Title: Help-seeking behaviour and associated factors among women who experienced physical
and sexual violence in Ethiopia: evidence from the 2016 Ethiopia Demographic and Health
Survey.
Version: 1 Date: 06 Aug 2021
Reviewer's report:
Thank you very much for the opportunity to review your article. I really enjoyed reading it as this
subject matter is extremely important. Understanding help seeking behaviour of women who
experience violence is extremely important to properly target interventions, resources, policies,
and programs. Overall, the study was well done and the analysis was sound.
Please see my comments (first general) and then specific to each section which I hope you find
helpful to your revision:
GENERAL:
Can you please clarify the definition of violence in your study? Is in just physical and sexual
violence (i.e., not including emotional/coercive/controlling behaviours)? Later in the comments
you will see the section I am more specifically referring to as this has implications for the sample
size and how you decided on selecting the women who only experienced physical and sexual
violence for your ultimate sample of 1540. It would be great if you could please provide your
rationale (please feel free to address this in that section instead of here #).
I liked the rationale of the independent variables used (based on previous work); it would be
great if you could provide a supplemental file that has your STATA coding so other researchers
interested in this work could refer to it and see how you actually coded our variables. I
understand that there are space/word limitations that don't allow fulsome explanations; a STATA
supplemental file outlining your coding and commands would be a great way to do this.
There are some statements and explanations which are stated but not supported by references,
please refer to the specific comments below in the sections for more details.
Section specific comments:
TITLE
line 1 - 3 - Suggest rewording slightly - Help-seeking behaviour and associated factors among
women who experienced physical and sexual violence in Ethiopia: evidence from the 2016
Ethiopia Demographic and Health Survey.
ABSTRACT
line 4 - Suggest specifying the violence as you have in the title. It is physical and sexual  (as I
believe DHS also collects data on emotional – correct?).
line 7 - there is an extra bracket in front of (EDHS)
Line 8 - suggest adding "in Ethiopia" at the end of the sentence so it reads "Using the 2016
Ethiopia Demographic and Health Surveys (EDHS), this paper analyzes the determinants of
help-seeking behavior of women subjected to violence in Ethiopia".
Results - Lines 13-17 - Suggest rewording (to improve grammatical errors) - "
Only 22.5 % of the  women who experienced violence sought help. Being aged 30 and above,
working in sales, or an agricultural job, being in the richest wealth quintile, and experiencing
severe violence were associated with increased help-seeking behaviour. Living in a rural area,
having a husband who attended primary, secondary, and higher education, having a husband
working in a professional job and agriculture were factors associated with lower odds of help
seeking behaviour. "
Conclusion - suggest rewording: "In Ethiopia below one-fourth of women who were subject to
violence sought help. Socio-demographic factors and severity of the violence were associated
with seeking help. Preventing child marriages and reducing poverty as well as increased
employment and education for women enhance help seeking behaviour by the women.
Interventions could include creating awareness, law enforcement, and support for victims."
BACKGROUND
lines 2 -4 - please provide references for your statements
line 6 - should that read "long standing" not "long sating"?
line 12 - please provide reference for this statement.
Lines 19 +: suggest adding references to "When violence is experienced, seeking help has a
significant impact in reducing the repercussions of violence (REF?). However, the presence of
various barriers makes seeking assistance difficult (REF?). Different studies identified factors
that are associated with seeking help during the time of violence (REF?).
Line 22 - Suggest minor change (have instead of has) - "Factors such as unemployment, low
educational status, economic dependence, and repeated previous violence have been associated
with staying in an abusive relationship. The age, education level, and severity of the injury all
influence help seeking behavior [14–16]. In addition, the length of marriage and the number of
children have been linked with help seeking practice [15].
Line 6  that reads "This study examines help-seeking behavior of women who experienced
physical and sexual violence.", should add "who"
Line 6-8 that reads: "Despite there are studies conducted in different countries, help seeking
behavior among violence victim women is not studied in Ethiopia” [Awkward sentence; suggest
revision. Are the countries in a specific region or globally? Also please provide references – you
some them already, just make sure to include them to support your statement.  Your reference
15 and 20
Linos N, Slopen N, Berkman L, Subramanian SV, Kawachi I. Predictors of help-seeking
behaviour among women exposed to violence in Nigeria: a multilevel analysis to evaluate the
impact of contextual and individual factors. Journal of Epidemiology and Community Health
(1979-) [Internet]. 2014 [cited 2021 Aug 6];68(3):211–7. Available from: https://www.jstor.org/
stable/43281950
Leonardsson M, San Sebastian M. Prevalence and predictors of help-seeking for women
exposed to spousal violence in India – a cross-sectional study. BMC Women’s Health
[Internet]. 2017 Nov 3 [cited 2021 Aug 6];17(1):99. Available from: https://doi.org/10.1186/
s12905-017-0453-4]  Suggest reword: Some countries have investigated help seeking behaviour
amongst women exposed to violence (i.e., India, Nigeria), however, this has not been studied
in Ethiopia.
Line 8-10 sentence that reads:  "So, the aim of this study was to assess the magnitude and
determinants of help-seeking behavior of reproductive aged women who experienced physical
and sexual violence in Ethiopia."  Suggest taking out “So” at the beginning of the sentence and
just start with “The aim of this study was….”
METHODS
Line 18-19 - last sentence of the paragraph on Study design, period and data sources could be
taken out as repetitive.
Line 21 under sampling and population - suggest "A two-stage stratified cluster sampling
technique was employed" (take out has been).
Last sentence in the sampling and population - suggest it reads "A total of 15,683 reproductive
women were interviewed and 1540 (weighted) women who experienced physical and sexual
violence were included in the final analysis [17]."  Please clarify why you chose only the
women who experienced physical and sexual violence? Women also answer questions regarding
emotional violence, why were those not included? Can you provide a rational for limiting
violence to sexual and physical to contextualize your study? Perhaps provide a definition of IPV
or violence that you chose to focus on? Is help seeking in DHS related to sexual and physical
only? You may have a larger sample size with women who  experienced other forms of violence
and also answered questions on seeking  help? So, if seeking help for violence is the limiting
factor that lead you to the 1540 final sample, that is not entirely clear in description. As it stands
now, I read it as the 1540 who experienced physical and sexual violence.
OUTCOME VARIABLE
line 7-8 - suggest revise (change to was and add who) to "...women who experienced physical
or sexual violence was the outcome variable. Women who experienced violence were asked..."
Last sentence in outcome variable - suggestion - "...assess factors associated with help-seeking
behavior among women of reproductive age."
Related to the comment above in the sample, please clarify if help seeking behaviour is related
to sexual and physical only for the questionnaire or is it violence in general? Was the violence
by an intimate partner (i.e., husband/partner) or was it any physical or sexual violence and
help seeking behaviour. Please provide a rationale and/or definitions for your choices. Perhaps
a small clarification of the definition of help seeking and how it is particularly related to
seeking help for sexual and physical (and not other forms such as emotional, coercive/controlling
behaviours as identified by WHO definition of violence - https://apps.who.int/iris/bitstream/
handle/10665/77432/WHO_RHR_12.36_eng.pdf) violence would be helpful to contextualize
the study and whether it is related to intimate partner or experience of violence in by others
as well.  Would it be possible to please provide a description of how the sample was selected
through STATA commands (i.e., who were dropped from the sample of 15,683) to get to the
1540? perhaps if this is supplied in the supplemental file, that would be helpful with a brief
description provided in the sample section.
INDEPENDENT VARIABLES
line 14 - suggest revise to read "...availability of the variable in the 2016 EDHS dataset." (add
in the)
line 16 - for severity of injury - was this a stand-alone question? How was severity of injury
coded? [this could be addressed through supplemental file suggested in general commends).
OPERATIONAL DEFINITIONS
For the section on respondent and husband occupations - Were the EDHS categories the same
or different for occupation of respondent and husband? If the same, maybe it would be best
to list them in the same/consistent manner.  Does professional also include “professional” as
an option? Why is skilled and service under professional for the husband but under others for
the respondent/woman? Why would unskilled be on its own for husband but in others for the
respondent/woman? Suggest consistent recoding or explanation for this choice. If this is simply
a description and not necessarily the way it was coded (and they were coded consistently in the
actual analysis), please ensure the description is concise and clear in the manuscript.
STATISTICAL ANALYSIS
line 12, suggest changing to "...p-value less than 0.25 in bivariable logistic regression were
selected for multivariable logistic regression."
RESULTS
Characteristics of the respondents - line 18 - suggest change "From 2016 EDHS data set, a total
of 1540 women of reproductive age who experienced physical or sexual violence were included
for this study." [added comma after data set and changed of reproductive age who].
HELP SEEKING BEHAVIOUR
Line 3 - add a comma after violence "Of women experienced violence, 22.45 %..."
Line 4 - add 'a' before neighbour "...sought from a neighbour, 106 (30.6%)..."
Line 6-7 - suggest reword "On the other hand, for women who did not seek help, 174 (14.54%)
told someone about the violence after some time [ID1] (Figure 1)."Please clarify the context
of this finding – what was the question asked to all the women? Was it that only women who
said they did not seek help asked if they told someone about the violence sometime later? Were
all the women asked this question? Apologies, I cannot refer to or comment on Figure 1 and
corroborate the finding (unfortunately, I do not see figure 1 in the provided documents). Perhaps
the figure would help clarify this so thank you in advance for answering this question!
DETERMINANTS OF VIOLENCE
Line 15 - suggest adding 'for' and changing sought to seek to read "After adjusting for other
variables, women whose age was 30 years and above were 8.69 times more likely to seek help
than women aged 15-19 years old..."
Sentence that reads "...secondary (AOR = 0.39, 95% CI: 0.17, 0.88) and higher (AOR = 0.37,
95% CI: 0.15, 0.95) education compared to women who had husbands with no education." [add
women and s to husbands].
Sentence that reads "....husbands were working a professional job (AOR = 0.48, 95% CI: 0.24,
0.96) and agriculture (AOR = 0.36, 95% CI: 0.20, 0.63) were 52% and 64% less likely to seek
help than..." [add a before professional and seek instead of sought.
Sentences that read "Women in richest wealth quintiles (AOR= 1.76, 95% CI: 1.02, 3.04)
were nearly twice as likely to seek help than women in poorer wealth quintiles. The odds of
help-seeking behaviour of women who experienced serious violence were 5..." [see underlined
section].
DISCUSSION
Section of the first paragraph - some suggested adjustments + comment:
This study found that less than a quarter (22.5%) of women who experienced violence sought
help, which is in-line with a study completed in India [15], demonstrating that most female
victims of violence did not seek help. This result is higher than findings in Mali (17.6%) [18],
Dhaka Slums (19%) [16], and Afghanistan (20%) [19]. But lower than other developing nations
[18], and a study done in Nigeria (39.7%) [20], and Uganda (63.5%) [21] [You have great
references that can be used to address my comment at the beginning where you introduce the
concept of many countries that have done work in help seeking behaviour for violence but not
in Ethiopia.
Sentence that reads “The discrepancy may be due to the difference in religious and cultural views
to violence.” [You may want to provide a reference for this statement – here’s a great resource
from WHO that may be of assistance:
https://www.who.int/violence_injury_prevention/violence/norms.pdf
Paragraph 2 - apologies for cutting and pasting entire sections, but this is the best way to provide
the detailed feedback.
“We found that older women (30 years and above) were more likely to seek help compared to
their younger counterparts. This finding is in line with a study done in developing countries [18]
and Canada [22]. A study in Afghanistan revealed women aged 25–34 years were more likely to
seek help than the youngest group [19]. This may be because older women know about sources
of help and develop confidence to report the violence that occurs [Please provide reference
to support this statement]. However, in other cases, as the age of the women increased, the
relationship became longer, they became more autonomous, and learned how to deal with the
violence which may have contributed to a decrease in help-seeking behavior by the victims
[23]. Studies completed in India, Nigeria, and Uganda did not show any significant association
between age and help seeking behaviour [15, 20, 21].
In urban areas, various institutions are available to support women who seek help [24].
Please provide references for these two statements:
#1"In the rural area, cultural and socioeconomic factors as well as accessibility of sources of
help, may make help-seeking behavior difficult.”
#2“Besides, rural women may consider violence as a private domain which is highly
confidential."
Suggest rewording: "The other factor that was found to be associated with help-seeking behavior
was occupational status. Women employed in sales and agriculture jobs had higher help-seeking
behavior. This may be due to employment which enables women to generate their own income
and greater freedom to seek help [25]. Therefore, targeting women’s employment..."
The section that reads:
On the other hand, having a husband with professional and agriculture jobs was associated with
lower odds of seeking help. The odds of help-seeking behavior was lower among women whose
husband had primary, secondary, and higher education compared to husbands with no education
[This is a very interesting finding. The more educated the husband and the more professional
the job, the less likely the woman will seek help. It is counter intuitive and perhaps the literature
is mixed on this? Is there any literature that looked into this? What have the other studies shown
that are referenced? ].
This may be due to high controlling behavior of husbands and other confounding factors which
negatively influence help-seeking among women. [In line with the above comment, is this
supported by any other studies? This statement maybe a viable (and logical) explanation, but it
requires support from literature. Have there been studies that have linked controlling behaviours
with more educated partners or those with professional careers? What other confounding factors
do you mean? That would be interesting to explore this further and include in the discussion.]
Sentence that reads "Compared with the poorer wealth quintile, being in the richest
quintile..." [add the and change quartile to quintile].
Suggest sentence reword "...that women with lower incomes were more likely to seek help than
women with higher incomes [22]."
Suggest sentence reword "...three wealth quintiles were more likely to seek help than the
poorest..."
The sentence - "This implies that women with higher incomes are more likely to access resources
to seek help." This statement should be supported by a reference.
For the second last paragraph in the discussion suggested rewords and comments:
"Women who experienced severe violence have higher odds of help seeking behavior than those
who experienced less severe (mild) violence. Similarly, evidence suggests a positive association
between severe violence and help-seeking behavior [PLEASE PROVIDE THE EVIDENCE/
REFERENCE FOR STATEMENT]. This might be because experience of severe violence is
more easily identifiable while seeking help. On the other hand, it is somewhat difficult to
disclose mild violence since they are not visible and might elicit different responses from the
source of help [25, 26]. Unlike other studies [PLEASE PROVIDE REFERENCE FOR  THIS
STATEMENT].
Last  paragraph in discussion, first sentence - "This study has some limitations...."
Suggest adding cross sectional nature of the study which limits causality as a limitations.
What are the strengths of the study – these should also be included.
Conclusion was great! Please see some minor suggestions for rewording:
"In conclusion, this study examined help-seeking behaviour of women who experienced physical
and sexual violence in Ethiopia. Despite high prevalence of violence, a substantial proportion
of women who suffered..." "Prevention of child marriages, creating job opportunities, poverty
reduction..."