Title: The impact of social determinants of health on feminicide in the second-largest state of
the Brazilian Amazon: a spatial epidemiological analysis.
Version: 1 Date: 10 Mar 2025
Reviewer:  Hisrael Passarelli-Araujo
Reviewer's report:
The manuscript makes an important contribution to the study of feminicide in Brazil, particularly
in the understudied region of Pará. Recognizing the importance of this topic, I have provided
a detailed revision to help them strengthen their work. While methodological concerns remain,
particularly regarding crude feminicide rates, I believe that with thoughtful revisions, the paper
will be in good shape for publication. To assist the authors as much as I can, I am sending a Word
file with minor revisions and additional suggestions. I wish them success with the revisions and
look forward to seeing the new version of their manuscript.
POINT-BY-POINT REVISIONS
TITLE
The title is clear and informative, giving a strong indication of the study's focus on feminicide,
social determinants of health, and spatial analysis in Pará, Brazil. However, I have three main
suggestions:
• The phrase "in feminicide" is grammatically incorrect; it should be "on feminicide" or "in cases
of feminicide" to clarify the impact on occurrences.
• The term "second largest Brazilian Amazonian province" is a bit confusing. The word
"province" is not a standard administrative division in Brazil. I suggest the authors use "State",
which is more appropriate (e.g., "the second largest state in the Brazilian Amazon").
• Specify "spatial analysis study" more precisely. For example: "A spatial epidemiological
analysis of feminicide in Pará, Brazil."
Here is my final suggestion: “The impact of social determinants of health on feminicide in the
second-largest state of the Brazilian Amazon: a spatial epidemiological analysis”
ABSTRACT
• The sentence "Despite humanity’s progress, feminicide is still a global problem" is somewhat
vague. My suggestion: "Despite global advancements in gender equality and legal frameworks,
feminicide remains a persistent issue worldwide."
• The sentence "subsidies to implement more efficient policies" is unclear. The term "subsidies"
usually refers to financial support. Consider "evidence-based recommendations for more
effective policies".
• Does "epidemiological pressure" refer to feminicide incidence, clustering, or policy gaps?
Consider using "areas with a high burden of feminicide".
INTRODUCTION
• The introduction provides a comprehensive and relevant overview of feminicide, effectively
situating the issue within both a global and Brazilian context. However, the text has some issues
with logical flow, clarity, and conciseness. The sequencing of ideas could be more structured
to ensure a smoother transition between global trends, national data, legal frameworks, and the
rationale for spatial analysis.
• Additionally, there appears to be an issue with Reference 3, which does not seem to support
the claim the average of four women killed per hour. Instead, the data presented in that source
seem to reflect a daily metric. The authors should carefully verify and revise this information.
• To assist the authors, I have provided detailed suggestions in the manuscript to improve clarity,
coherence, and conciseness. I strongly encourage them to review the revised version.
METHODS
• While comparing crude feminicide rates across different regions can provide a useful initial
overview of spatial disparities, this approach has several methodological limitations that could
impact the validity of the findings. The primary concern is that crude rates do not account for
variations in population structure, particularly age distribution.
• Why is this important? Differences in the age composition of the female population can
naturally influence feminicide rates. For example, some regions in Belém may have a higher
proportion of younger or older women, which could affect feminicide risk. This is a well-
documented issue in demographic and epidemiological research.
• To enhance the accuracy and comparability of the findings, I suggest that the authors consider
using age-adjusted or standardized rates. This would help control for demographic differences
and provide a more reliable measure of feminicide prevalence across regions. For reference,
the following paper (https://doi.org/10.1016/j.lana.2024.100935) demonstrates an approach to
calculating age-standardized feminicide rates in Brazil, which may be helpful for this study.
• The rationale behind using a three-year period (2016–2018 and 2019–2021) is not well
explained. While it is stated that this avoids annual fluctuations, it would be helpful to justify
why this specific interval was chosen.
• Explicitly justify why certain variables were selected over others. Was this decision purely
data-driven (based on correlation and stepwise regression), or were theoretical considerations
applied?
• I have included minor comments and a revised version of the manuscript to address these
points. I strongly encourage the authors to review these suggested changes, as they will help
improve the overall clarity, coherence, and methodological robustness of the paper.
RESULTS
• This section has some issues with data presentation and terminology. “Feminicide crude rates
had territorial expansion” # This phrase is unclear. Instead, describe the trend in more precise
terms (e.g., feminicide rates increased and expanded spatially over time).
• The description of Figure 4 (spatial autocorrelation analysis) could be more intuitive. The terms
hotspots and cold spots should be defined in simpler terms before using technical language.
• The manuscript states: "The Gi global autocorrelation was statistically significant for the first
three-year period (2016–2018: G=0.054; p=0.001) and non-significant for the second three-year
period (2019–2021: G=0.42; p=0.36)". The non-significance in the second period suggests a
change in the spatial clustering pattern, but this is not clearly interpreted in the text.
• The sentence: "The risk of feminicide was greater in northern Pará, where most municipalities
had low youth homicide rates and higher high school pass rates, and in southern Pará, where
there was higher primary healthcare coverage". This does not clearly explain how these variables
contribute to feminicide risk. Are low youth homicide rates protective or risk factors? The
direction of influence (positive or negative association) should be explicitly stated for each
variable.
• For the next round, please provide the figures and tables in the main document as well.
DISCUSSION
• The discussion presents multiple themes (demographic factors, political influences, economic
development, COVID-19, SDH), but they are not well-structured. Some arguments lack
clear transitions, making it difficult to follow how each factor influences feminicide risk.
I suggest the authors to reorganize the discussion into clearly structured subsections, such
as: Spatial distribution of feminicide and hotspot changes; Demographic and socioeconomic
factors influencing feminicide risk; impact of political and policy changes on feminicide; and
association between social determinants of health and feminicide.
• The term “territorial expansion” is vague. Does it refer to increased feminicide cases, increased
affected areas, or both? My suggestion: “Our results indicate that feminicide rates increased
over time, with a spatial expansion into municipalities in the northeast, southeast, and southwest
of Pará".
CONCLUSION
• Avoid vague statements like "Feminicide expanded territorially". Instead, explicitly state how
feminicide trends evolved and what social factors were most strongly associated.
• The recommendations in the conclusion are vague and need to be more actionable. Provide
concrete recommendations for improving primary healthcare training on gender-based violence.
For example: "Our findings highlight the need for policy interventions, including increased
investment in women’s shelters, expanded access to legal and psychological support for victims
of gender-based violence, and the integration of gender equality education into school curricula".
After addressing these issues, I think the paper will be in good shape for publication.