Reviewer's report
Title:Perceived control over condom use among sex workers in Madagascar: a
cohort study
Version: 1Date:22 May 2009
Reviewer: Laura Murray
Reviewer's report:
First, my congratulations to the authors. This article makes an important
contribution to the literature on condom use and female sex work. Perhaps its
most important finding is sex workers’ increased vulnerability with their main
partners as opposed to clients, which has important policy implications in thinking
about how to structure HIV/STI prevention interventions. The methods are
appropriate and generally well described. It presents its analysis in a clear,
well-written and straightforward way and if the following issues are addressed, I
would recommend publication.
Minor Essential Revisions
1. One issue I found a little confusing was the authors’ criteria for defining who
were clients and sex workers. My suggestion is to more clearly define both terms
and how the project knew that the women were sex workers and the men who
were not “husbands/boyfriends” were clients. The demographic data support this
hypothesis, yet it is unusual to see a study that considers the women as sex
workers yet does not include “trading sex for money or material goods in the past
X amount of time” as a criteria for participation and fitting this definition. It would
be great it the authors could address this issue in the text, perhaps either through
more contextual information about sex work in Madagascar or even citing other
studies that have used a similar criteria if they exist.
2. The stated objective of the study is to “describe baseline indicators of condom
use control by type of sex partners”, yet the authors include some data from the
follow-up surveys, even through their dependent variable was not measured at
follow-up. This creates some confusion. I would suggest taking out the follow-up
study part and focusing the text exclusively on the baseline data findings
regarding perceived control over condom use and condom use (and therefore
revise the title as well). If the authors feel strongly about leaving in the follow-up
data, I would suggest comparing the follow-updata more clearly to the baseline
data (perhaps in a separate section of the results).
3. One limitation is the basis of comparison between the perceived control
variables of whether anyone had ever refused to use a condom or become angry
when condom use was suggested. For the clients, the question only referred to
the last client as opposed to “ever” for a main partner. It would seem that a sex
worker would perhaps be more reticent to negotiate condom use with a client if
other past clients (not necessarily the last one) had ever refused or become
angry with them for insisting on condom use. Could the authors please address
this and explain why they chose to make this distinction for these two questions
specifically?
4. It may be helpful if the authors engage a little more with issues surrounding
gender. For example, could the authors include a little more information about
how and why they chose these proxies for “gender-power”? It seems that it may
not be exclusively related to condom negotiation and of course could be reflected
in other areas of the women’s lives as well. I realize that this is outside the scope
of the article, but it may be worth adding a sentence or two in the discussion or
limitations about how this study measures a very specific aspect of
gender-power, but recognizes that there are other measures of gender power
that would be important to take into account (for example, who supports the
household financially, etc.).
5. In Table 1, of perceived control over condom use, it would be helpful if the
authors indicate if the differences between main partners and clients was
significant or not.
6. In this same table, it would be helpful if the authors included all of the
frequencies for perceived condom use control in Table 1.
Discretionary Revisions
1. As someone less familiar with the country, I would have found it helpful to
have more contextual information about sex work is in Madagascar, previous
research conducted there, and again, how the authors were able to assume that
all of the women interviewed were sex workers. I would specifically suggest the
work of Kimberly Stoebenau.
2. I would suggest including a few sentences about the studies cited in the text
and more clearly elucidate what the studies left out and what these findings hope
to show.
3. The introduction and the discussion could also be strengthened with the
inclusion of more studies about the influence of gender on safer sex behavior in
other contexts.
4. Did the authors look at the relationship between the variables included in the
perceived control measurements? For example, the finding that unprotected sex
was not significantly associated with their main partner ever becoming angry or
even violent when asked to use a condom as opposed to being significantly
associated with the main partner ever refusing to use a condom is surprising and
made me question if there was any relationship between the variables (i.e., if the
women who reported a violent reaction to condom use also reported main
partner refusing to use a condom).
5. Finally, on page 10, it would be great if the authors could include the data
about the difference in condom use between regular and non-regular clients. This
data, along with the increased vulnerability with main partners would seem to
indicate that intimacy is also a factor in negotiating condom use.
Level of interest: An article of importance in its field
Quality of written English: Acceptable
Statistical review: No, the manuscript does not need to be seen by a
statistician.
Declaration of competing interests:
I declare that I have no competing interests.