Reviewer ’s report  
 
Title:  'I STAYED WITH MY ILLNESS': A GROUNDED THEORY STUDY OF HEALTH 
SEEKING BEHAVIOUR AND TREATMENT PATHWAYS OF PATIENTS WITH 
OBSTETRIC FISTULA IN KENYA.  
 
Version: 0 Date: 29 May 2017 
 
Reviewer:  Colleen  Fisher  
 
Reviewer’s report:  
 
Thank you for the opportunity to review the  manuscript "I stayed with my illness:  A grounded 
theory study of health seeking behaviour and treatment pathways of patients with obstetric fistula 
in Kenya".  The manuscript addresses a very important issue internationally, and of consequence 
in the cou ntry where the study was undertaken.  The authors are to be congratulated on 
undertaking this study and on presenting a very readable manuscript.  
 
 
I make the following comments in reviewing the manuscript:  
 
Methods  
 
A hallmark of grounded theory is theoreti cal sampling.  There is no indication that participants 
were sampled theoretically.  Discussion on how the sampling undertaken aligns to grounded 
theory requirements should be included.  
 
There is no real description of how data were collected.  We know tha t a narrative approach was 
utilised, but how did this play out in the interviews?  How long did the interviews last?  In what 
language were the interviews undertaken? Swahili?  English? Both?  If any were undertaken in 
Swahili, a description of the transla tion processes needed.  Who undertook the interviews?  
 
It is noted that the interview guide had two phases - what were the two phases (events around the 
birth, the context of occurring fistula illness, living with fistula and health seeking behaviour are 
mentioned - ie, 4)? Was audio recording voluntary?   
 
Did the 121 participants constitute theoretical saturation?  If so, this needs to be explicit, ifnot, 
what is the rationale for 121 sample size and how does this fit with grounded theory?   
 
Data analysis - it is noted that the analysis followed that described by Glaser.  What was the  core 
phenomenon?  We are told on page 16 (line 8) that 'seeking the formal health facilities' is a core 
narrative.  Is this the core phenomenon?  If so, it needs  to described in the data analysis section.  
Memoing is a hallmark of grounded theory.  Details of memoing undertaken needed.   
 
 
Results - Composite Pathway of Health Seeking Behaviour  
It is noted that 121 participants 'gave their narratives of the experie nce of health seeking 
behaviour during fistula illness ' (page 7, lines 55 -56), yet there are very few quotes provided as 
evidence in the results section. In the first theme 'Composite pathway of health seeking  
behaviour' only one quote is provided.  This  is insufficient to support such an important 
component of the research.  It is noted that 'I stayed with my illness' was commonly used by 
participants, yet it is not attributed back to any of these participants (a number of participant 
identifiers would b e expected to be included). What are the range of experiences of living with 
fistula (page 9, line 27)? What challenges did this pose? Additionally, quotes are required as 
evidence of these challenges.  All in all, where results are reported, quotes should  be provided as 
evidence.  It would be expected that the quotes would come from a range of respondents.  
 
 
Results - The Role of Formal Hospitals  
 
Three quotes to support 'The role of formal hospitals' is insufficient.  
 
Evidence (ie, quotes) need to be provide d for all statements made - they are results from your 
study.  For example page 10, lines 7 -12:  why did the women consult these alternate 
individuals/organisations?  Why did the women stay at home for long periods of time?  The 
quotes would provide this i nformation and evidence to the reader that that is what they had 
said/meant.  
 
Overall, the results section did not provide sufficient evidence to support the claims made.  If no 
quotes are provided, at the very least the identifiers from a sample of those w hose data supported 
(and refuted) what was being described, should be included.  
 
 
Discussion  
 
The heading on Page 13 (line 6) is misleading and needs to be amended.  In this section I was 
expecting a discussion of the previously reporting findings in terms o f the literature.  Instead, 
more description (or results) is presented (ie, new information):  eg, hygiene concerns, regaining 
of bowel control and reproductive function (page 13, lines 34 -36), transport, use of mobile 
phones, (page 13, lines 56 -58); commu nity groups (page 14, line1); shame, stigma and isolation 
(page 14, line 21); links between hygiene and accessing public transport (page 14, line 34); 
divorce and separation (page 14, line 45).  All these findings require evidence (eg quotes from 
participa nts) in support.   
 
Where is section 2.2.1 (page 9, line 34)?   
 
What do the findings mean for women's health seeking behaviour?  
 
It is noted on page 15 (lines 6 -11) that the conceptual framework was tested on the data.  This 
needs to be discussed in the met hods section (rather than here) and greater detail of how it was 
tested included.  
 
Once again in this section (as per the Discussion section (above) , new information (ie, results) is 
presented.  There are a number of instances of this in the section, but examples include: lack of 
motivation for surgery because of poverty and potential death (page 15, line 39); lack of social 
support (line 40); regaining normalcy (line 43) through radio and mobile phones (line 48); word 
of mouth encourages women to refer or  not refer (Page 16, line 41).  The issue of mobile phones 
specifically needs elaboration due to the extensive discussion of it in the remaining sections of 
the manuscript, including in follow up care (page 20, line 54 -56).  It is also noted (page 20, line  
27-32), that mobile phones were used to 'contact the regional representative……after surgery'.  
Overall, all results that are presented, in all sections, require quotes as evidence.  
 
It is noted on page 16 (line 11) that 'Emerging themes examined in this pa thway include cost of 
surgery, unavailability of surgery….." If these are themes, there should be evidence from a 
number of participants provided in support.  
 
 
Conclusion and recommendations  
 
There is inconsistency in this section:  Page 21 (line 14) it is no ted that women follow a 'linear' 
pathway in seeking treatment, yet it is noted at line 50 that this pathway is 'convoluted'.  Clarity 
needed.   
 
 
General  
 
Page 5, line 21 - delete 'annually' at end of sentence.  
 
Page 5, line 38 - there is a word missing betw een 'sought' and 'to'.  
 
Page 6, line 41 - change 'include' to 'included'  
 
Page 7, line 5 - word missing between 'system' and 'rather'  
 
Page 9, line 8 - it is noted that 'Siaya' has no children. Should this be no surviving children?  It 
would be useful to have  a 'key' so the reader is aware how you are referring to each participant.  
Eg, was does the '018' refer to?  1,25 years (what does this refer to)?  
 
Page 9, line 39 - write VVF in full before abbreviating it  
 
Page 9, line 43, changes 'faces' to 'faced'  
 
Page 13, line 39, consider using 'barriers' rather than 'disablers'  
 
Page 14, line 57 - change 'doesn't' to 'does not'  
 
Page 16, line 49 - what is meant by 'superfast cases'?  
 
Page 16, line 54 - write RVF in full before abbreviating it  
 
Page 17, line 44 - chan ge 'residential' to 'resident'  
 
Page 17, lines 39 -46 - it is unclear whether the women being referred to as staying in their home 
are from the current study or the one from the literature  
 
Page 17, line 46 - who does 'these authors' refer to?  
 
Page 18, line 5  - change 'basing' to 'based'  
 
Page 18 line 10 - who is being referred to when described as 'in the other study'?  
 
Page 18, lines 32 - 34 meaning unclear in the sentence 'Further, there is need to deliver her 
subsequent pregnancies……birthing experience'.  Cl arity needed.  
 
Page 18, line 42 - check recording of reference 'Yeakey, Chipeta' - there are more than 2 authors.  
 
Page 18, line 48 - who is being referred to as 'These authors'?  
 
Page 18, line 50 - what is meant by 'participants unravel similar….'  
 
Page 18, l ine 50  - change' direr' to 'more dire'  
 
Page 18, last sentence  - this is repetition - it can be deleted.  
 
Page 19, line 28 - change 'this' to 'the'  
 
Page 19, line 42 - what is mean by a 'broad range of multiplicity of actors'?  
 
Page 19, line 61 - delete 'how ever phenomenon'  
 
Page 20, line 53 -56 - reword sentence 'The centrality…..is emphasised' for clarity  
 
Page 21, line 45 - change 'Basing' to 'Based'  
 
Page 21, line 45 - change 'First' to 'Firstly'  
 
Page 21, line 57 - change 'availed' to 'available'  
 
Page 21, li ne 58 - what is meant by 'eliminating all new cases'?  
 
Overall - where a number is less than 9, it needs to be written in words.  
 
Figure 1 - title is misleading.  I would encourage the authors to add 'for surgery' at the end to 
denote that the final outcome is surgery.  
Figure 2 = it is unclear what is mean by 'Outcome Health Steps/Actors'.  This needs clarity.  
Additionally at this stage, the results section to do not fully support the model in section A.  
Greater discussion of each of those components is nee ded to enable the reader to understand how 
they fit together and indeed, if they exist. In this latter case, the evidence I have been asking for 
earlier in this review is needed to address this.  
 
Are the methods appropriate and well described?  
If not, please specify what is required in your comments to the authors.  
 
No 
 
Does the work include the necessary controls?  
If not, please specify which controls are required in your comments to the authors.  
 
Unable to assess  
 
Are the conclusions drawn adequately supported by the data shown?  
If not, please explain in your comments to the authors.  
 
No 
 
Are you able to assess any statistics in the manuscript or would you recommend an 
additional statistical review?  
If an additional statistical review is recommended, please specify what aspects require further 
assessment in your comments to the editors.  
 
Not relevant to this manuscript  
 
Quality of written English  
Please indicate the quality of language in the manuscript:  
 
Acceptable  
 
Declaration of competing interests  
Please complete a declaration of competing interests, considering the following questions:  
 
1. Have you in the past five years received reimbursements, fees, funding, or salary from an 
organisation that may in any way gain or lose financially from the publication of this 
manuscript, either now or in the future?  
 
2. Do you hold any stocks or shares in an organisation that may in any way gain or lose 
financially from the publication of this manuscript, either now or in the future?  
 
3. Do you hold or are you currently applying for any patents relating to the content of the 
manuscript?  
 
4. Have you received reimbursements, fees, funding, or salary from an organization that 
holds or has applied for patents relating to the content of the manuscript?  
 
5. Do you have any other financial competing interests?  
 
6. Do you have any non -financial competing interests in relation to this paper?  
 
If you can answer no to all of the above, write 'I de clare that I have no competing interests' 
below. If your reply is yes to any, please give details below.  
 
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