Title: Sexual Behaviors, Contraception Use and Barriers among Adolescents and Young Adults
in Rural Haiti
Version: 5 Date: 08 Jan 2023
Reviewer:  Ruth S. Buzi
Reviewer's report:
The current cross-sectional study was designed to assess sexual health and pregnancy prevention
behaviors among 200 adolescents and young adults (AYAs) females in two rural communities
in Haiti.  The study also included semi-structured qualitative interviews with 25 females.  The
Theory of Planned Behavior (TPB) guided the study.  This is an important area of study in light
of the high rates of unplanned teen pregnancies in Haiti. However, the barriers identified in the
study are similar to ones experienced by youth in other countries.  The reviewer would like the
authors to highlight aspects unique to Haiti that can explain the high rates of teen pregnancies.
There are several areas that could be strengthened.  They are as follows:
1. Introduction:
• The introduction should highlight unique socioecological aspects that explain factors affecting
sexual health related behaviors I Haiti.  The authors only briefly mention contextual factors.
These should be separated from individual level factors.  It would also be helpful to briefly
mention trends in teen pregnancy rates in Haiti.  The authors should specify in the introduction
whether or not adolescents in Haiti can access sexual health services without parental consent.
The authors should be consistent in referring to teenage pregnancy rates or birth rates.
• The authors should add references to support their statement that TPB was used with AYAs.
Also, briefly mention why the theory is a good fit for youth.
2. Methods:
• The authors should indicate whether or not they used standardized instruments to assess TPB
constructs.  Information on psychometric properties should be added.
• The authors should briefly describe the interview guide they used.  Adding the guide as an
Appendix will be helpful.
•  The authors should mention how the quantitative study supported/guided the qualitative study.
Also, the authors should highlight what were the specific goals for the qualitative component.
3. Results:
• The reviewer finds the integration of quantitative and qualitative data in the same sections
confusing.  The reviewer would like to encourage the authors to consider separating the results.
The authors could start with the quantitative data and later discuss how the data from the
interviews supported their findings, while highlighting the identified themes.  Also, integrating
the themes and the quotes in a narrative format will be helpful.
• The authors collected various sociodemographic data.  Were there any group differences?
4. Discussion:
• The authors make a statement on page 12, line 297 about contraception use differences by
age.  Are the findings related to their own study? This has to be clarified. The authors should
pay attention to the statements in this section to clarify if the statements are related to their own
study or to studies in general.
• The authors mention issues related to stigma while it was not mentioned in the introduction.
It should also be included in a more systematic manner in the introduction if it is relevant to
the current study.
• The authors could improve on the conclusions/implications of the study and keep it separate
from the general discussion and reference to the literature. The authors should also include policy
recommendations in light of their findings.  This is also an opportunity to highlight unique
aspects related to the youth in Haiti.
• Participants mentioned partners as barriers to condom use.  However, the authors do not
mention partners in their recommendations.  This should also be related to female empowerment
and to the general status of females in Haiti.