Reviewer’ s report
Title: “You better use the safer one…leave this one”: The role of health providers in women’ s
pursuit of their preferred family planning methods
Version: 1Date: 16 Apr 2020
Reviewer: Alexandra Alvergne
Reviewer's report:
I have enjoyed reading this well-written paper, of which I think the findings are important for
improving family planning services in Ethiopia. It investigates patient-provider interactions usingqualitative data and analysis. The most interesting finding (to me) is that in some cases providersare biased against women's preferred methods. A finding that echoes with what I have experiencedthroughout my research in Ethiopia. At this stage of the process (Revision 1), I only have minorcomments pertaining to the methods and discussion sections. If those could be addressed, Irecommend publication.
Abstract
-From the abstract the sentence "and matrices were created based on themes and sub-themes" is
not immediately clear/too specific for the general reader at this stage.
-From the abstract it is not clear that in fact it is couples that have been interviewed, i.e. 12 pairs
rather 24 individuals.
Methods
- P7. "Amharic and Ethiopian norms" - What do you mean? Amharic is a language spoken by
many ethnical groups, and Ethiopian is a nationality.
- P8, L7. To what extent did HEW or other providers help with the recruitment? Please clarify. If
HEW were involved then the sample might be biased towards individuals with good relationshipswith them.
- P8. Purposive sampling. Does the sample include views from Christian Orthodox and/or
Muslims? What about diversity in income/occupation/wealth? This is because issues ofempowerment might relate to level of income or occupation.
- P8. Please clarify that interview guides were developed for another study.- P8, L20: Please unpack the procedure. Were both the FGD and IDI conducted with women and
their partners? Were the IDIs conducted in pairs with husbands present when women answered
questions? If that were to be the case of course that would have consequences for issues of
empowerment. If most of the sample is composed of couples where the woman gave her consent
to approach the husband, the sample might be biased towards women with relatively strongsupport from their husbands. Thus, the findings might underestimate issues of non-empowerment,which should be discussed/acknowledged.
- P8, L22: Please indicate that interview guides are available in Annexes.- P8, L24: "autonomy, self-efficacy, and agency". I feel those terms need defining if one is to
understand the difference between them, and the extent to which the results inform on those
specific issues. My understanding is that self-efficacy is a psychological concept while agency is
an anthropological one that is often opposed to structure, and the latter one might more relevant tothe concept of empowerment in this study. Please clarify why all those terms are needed and howthe findings illustrate each of those.
- P9. Could you include a reference for the universal upset screener?- P10. How many women did not want their husbands to be approached for an interview?- P10. "An inductive thematic analysis was used." The paper assumes the reader is well-versed
with qualitative data analysis and that thematic analysis is the only method. A little bit more detailson what thematic analysis is (and why this method is used) would be helpful.
Leech N.L & Onwuegbuzie A. J (2007). An Array of Qualitative Data Analysis Tools: A Call for
Data Analysis Triangulation.
- P10. Codes specific to women's interactions. Do those refer to this study objectives or the initial
study's objectives? Please clarify - The paragraph lines 15 to 19 goes quickly and could do with a
reference. Please clarify which themes were known a priori, due to the questionnaire used, or
objectives of the initial study, and which themes actually really emerged.
Bazeley, P. (2009) Analysing Qualitative Data: More Than 'Identifying Themes' Pat. Malaysian J
Qual Res.
- Table 1: what do you mean by codes "pulled" for present analysis, pulled from the cross sites
book or from the qualitative data? How did you decide to pull them? Because it fitted the studyobjectives?
Results- P13. Explain what a 'kebele' is for readers not familiar with Ethiopia- P17. The quote "There are HEW in every kebele…[…]" seems like a description of the HEW's
job and does not illustrate the point made about trust and reliability of information.
Discussion
There is little discussion of the attitudes of health providers - But the findings call for this
question: Where does it come from? Why do some providers push for LARCS? Perhaps it wouldhelp to contextualize the attitude of HEWs and other providers as embedded within a largernetwork of stakeholders, including non-governmental organizations and funders (those might be"pushing for" LARCs as opposed to SARCs if LARCs are more cost-effective). Although theauthors might not have this information, acknowledging that HEW/primary health care providersalso face constraints of their own / are subject to forces beyond their control, might help withsituating patient-provider interactions and discuss "agency" within the health system structuremore generally.
Are the methods appropriate and well described?
If not, please specify what is required in your comments to the authors.
YesDoes the work include the necessary controls?
If not, please specify which controls are required in your comments to the authors.
YesAre the conclusions drawn adequately supported by the data shown?
If not, please explain in your comments to the authors.
YesAre 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 furtherassessment in your comments to the editors.
Not relevant to this manuscriptQuality of written English
Please indicate the quality of language in the manuscript:
AcceptableDeclaration of competing interests
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