……".  Peace is actually referred to as a 'pre=requisite for health'.  
 
 
Is the social determinants of health a public health theory? (line 428)  
 
 
 
 
Miscellaneous issues  
 
Line 282 - NBPOL is written, but t here is not explanation of what this acronym means  
 
 
Line 295 - what is a "B category"?  
 
 
What is meant by "….(own status separate from husband, resources, income etc)…. (line 365)  
 
 
Line 384 - blame their mothers for what?  What kind of 'negative consequences' are being 
referred?  As a result of what?  Needs unpacking.  
 
 
Lines 394 -396 makes a grant claim about the impact of violence influencing "every decision a 
woman makes".  What is the evidence for this? (if this is from the data for the study, it needs 
verbati m quotes as evidence)  
 
 
Line 417 - page number required for a direct quote  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Are the methods appropriate and well described?  
If not, please specify what is required in your comments to the authors.  
 
No 
 
Does the work include the necessary controls?  
If not, please specify which controls are required in your comments t o the authors.  
 
Unable to assess  
 
Are the conclusions drawn adequately supported by the data shown?  
If not, please explain in your comments to the authors.  
 
Yes 
 
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 require further  
assessment in your comments to the editors.  
 
Not relevant to this manuscript  
 
Quality of written English  
Please indicate the quality of language in the manus cript:  
 
Acceptable  
 
Declaration of competing interests  
Please complete a declaration of competing interests, considering the following questions:  
 
1. Have you in the past five years received reimbursements, fees, fu nding, 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 future?  
 
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 content 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 have any non -financial competing interests in relation to this paper?  
If you can answer no to al l 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 competing interests.  
 
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