Title: Women empowerment and Health insurance utilisation in Rwanda: a nationwide cross-
sectional survey
Version: 1 Date: 12 Jun 2022
Reviewer:  Emmanuel Biracyaza
Reviewer's report:
Title: Women empowerment and Health insurance utilisation in Rwanda: a nationwide cross-
sectional survey
Thank you for the opportunity to review this important study that was conducted in the area
than needs scientific evidence not only in Rwanda but also in Sub-Sahara Africa where there
exist less researched countries context. This work uses a large nationally representative dataset
to determine the prevalence of health insurance utilisation and its association with women
empowerment in Rwanda. The size and representative nature of the data makes it potentially an
essential contribution to assessing prevalence of health insurance utilization and its association
with women empowerment in Rwanda. However, before its publication, this study needs
considerable revision in all aspects to be of publishable quality work; background, methods
and measures, results and discussion. The authors have to provide more comprehensive and
deeper literature review on the women empowerment, its impact and indicators of women
empowerment including on the validity of the indicators used. There are problems in the
description of some of the variables considered.
Abstract
One sentence each on the problem and justification that drive the conduct of this study should be
provided in the background section of abstract. The method section should give an operational
definition of the outcome variable. The conclusion section is okay. It lacks rationale or why you
are interested in conducting this study. Restructure the following sentence and add the statistical
results (AOR) from the result section: “Other factors that were significant include; educational
level, wealth index, residence, region, household size, and household head”
Background
The background section of this study needs some adjustments. For example; the reference [1]
was provided many times in the first paragraph, as there is a scarcity of the literature on this area.
This should not be the case. The opening paragraph should clearly show the global problem of
the research problem, then in the continent, then the region where Rwanda comes from. Indeed,
the second paragraph should be indicating the literature on the association between women
empowerment and health care access in high income countries and then in LMICs or SSA. At
the end of the background, the authors have to provide convincing argument on why this study
needs to be conducted in Rwanda at the present time.
I am missing some important parts in the methods (e.g. description of the study settings, study
design, data collection, sample size, and sampling methods).
The section of study variables is too long. You have to shorten it. Regarding the outcome
variable, how did you score women empowerment index scores? Did you find low, moderate
and high empowered women? Among the measures of women’s empowerment, you need to
revise and summarise them. Besides, the subheading “Other explanatory variables or potential
confounders” must be removed and you can replace it by socio-demographic variables.
In analysis, please, improve this part. For example; write in full “SPSS” before writing it in
abbreviation.
Statistical analysis needs to be shorted. Please, some texts are not necessary in this part and others
were unimportantly repeated (e.g. 95%CI,…). Paraphrase, the second sentence of analysis. You
can simply say “Statistical Package for Social Sciences was used to conduct descriptive and
analytical analyses”.
Results and discussion
The results and discussion stories would change if re-analysis of the data as expressed in my
comments is implemented.
The reporting of the analyses is also problematic at times. The multivariate analysis of the
association between the women's empowerment composite measure and problems in accessing
healthcare is not sufficiently discussed. The authors stated that "only variables with significant
association in the bivariate analyses were included in the multivariable logistic regression
model" (lines 146-147) but it is not clear which variables were adjusted for, in the text or in
Table 3.
Results
In the table 3 and Table 4., you need to improve the visibility of the tables. Again, write
appropriately the decimals numbers by reducing the number of the digits at the decimal. Please,
use one digit to express decimal number.  I doubt that what you said in the analysis that all
significant variables in bivariate logistic regressions analyses were exported in multivariate
logistic regression models was not respected in table 3. Please, write well table 3 and make sure
that only significant variables were exported into models. Re-analyse table 3 for bivariate logistic
analyses (then do a relevant interpretation). After this, you will need to include another table
for multivariate logistic regression models to assess the associated factors of health insurance.
For example; model and model 2, how are they different? I can recommend you to divide table
3 into two tables.
Do an appropriate interpretation of the results from bivariate logistic regressions analyses? The
interpretation in bivariate and full and/or reduced models are different as well.
Discussion
There needs to be a more robust account in the discussion on what this paper adds to the current
literature on the association between women's empowerment and other factors.
Minor issues
Where you said “In 2020, 35% of nations reported ….”. Are these 35% of nations of the world
or Africa? Please, revise this sentence.
On page 4, provide more indicators where you said “…access to some indicators of maternal
health such as the utilization of at least four antenatal care contacts is still very low at 47%”.
Please, write sub-Saharan African as Sub-Saharan African
One page 5; please write in full “CBHI”. Then, translate the “Rwandaise d’Assurance Maladie”
into English.
Please, include other schemes if they exist and provide other health insurances of Rwanda.
Again, define women empowerment and provide more indicators of the women empowerment.
Replace; bivariable…. and multivariable…. by bivariate… multivariate
Discussion
You have to revise the discussion part after revising analysis for bivariate and multivariate
analysis.
Two first sentences of discussion must be removed from this part.
Start appropriately the discussion. Eg. you can start it with the purpose of the study.
You also have to discuss the main results (such as significant factors in the multivariate logistic
regression models).
In the line 24 of the discussion, did you explore the indicators or factors? Please, more
explanation is needed.
Conclusion and recommendations
Based on your results, it is better to recommend further researchers.
Declaration section of this study needs to be revised and you insert it after the conclusion section.
Declarations
• Ethics approval and consent to participate
• Consent for publication
• Availability of data and materials
• Competing interests
• Funding
• Authors’ Contributions
• Acknowledgements (if optional)
References
Some references needs to be improved (reference 1, 2, 15, 39 and 44 needs the date of accessing
them).