Reviewer's report
Title:Assessment of Reproductive Health and Gender-Based Violence among
Displaced Syrian Women in Lebanon
Version: 1Date:3 August 2013
Reviewer: Natalia Linos
Reviewer's report:
This paper is very timely, providing valuable current information on the health
status of female Syrian refugees in Lebanon, which could be used to improve
services for this underserved population. It also contributes to the broader
literature on conflict and health, by documenting an increase in poor reproductive
health outcomes among female survivors of violence. The following revisions
could help improve the paper:
Major Compulsory Revisions
1. The paper title, discussion, and conclusion that the information contributes to
our understanding of gender-based violence among conflict-affected women is
somewhat misleading since the data collected on violence exposure seems to
include both conflict-related violence which may be due to political or ethnic
affiliation, rather than gender, and sexual violence (which may indeed be
gender-based). The term “Violence Against Women (VAW)” or simply “women’s
exposure to conflict-related violence” may be preferable since it is more
encompassing and since the authors did not collect intimate-partner violence
data but only data on violence perpetrated by armed persons. In the introduction
and discussion the authors can link their findings to the existing GBV literature,
but given that men and boys in Syria are also experiencing conflict related
violence, which may be similar in type, it is not convincing that all the violence
can be grouped as GBV simply because the survivors are female. Table 4, which
notes “Exposure to any Conflict Violence” seems more accurate a description of
the data collected.
2. With regards to the multivariate analyses and table 4, it is unclear why the
authors have adjusted for different things based on the outcome as indicated in
table 4 (i.e. not adjusting for age and education when looking at RTI as the
outcome) and that these are somewhat different from what is included in the
Methods section text. Also, it would be important to explicitly state the
hypothesized relationship/mechanism between violence, stress, and poor
gynecologic outcomes (i.e. is stress a mediator variable?) and why each ‘stress’
outcome is shown separately rather than having one ‘stress’ variable. It is also
unclear why beating one’s child is ‘stress’ and not violence and how that would
be on the ‘causal pathway’ between violence experience and poor reproductive
health outcomes.
3. The discussion section should expand on the limitations related to the sample
and timing of the survey. For example, one of the limitations of the study that
hasn’t been acknowledged is that although the authors note in their introductory
paragraph that the number of displaced Syrians seeking refuge in Lebanon has
increased from 48,000 in August 2012, the date their needs assessment was
completed, to over 400,000 in April 2013, the possible different characteristics
(age, SES, ethnic/religious affiliation, etc) of newer refugees are not discussed,
nor the potential different needs. Although the authors acknowledge that the
results cannot be generalized to all Syrian refugee women, data may be
available from other sources, such as UNHCR, in terms of these characteristics
that could be mentioned in the discussion. Similarly, another limitation related to
the findings around help-seeking behaviors and barriers to access to care, which
hasn’t been fully acknowledged, is that the sample was from clinics (selected
because of their size and provision of reproductive health services) which may
mask the unmet needs of women unable to even reach those clinics. It may be
useful for the reader to have a sense of what percent of female refugees in
Lebanon do not have access to such clinics (i.e. did these clinics receive tens of
thousands of patients given the 48,000 refugee figure or hundreds which may be
a distinct subset?).
Minor Essential Revisions
1. The abstract needs to be revised to make not of the multivariate analyses
under ‘methods’.
2. The conclusion that the paper “highlights the need to tailor the humanitarian
response to the cultural background of the refugees and to the existing situation
of the host country” doesn’t seem to be derived from the data (or it is unclear
what cultural background is referenced).
Discretionary Revisions
1. Although the needs assessment conducted was broad and addressed both
reproductive and general health status, the paper is currently written and
structured in a way which makes it seem like there are several sub-papers with
each having a distinct aim, namely to: A) document the characteristics of the
Syrian refugee population and their unmet needs; B) examine the relationships
between exposure to violence, stress, and gynecologic conditions; and C)
describe the particular vulnerabilities of pregnant women. This makes the paper
harder to follow and somewhat less coherent. The authors may wish to
re-consider the emphasis given to each. From my perspective part A could be
better presented in the form of a table, since the text in the first paragraph of the
Results section is somewhat long and only relevant in the analysis in terms of
control variables and the emphasis should be placed on B.
Level of interest: An article whose findings are important to those with closely
related research interests
Quality of written English: Acceptable
Statistical review: No, the manuscript does not need to be seen by a
statistician.
Declaration of competing interests:
I declare that I have no competing interests