Reviewer’s report
Title: 
The effect of rural-urban residence and education on Intimate Partner
Violence among women in Sub-Saharan Africa: A Meta-Analysis of Health
Survey Data
Version: 
0 
Date: 
26 Mar 2020
Reviewer's report:
This article documents intimate partner violence in Sub-Saharan Region. 
Although the results do not constitute novelty, there is some merit in the
synthesis of information. However, to my view, several elements are lacking to
classify the study as a clear-cut meta-analysis. In essence, the study question
does not bring novelty to the field and there was no systematic literature search
to include studies (authors simply retrieved DHS data for 29 countries), or data
abstraction from such studies. For this reason, a funnel plot or sensitivity
analysis might not apply, to assess the quality of the meta-analysis. 
The strength of using DHS data lies in the cross-country comparability of
methods used. This leaves room to question how informative is the heterogeneity
test, typically used in a meta-analysis. And also whether the summary statistic is
more informative when compared to a more simple (weighted) average of
prevalence ratios across sites. In fact, a multi-level approach that accommodates
country-level differing characteristics/variables, would provide more interesting
details about the reasons why there is cross-country variability in the association
estimates. To my view, such analysis plan might be better suited to answer the
study question presented.
Importantly, authors stratify the analysis according to African regions, but it
would make sense to have it further stratified according to other known IPV
confounders (for example, by age groups, since the age distribution might also
differ across studies, across the years considered and is a known confounder of
IPV). 
Besides this structural comment, I have some other comments/suggestions, that I
believe could improve the manuscript.
Introduction:
The authors define intimate partner violence (against women) and the
consequences to women's health. However, the first and second sentences (page
4), lack references. The authors cite the 2013 WHO report and the synthesis of
consequences by Devries et al, but only afterwards and not referring to these
definitional aspects.
The authors should introduce a clear definition (or difficulty in defining/ or
different definitions used) for urban and rural residence. Also, the mechanism
through which the educational level of women (and men!) and urban/rural
residence impact on IPV frequency should be unpacked. Are more educated
women more empowered to seek help and leave abusive relationships? Women
living in urban areas have more support (closer) from the healthcare sector or
victim-aid organizations? Are the latter existent (although heterogenous)
throughout SSA countries?
Page 5, line 67 - the sentence seems incomplete
Page 5, line 81 - is "vice" a typo?
Page 5, line 82 - "athat"
Page 5, line 83 - the authors refer that "norms change more slowly" in urban
areas. It is not clear what is meant? Norms social acceptance? Actual regulations
to be implemented? This should be further explained.
Page 6, lines 91-93 - this sentence is unclear. Participation in household
decision-making, the same as women empowerment?
Page 6, line 96 - two dots. And "Poverty increases the risk of IPV among women
living in poverty". What is at play? The authors should explain further.
Page 6, line 110-111 - the authors state that: "These results (of population based
surveys in Africa) present a confusing picture on the advantages of urbanization
and increased education in relation to IPV against women in the SSA region."
Are there examples of mixed results found? Or confusing picture, means gaps in
specific findings? Method not directly comparable?
Lines 113-116 - the sentence is very confusing, and punctuation is missing.
Please consider revising it - e.g. "the study will provide greater objectivity,
generalizability and increased power for prevalence of IPV"?
Methods:
What is the referent period for violence victimization experiences? Lifetime
prevalence? Past year? This should also be included in the abstract.
The CTS asks about acts of victimization and perpetration. What about the
Modified version included in the DHS module? Does "experience" refer to any
type of involvement, as victim/perpetrator?
What are the definitions used for rural/urban areas? Population density? Presence
of specific infrastructures? Based on nationally-documented definitions (e.g.
National Statistics Institutes?).
Does primary, secondary school … correspond to the same years of school
completed across all 29 countries analyzed? In some countries, secondary school
is 13 years, while in other is 12 years?
Why were RRs computed when prevalence were extracted? Although the meta-
analysis statistic computes RR by default, (assuming a ratio of "incidences" in
exposed vs. unexposed groups) the imputed data comes from DHS cross-
sectional surveys? 
Did the authors consider PRISMA guidelines?
What type of quality assessment was used for the meta-analysis? Would a funnel
plot be applicable?
Results:
The authors mention testing the region of country as heterogeneity factor. There
are, however, several other known factors that could plausibly explain between-
study variability that should be explored (from individual-level factors, such as
the age distribution of the population, to country-level factors such
criminalization of IPV acts).
Forest plots and tables (and also results text) has "middle Africa" instead of
"Central Africa" as described in the methods.
Discussion:
The English should be revised throughout the manuscript. Several sentences miss
punctuation and their meaning is not clear.
Ex: Page 14, line 286 - "The East Africa has countries with some of the highest
IPV against in the world." Highest prevalence of IPV against women? 
Line 291 - "Eregion", line 307 "hat"
Line 308 - asterisk
Line 320 "The findings on education effect mediated through partners education
and type of residence". Do authors mean that findings might be mediated by
partners education? 
Line 325 - parenthesis and dot
Lines 326-328 "The study gives an alternative of answering questions regarding
comparisons (control and intervention arms) using data that has been already
collected." Meaning it is an advantage to use this secondary data?
Line 338 - "coutntires"
Line 344 - ending of sentence "x. an"
Line 347 - telegraphic language and double dot: "Burden of emotional, physical
and sexual violence among less educated and rural women dependent on the
Region of the Sub-Saharan Africa region.."
Line 351 - "aginat"
The authors found significant associations for urban/rural residence and IPV in
Eastern countries, but they do not discuss why in these countries compared to
Central or South Africa. The argument about acceptance of attitudes of VAW or
more traditional norms does not differentiate Easter vs Westers/Central/South
countries. Authors should put forward some hypothesis why these countries are
different. 
Several references seem incomplete/unformatted. Example: 6, 13, 14, 33, 45, 52
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.
No
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.
I recommend additional statistical review
Quality of written English
Please indicate the quality of language in the manuscript:
Not suitable for publication unless extensively edited
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