Title: Do health sector measures of violence against women at different levels of severity
correlate? Evidence from Brazil
Version: 1 Date: 14 Jan 2022
Reviewer's report:
Congratulations on the work done. I believe there was a lot of effort involved in analyzing the
data and building the article.
However, there are issues to be reviewed:
In “Introduction”:
1.  Do you have a reference to support what you said in “Since women are biologically weaker
on average, they are more likely to be hurt in these conflicts.”? I would say that this assumption
has been superseded by gender studies.
2.  I did not understand the reasoning of the sentence: “Such an analysis of similarities in
measures of violence across levels of severity is also useful to determine if indicators of violence
at one level could be a plausible proxy for indicators at a distinct level of severity.” Thus, I
would suggest rephrasing it.
3.  The last paragraph contains information about methods and results. So, I would suggest
removing it from the Introduction.
4.  General comment: The three databases used have different purposes. Notification in SINAN
can be done at any level of care, from the basic health unit to hospitals. The choice of which
unit to look for in case of violence will depend on the size of the municipality and access to
health services. Women may have the same case notified by the basic health unit and later by
the hospital. In this case, only the first record in the basic health unit remains in Sinan. Women
hospitalized for aggression must be notified on Sinan. SIM records death, that is, the most
extreme impact of violence. If a woman seeks care at the basic health unit, then be hospitalized
and die, she can be registered in the three systems. So, assessing the levels of severity of violence
from the different levels of care (or in those different datasets) makes no sense. I would suggest
using the variable "type of violence" in SINAN to measure the different levels of violence by
combining different types of violence, for example only psychological, only physical, physical
+ psychological + sexual, and so on…
In Methods:
5.  In the third paragraph I would suggest informing which ICD-10 codes are used in the analysis.
6.  I would translate SINAN as “Notifiable Diseases Information System”.
7.  As I said before, I would say that is not possible to assume that “The more severe reports
were those from hospitals and emergency rooms while the less severe were those reported by
clinics and other establishments (eg. psychiatry or dentistry).” Cases registered first in basic
health units can progress to hospitalization and even death, and the notification remains that of
the basic health unit.
8.   It was not clear whether all municipal measures are from 2011. The 2018 MUNIC survey
has important data on women's rights policy in all Brazilian municipalities.
9.   Could you explain why you compare the year 2016 for all incidents in Brazil with the period
2011-2016 for the 63 municipalities?
In Results:
10.  It would be necessary more discussion to assume that: “Yet the multiple incidents were
higher in the correlation sample, which may reflect that urban women can seek medical attention
more frequently. The percentage of IPV incidents in the larger municipalities was smaller
than the percentage in all of Brazil, suggesting urban crime may represent a number of these
incidents.” You didn´t present the characteristics (urban or rural areas proportion, for example)
of those 63 municipalities. In addition, according to the criteria that you used to select this
subset, I would say that these municipalities would be the most sensitive to notification and not
necessarily those with the highest incidence of cases of violence.
11. Figure 1: I would suggest rewriting the title, adding place and year. Also, you need to add
“source”.
12. When you explain Figure 1, you use the term "domestic violence" synonymously with IPV.
In Brazil, the concept of “domestic violence” is broader, including authors as family members
and people who live together. It might be interesting to review the concepts.
13. Table 3: I would suggest rewriting the title, adding place and year. Also, you need to explain
what the numbers in parentheses mean.
14. Figure 2: I would suggest rewriting the title, adding place and year.
15. It would be necessary more discussion to assume that: “A justification for the negative
correlation between IPV from registries and overnight hospitalizations is that in larger
municipalities there are more clinics to treat less severe wounds, so these do not become more
severe avoid being treated in the hospital.” Why did you consider larger municipalities? The
reader has no information on the size of the selected municipalities. In addition, other analyzes
would be necessary to know the assistance network of these municipalities to make this kind
of assumption.
In Discussion:
16. I would wait for a more critical comparison with the relevant literature.
Considering all the points raised, I believe that it will be necessary to review the objective and
methods, in search of variables and data sources that best answer the research question.