Title: Barriers to Pregnancy Prevention for Adolescents in Rural Haiti: Perceptions of
Healthcare Providers
Version: 1 Date: 09 Jan 2024
Reviewer's report:
This is a mixed methods study of healthcare provider  beliefs about the adolescent and young
adult contraceptive care in Haiti.  The study showed that HCP felt that more education would be
helpful for all: patients, providers, parents.  More access to all contraceptive methods would also
be appreciated by the HCP's, with some poignant quotes related to patient-centeredness given.
The methods and results are informed by a theoretical model (Theory of Planned Behavior),
which is well-done.
Overall the paper is technically sound but this assumes details missing from the manuscript.  I
think  the paper  would benefit by:
1. Better description of the research team.  The team appears to all be in metro Kansas City and
at least one co-author is fluent in Haitian Creole.  Who were the study team members reading
the survey and interview to participants?   Were they co-authors or unacknowledged research
staff?   I don't normally look for this level of detail, but the description was confusing, especially
given potential language differences.
2. Better description of recruitment.  How and by whom?
3. Better description of data collection.  The methods state that the survey was read aloud but
the discussion contradicts this. It seems unlikely that the survey and a 19-item interview guide
could be completed in 30 minutes.
4. Better description of setting: how are the two organizations related, how many clinics (or in-
patient care providers in a hospital) are involved, and what type of clinics are these (e.g., general
practice, peds, adolescent health, repro health, women's health, prenatal)?
5. More on sample and some mention of sample size: what was the denominator for potential
survey respondents?  How representative were the respondents of all  relevant HCP in the clinics/
hospital and in Haiti?   I'm not an expert qualitative researcher, but was thematic saturation
reached or did the authors cease to see new emerging themes/codes?  One would assume so with
so many participants, but this should be mentioned.
6. There seems to be some aspect of community engagement, but it's difficult to understand
who community representatives were in the methods.  Similarly, it's not clear what "by a local
organization or community representative" means for ethics approval.  Is this the HAS and/or
GBFH board(s)?  Is it a compliance or other regulatory officer/office?
Related to the above comments, it would be helpful to go through STROBE (observation study)
and SRQR (qualitative) checklists to make sure all the study components are well-described.
The claims are supported by the data.
Statistical analysis of the descriptive data was appropriate.
Claims are discussed within context of previous literature.  It would be great if the co-authors
could more directly discuss how the patient-level issues noted by HCP align with the patient
issues from their other paper.
I agree with the authors that social desirability was a likely source of bias.  If the survey was
truly anonymous, then that helps mitigate this bias, as noted.  The results of the survey and
interviews were similar.
Consider placing the interview guide and survey into supplemental materials.
Smaller detail:
1. Consider reporting age as mean(SD) or grouping everyone >=50 together so as not to have
an identifiable cell size of 1.
2. Please cite REDCap in the references.  If a grant supports REDCap for one of the
organizations, it's common to acknowledge that grant (e.g, a CTSA or other institutional grant).