Reviewer's report
Title:Using Verbal and Social Autopsies to Explore Health-Seeking Behaviour
among HIV-Positive Women in Kenya: A Retrospective Study
Version: 2Date:12 June 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?
Only partly as it is not clear from the methods section which period the
care-seeking behaviours refer to. When reading the manuscript I get the
impression that the focus is on care-seeking in the period of illness just before
the women died, but it is not explicitly stated.
2. Are the methods appropriate and well described?
A lot of essential information is lacking. See below
3. Are the data sound?
Yes, as far as I can judge, but since the methodology is not clearly described, I
cannot determine this for sure.
4. Does the manuscript adhere to the relevant standards for reporting and data
deposition?
Yes, but some important pieces of information are not reported (see below)
5. Are the discussion and conclusions well balanced and adequately supported
by the data?
Most of the discussion and conclusions are supported by the data, but the part
about power imbalances between men and women is not supported by a
description of findings supporting this (see below).
6. Are limitations of the work clearly stated?
More information about limitations should be added.
7. Do the authors clearly acknowledge any work upon which they are building,
both published and unpublished?
The authors acknowledge the Kenya reproductive health voucher program, but
do not explain what this program is about and how the study is related to this
program.
8. Do the title and abstract accurately convey what has been found?
Yes
9. Is the writing acceptable?
Yes
General comment: The paper is interesting, and the qualitative findings are
particularly interesting, but the Methods section lacks of lot of essential
information which is necessary to properly understand the findings and the
recommendations that can be made from this study.
Major Compulsory Revisions:
Background:
Third paragraph: I don’t understand the relevance of mentioning condom use in
the Background. It disturbs the logic of the text. I am also not convinced that the
other information provided in this paragraph is relevant enough to be put here.
The paragraph preceding the justification/objective of the paper should focus on
the topic of the paper, i.e. factors affecting health-seeking. Delete paragraph 3 or
move the text to a more appropriate place such as the Discussion or the first
paragraph of the Background.
Methods
First paragraph: The following text should be moved to the Results section as it is
parts of the results: “The median age of the women at the time of death was 34
years (results not shown). The majority of them had primary or lower levels of
education, were divorced, separated or widowed, and were from non-poor
households. In addition, for the majority of the women, information was provided
by their parents.”
Please define what a verbal autopsy is versus a social autopsy.
Important information about sampling is completely lacking. How were the
women who had died of AIDS-related illnesses identified? Who identified them?
Were all villages in the six districts covered? In which period did they die? Were
all the women who had died of AIDS-related illnesses in the districts sampled?
Did you do a census of all the caregivers of each woman (since you make
conclusions about the majority of care-givers being family members)?
Second paragraph: Specify which care-seeking process you collected
information about. Was it care-seeking during the last illness before death or the
first time they suspected that they had HIV?
No information is currently provided on the main independent variable
poor/non-poor. What information was collected on socioeconomic status? How
was poverty defined?
I miss more information about the qualitative data collection. Were the caregivers
of all the 218 women interviewed?
Third paragraph: The qualitative analysis approach is not described. In my
opinion it is completely irrelevant whether you used NVivo. The question is how
you went about when you interpreted the data. Did you use codes and
categories? Were these predetermined or emerging? Did you search for both
commonalities and differences between interviews?
Results
Information about participation rates must be provided. How many participants
refused to be interviewed? How many participants were interviewed per dead
woman? For how many women was it not possible to find caregivers to
interview?
It seems to me from the quotes provided that there are some important factors
that are also emerging which should be reflected in the subheadings under the
qualitative results. “HIV stigma and denial” could be added to the subheading
that currently reads “Low HIV risk perception and other barriers to testing“ and
“bread-winning/care for others” could be added to the subheading
“Non-disclosure of HIV status”.
Discussion
General comment: when comparing your findings with findings from other
studies, please specify where these other studies were conducted so that the
reader may understand whether the other studies were conducted in similar
contexts.
First paragraph: when explaining why poverty is a barrier to utilization of health
services, the authors should add that transport costs may have contributed in
addition to user fees. Thus I suggest that the first two sentences in the second
paragraph are moved to this first paragraph. That would also make the second
paragraph on more focused (instead of mixing in many topics).
I miss a discussion of the impact of marital status on health care seeking.
Third paragraph: the statement “Lack of family support particularly among men
who forced their spouses to decline hospital admission in order to look after the
children was also a barrier to accessing treatment.” is not supported by the text in
the Results section. In the Results it appears as if it was the women themselves
who did not want to seek care because they did not want to leave their children.
Fourth paragraph: Since the Results section does not address unequal power
relations between men and women, this paragraph also seems completely
disconnected from the findings in the study.
Seventh paragraph: please provide explanations for the observed associations
between medical pluralism and age.
Last paragraph: I miss a thorough discussion about bias related to sampling and
participation here.
Conclusion
I miss more specific recommendations.
Minor Essential Revisions:
Abstract
Methods: specify which care seeking process and how the women were
identified
Results: should clarify what comes out of quantitative analysis and what comes
out of qualitative analysis.
Conclusion: can this be made more specific than it is now?
Key words: why isn’t “health care seeking” mentioned?
Results
How many of the women died while being pregnant and how many of them did
not attend ANC? This would be useful background information to understand the
qualitative findings related to ANC testing.
“Poor understanding of HIV-related opportunistic infections”: insert “perceived to
be” before “associated with witchcraft and evil spirits” in the sentence “Due to
poor knowledge and lack of understanding of symptoms associated with
HIV-related illnesses, it emerged that in some cases HIV/AIDS was associated
with witchcraft and evil spirits.”
“Access to health services”-section: insert “perceived” before “lack” in the
sentence “Due to lack of confidentiality in handling client information by facilities
that were nearby, women preferred to seek care in health facilities that were
further away from their homes.”
Discussion
Second paragraph: I miss a comparison with other studies on lack of knowledge
as a barrier to seeking care.
Fourth paragraph: The statement “The delay to seek medical care in women
within the study context was largely influenced by lack of recourses and the
socially constructed role of women and the only caregivers; women, therefore,
prefer attending to socially constructed roles to seeking medical care.” is not
clear. There seems to be something missing in relation to the phrase “the only
caregivers”. And what is the “socially constructed roles to seeking medical care”?
Please be specific.
Sixth paragraph: I suspect that a reference from 2009 is completely outdated
when you refer to the percentage of HIV infected people who know their status
since many people have been tested after the introduction of routine HIV testing
and counselling. If you cannot find more recent estimates, you should provide the
year the estimates refer to and write the sentence in the past tense.
Conclusion
Who should be provided with subsidies “as part of the national social safety-net
strategy”?
Minor issues not for publication
Background
First paragraph, last sentence: replace “those” with “HIV positive individuals”
Second paragraph: remove “-“ in “costs-related”, i.e split into two words
Third paragraph: something more needs to be added to the text in the
parenthesis in the first sentence so that it is clear that the percentages refer to
condom use rather than the percentage of married couples that are women and
men.
Third paragraph, last sentence: remove 2 in “affects”
Methods
Move the sentence “Written informed consent for participation in the study was
obtained from participants and in cases where participants were aged 15-17
years, a parent or guardian” to the section “Ethical considerations”.
Results
First paragraph, line 5: insert “to” between “prior” and “death”
“Poor understanding of HIV-related opportunistic infections”-section: insert
comma after “malaria”, before “prompting” in the sentence” Many people
interpreted AIDS-related conditions as malaria prompting them to seek
over-the-counter malaria medications.”
Discussion
First paragraph: insert “to” between “prior” and “death” in the sentence “In
particular, a higher proportion of poor women did not have any contact with
formal health services one month prior death compared to women from non-poor
households.”
Second paragraph: Insert “Other” before “studies” in the sentence ”Studies on
barriers to utilization of HIV-related services also found that distance to facility
and transportation costs were critical barriers to accessing treatment [13, 17, 18,
20].”
Figure 1: explain the abbreviation FBO
Level of interest: An article whose findings are important to those with closely
related research interests
Quality of written English: Needs some language corrections before being
published
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