Reviewer's report
Title:Preliminary development of a scale to measure stigma relating to sexually
transmitted infections among women in a high risk neighbourhood
Version: 1Date:23 April 2008
Reviewer: Adina Nack
Reviewer's report:
Overall, I believe that this article is interesting, important, and useful. I have
several suggestions on how to strengthen the piece and will first share these as I
address the questions posed by the editors of BMC Women’s Health, using their
categories of revisions
1. Is the question posed by the authors well defined?
Yes, the question posed is well defined and compelling.
2. Are the methods appropriate and well described?
The methods may be argued to be appropriate, but they are not as well
described as they should be. The following may all be considered “Minor
Essential Revisions.” In the “Methods” section of the paper, it seems that this
program may be targeted for women who are in lower socioeconomic statuses,
but this is never clarified by the authors.
In addition, this section notes that the sample included transgendered individuals,
but the authors do not clarify whether these were male-to-female,
female-to-male, intersexed individuals, etc. This detail is relevant because the
authors’ arguments hinge upon the idea of gender socialization (experienced
differently by those who’ve been raised as female their whole lives versus those
who’ve taken on a female/feminine role later on in life).
In the “Methods” section, the authors note that participants had the option of
providing a urine sample for STI testing. It should be noted that only a few STIs
can be detected by use of a urine sample, and the authors should specify which
ones. Though, it’s not clear that this data is used in the analysis presented in the
paper, so perhaps it could be included as a possible benefit of participating in the
project?
Finally, in describing the measurement tool, it’s important it be referred to as a
structured interview or an orally administered survey, rather than just “the
interview,” which readers may confuse with semi-structured or unstructured
interviews.
3. Are the data sound?
The authors should strongly consider revising and redefining their analytical
categories. On page 7, they refer to “Goffman’s (1963) basic three categories,”
but they do not list them clearly here or earlier in the paper. I strongly
recommend that the authors reframe their indexes to mirror his categories:
abominations of the body, blemishes of moral character, and tribal stigma. The
categories they construct and use are not mutually exclusive and change during
the course of the paper: “Physical stigma” (page 8) parallels well with
“abominations of the body, but in the table and throughout the paper, it seems
that the authors combine it with “Moral stigma” (page 8) to create their “Factor 3:
Internal stigma.” When I look at Table 2, it’s not at all clear why feeling like
“damaged goods” is considered part of “Tribal Stigma,” rather than “Internal
Stigma.”
In order to accomplish this, I recommend the following as a “Major Compulsory
Revision” that will improve the clarity of the data and the usefulness of the scale:
Stick with Goffman’s categories, which distinguish between types of stigma
(reasons for which one becomes stigmatized), rather than the current labels
which conflate experiences of stigma with types of stigma. Factor 1 can still be
“Tribal Stigma” but, in addition to the items already included, it should also
include the item “Bad person” as this parallels well with the use of the ‘two tribes
of femininity theory’ (Nack 2002). I also think you can make the argument that the
following items are also part of the STI Tribal Stigma: Community gossip and
Staff morals
Factor 2 can be “Blemish of Moral Character” and include the following items:
Guilty, Embarrassed, and Stupid.
Factor 3 can be “Abomination of the Body” and include the following items: Dirty
and Violated.
The remaining two items seem to address not a type of stigma but the women’s
perceptions of staff norms regarding confidentiality: Clinic discretion and Staff
discretion. It’s not clear that these items are measuring a woman’s experience of
any of the 3 types of stigma. Rather, they seem to measure her confidence in this
particular medical facility: useful for a user-survey for those who manage this
clinic but not necessarily useful for the larger questions posed by this paper.
4. Does the manuscript adhere to the relevant standards for reporting and data
deposition?
I believe so.
5. Are the discussion and conclusions well balanced and adequately supported
by the data?
Yes, the Discussion section presenting several important and useful ideas. I was
especially impressed with the final paragraph (beginning on Page 14 and ending
at the top of Page 15).
6. Are limitations of the work clearly stated?
Yes, but it’s important to clarify the population from which the sample was drawn.
On Page 13, the sentence that states, “…we cannot generalize findings to the
broader community of women.” Do the authors mean “all women,” “all women
living in Vancouver,” or “all women who utilize this particular evening social
program”? This is a “Minor Essential Revision” that needs to be clarified.
Also, given the roles described in the “Competing Interest” section, I recommend
a “Discretionary Revision” that clarifies how the researchers made sure that
participation was truly voluntary. For example, the authors could address the
question about whether or not the women assured that refusing to participate in
the study would not jeopardize their ability to receive health care services from
these same doctors.
7. Do the authors clearly acknowledge any work upon which they are building,
both published and unpublished?
In almost all cases, yes. But, please see my answer to question 9 (below) in
which I recommend the addition of a few more citations to key places in the
paper.
8. Do the title and abstract accurately convey what has been found?
Title: good, but the phrase “high risk neighborhood” is never explained in the
paper. As a “Discretionary Revision,” I suggest adding this clarification to the
description of the setting.
Abstract: needs some clarifications.
Background: the following phrases are vague and need to be clarified: “the moral
scale” and “sexual stigma.” I would consider these to be “Minor Essential
Revisions.”
Methods: the population from which the sample is selected is described as
“Women attending a social evening program.” This wording is vague and leaves
the reader wondering about the potential biases of the sample. As a “Minor
Essential Revision,” I recommend clarifying this – perhaps the authors meant to
make this is clear by the phrase “Vancouver’s DTES,” but many readers will not
be familiar with Vancouver.
9. Is the writing acceptable?
Yes, though the following corrections should be considered “Minor Essential
Revisions”:
- Page 2, add “STIs” in parentheses following the phrase “sexually transmitted
infections,” since the abbreviation is used throughout the remainder of the paper.
- Page 4, add citation referring to Nack 2002 in revising the sentence that begins,
“In relation to the categories of stigma…”, as this citation delineates the first time
that the argument was made that STIs can “be argued to cross all three.”
- Page 5, the sentence beginning “The continued impact…” should refer to Nack
2002, not 2000.
- Page 5, the mention of stigma being discredited or discreditable: those terms
should be briefly defined and Goffman should be cited.
- Page 5, a citation is missing from the sentence which begins, “A similar study in
the southern U.S….”
- Page 11, add a brief discussion of the three ethnic groups mentioned with
regard to how they have traditionally/culturally constructed feminine sexual
morality.
- Page 12, to the final paragraph about increased stigma among Aboriginal
women, refer to the literature on the historical targeting of women of color as
being the ‘vectors and vessels’ of sexual diseases.
Level of interest: An article of importance in its field
Quality of written English: Acceptable
Statistical review: Yes, but I do not feel adequately qualified to assess the
statistics.
Declaration of competing interests:
I declare that I have no competing interests.