Reviewer's report
Title:Using Verbal and Social Autopsies to Explore Health-Seeking Behaviour
among HIV-Positive Women in Kenya: A Retrospective Study
Version: 3Date:9 September 2013
Reviewer: Ingvild Sandøy
Reviewer's report:
Review of “Using Verbal and Social Autopsies to Explore Health-Seeking
Behaviour among HIV-Positive Women in Kenya: A Retrospective Study”
1. Is the question posed by the authors well defined?
Yes
2. Are the methods appropriate and well described?
Yes
3. Are the data sound?
Yes
4. Does the manuscript adhere to the relevant standards for reporting and data
deposition?
Yes
5. Are the discussion and conclusions well balanced and adequately supported
by the data?
Yes, with a couple of exceptions (see below)
6. Are limitations of the work clearly stated?
Yes
7. Do the authors clearly acknowledge any work upon which they are building,
both published and unpublished?
Yes
8. Do the title and abstract accurately convey what has been found?
Yes
9. Is the writing acceptable?
Yes
General comment:
The paper has improved a lot, particularly the Methods section is now much
better.
Major Compulsory Revisions:
In the Methods section the authors write under qualitative analyses: “We looked
for patterns and associations of the themes and compared and contrasted within
and between the different regions and age groups.” I can’t see that different
between regions and age groups are mentioned in the Results and Discussion
sections when commenting on the qualitative findings.
I miss some information about the care-givers. How many care giver informants
were there per woman (range)? Please provide a table showing the distribution
of their age, gender, residence.
Methods (p. 7): how can 218 + 64 be the majority when the total was 796? I think
“majority” is an inappropriate word here.
Discussion (p. 20): The statement “Lack of family support was mentioned as a
barrier to accessing treatment particularly among men who even when their
spouses were severely ill required them to undertake domestic chores.” cannot
be linked to the text in the Results section. Please provide a quote or a summary
of what was said about this in the Results section.
In a well written Discussion, there is one topic per paragraph. Right now each
paragraph touches on many topics, and some topics are mentioned several
times. E.g. poor understanding of signs of AIDS related illness is mentioned both
in the second and fourth paragraphs of the Discussion. Both the third and the
fourth paragraph are about lack of family support.
P.22: The last paragraph of the Discussion should be worked more on. The first
three sentences are a mere repetition of the findings. And then the authors just
write that they do not have plausible explanations for these findings. At a
minimum they should at least compare their findings with other studies. In the
cover letter the authors write that “we have not found other plausible studies that
have similar findings». It is not clear to me whether they found any other studies
at all, or whether they only found studies with different findings. If the latter is the
case, this should be mentioned in the Discussion.
The limitations paragraph should be moved from the Conclusion to the
Discussion.
The authors should write something about how well the vital registration system
in Kenya is functioning since this formed the sample frame.
The authors do not mention urban/rural residence. They should explain where
the women lived and why this variable was not included in the statistical analyses
since residence is a well-known confounder, particularly for socioeconomic
status.
p 23: The statement “There is a possibility that there were underlying differences
in the responses provided by caregivers depending on the level of interaction
with the health providers who attended to the women before they died. However,
since the study areas were randomly selected it was likely that these differences
had a minimal effect on our study findings” needs to be further explained. I don’t
see how reporting bias could be minimized by random sampling.
Table 1 should include information about the year of death and whether the
women were urban or rural residents.
Please provide the crude ORs in addition to the adjusted ORs in Table 2.
Minor Essential Revisions:
“p.22 The sentence “Married women sought care from more than one place
compared to never married women” should be rephrased to “Married women
were more likely to seek care from more than one place compared to never
married women.”
Please mention when the data collection was conducted.
In the Results section, a number of quotes are provided. I miss a short
description of who the quote is from. What was the relationship to the woman,
gender and age of the respondent, age of the dead woman, urban or rural
setting, when did the woman die?
p. 21: There has been a rapid increase in the proportion tested for HIV in Africa
after the introduction of provider-initiated opt-out testing. Thus the statement
“only a small proportion of those infected with HIV in Kenya are aware of their
status (16%)” is most likely very outdated. Please provide a more recent figure,
or as a minimum, mention the year the 16% figure was valid.
There is a problem with the layout for reference 11
Level of interest: An article whose findings are important to those with closely
related research interests
Quality of written English: Acceptable
Statistical review: Yes, and I have assessed the statistics in my report.
Declaration of competing interests:
I declare that I have no competing interests