Reviewer ’s report  
 
Title: Inadequate birth spacing is perceived as riskier than all family planning methods, except  
sterilization and abortion, in a qualitative study among urban Nigerians  
 
Version: 0 Date: 29 Jan 2017  
 
Reviewer: CARIE COX  
 
Reviewer's report:  
 
This manuscript aims to examine the risk perception ranking, as well as justification for the 
ranking, of family planning methods and pregnancy related scenarios among urban Nigerians. 
The comparison of the perceived risk of family planning methods to that  of pregnancy scenarios 
is novel and an important topic to explore. I enjoyed reviewing this manuscript thoroughly; 
however, I do have some concerns that I feel need to be addressed before the manuscript can be 
recommended for publication.  The majority of  my concerns relate to the methods described in 
the manuscript. I think more detail is needed and clarification about the processes and methods 
used.  Please see below for my specific comments and concerns.  
 
 
 
 
Introduction  
 
The introduction is well written a nd provides a compelling case for the need for this study.  
 
 
 
Methods  
 
You note that focus group discussions were selected as the method because "information on the 
social attitudes and beliefs regarding family planning as opposed to individual family planni ng 
experiences;" however, the ranking exercise asks participants to "rank the items based on the 
level of risk they think each action poses to health," which seems like a question about individual 
perceptions rather than community perceptions. To address t his discrepancy, it would be helpful 
to include a more detailed description of how participants were asked to participate in the 
ranking exercise during the focus group discussions. For example, was each participant asked to 
provide his or her own percepti ons of risk? How were disagreements among participants 
handled? How did each focus group come to a consensus?   
 
 
The procedures used for the ranking exercise is not clear to me. For example, it is stated that, 
"Participants were asked to rank the items bas ed on the level of risk they think each action poses 
to health."  However, in the next paragraph, it is stated that, "study participants could indicate 
whether they thought the item was most risky, somewhat risky, or least risky." Did participants 
rank ite ms or categorize them or both? Based on the description of the analysis, it seems to me 
that the items were categorized and not ranked (and that the ranking and scoring was done by the 
researchers). This needs to be clarified in the manuscript. Also, if pa rticipants were asked to 
categorize the items rather than rank them then the results need to reflect this.  
 
 
You state that participants were asked, "why one item was identified as posing greater or less 
risk than another." Were participants asked to compa re each item with all of the other items or 
just some of the items?   Please clarify.  
 
 
Please describe how the sample size was determined. On a related note, I have some concerns 
about disaggregating focus group discussions by so many variables (5 for men  and 6 for women). 
I think it is typical for data to be analyzed by their disaggregated groups (strata). However, based 
on table 1, it appears that there was only one focus group discussion per strata. In order to reach 
saturation and draw conclusions by s trata, you would need, at a minimum, two focus groups per 
strata. It would be helpful to include your rationale for having only one focus group per strata.  
 
 
Please provide more details about the conduct of the focus group discussions. For example: Who 
facilitated the discussions? What training did the facilitators receive? Was there a note -taker? 
What language were focus group discussions conducted in? How long did the discussions last? 
Where were the focus group discussions conducted?  How was privacy ens ured? etc.  
 
 
Please provide more details about the process used for data analysis. For example, how was the 
quality of transcription and translation checked? Who developed the coding scheme (one person 
or several people)? Were the transcripts double coded (this is later noted in the limitations 
section; however, it should be stated in the methods section as well)? How many codes were 
used? What process was used for identifying patterns/themes and interpreting findings?  
 
 
 
 
Results  
 
Typically, the first sectio n of the results section describes the study participants. I think it would 
be helpful to add this section to your manuscript.   
 
 
If I understand the analysis correctly, the researchers calculated and assigned scores for each 
item. If this is the case then  the following sentence should be reworded to reflect this, "focus 
group participants assigned teenage motherhood a far lower risk score than inadequate birth 
spacing."  
 
I think figure 1 can be eliminated since all of the information and more can be found  in figure 2.  
Instead, I recommend including a table that shows the ranking results for all 26 focus group 
discussions and a table that shows the scores for each item.  
 
 
You state several times that "perceptions of risk do not follow actual levels of risk s;" however, 
you never provide the rank order of items by actual level of risk. I think this would be interesting 
to include!  
 
 
 
The last paragraph describes differences in order of risks by demographic characteristics. I have 
a few comments and suggestions  about this:  
 
1) Please provide more details about the patterns that emerged. You indicate items for which 
there were differences; however, you don't describe the differences by characteristic. For 
example, you state that, "whether abortion was more risky than steriliza tion or vice versa 
was not consistent across any of the characteristics;" however, you don't tell us who 
ranked abortion as being riskier than sterilization and vice versa, which I think would be 
the most interesting part!  
 
 
2) It would be helpful to descri be differences by demographic characteristics throughout the 
results section. For example, did the description of risk vary by demographic 
characteristics for any of the items?  
 
 
3) Did you consider comparing results across meaningful groups rather than ind ividual 
demographic characteristics? For example, you might compare unmarried men, 
unmarried women, married men, and married women (rather than looking at differences 
by gender only or by marital status only). I am wondering if this might produce more 
appropriate comparisons than looking at, for example, all men together.   
 
 
 
 
Discussion  
 
Overall, the discussion was well written and provided a nice summary of the results and their 
implications.  The one section that I thought could be expanded was the discussi on of limitations. 
For example, one limitation to your analysis is that only one person coded the data. It would be 
helpful to expand on this and explain why this decision was made and what processes were used 
instead to ensure quality of analysis and vali dity of results.   
 
 
 
Are the methods appropriate and wel l 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 to the authors.  
 
Unable to assess  
 
Are the conclusions drawn adequa tely 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 recommende d, please specify what aspects require 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:  
 
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, 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 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 f or 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 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 competing interests  
 
I agree to the open peer review policy of the journal. I understand that my name will be included  
on my report to the a uthors and, if the manuscript is accepted for publication, my named report  
including any attachments I upload will be posted on the website along with the authors'  
responses. I agree for my report to be made available under a n Open Access Creative Commons  
CC-BY license ( http://creativecommons.org/licenses/by/4.0/ ). I understand that any comments  
which I do not wish to be included in my named report can be included as confidential comments  
to the editors, which will not be published.  
 
I agree to the open peer  review policy of the journal