Reviewer ’s report  
 
Title: Quality of care in family planning services in rural Mozambique with a focus on Long 
Acting Reversible Contraceptives: a cross -sectional survey  
 
Version: 1 Date: 23 Oct 2017  
 
Reviewer: Blair Grant Darney  
 
Reviewer's report:  
 
Overall comments to author  
 
This paper addresses an important topic. However, the study purpose/question and outcomes are 
not well defined and lead to a confused presentation of methods and results. In addition, the 
paper lacks a cohesive use of a framework for defining and  measuring quality (used in discussion 
but not to frame methods or results).  
 
 
 
Abstract  
 
It is not necessary to include the statistical package you used in the abstract  
 
"predictors" justify how this is prediction - did you predict out -of-sample? Or change la nguage to 
association  
 
 
What is your primary outcome and hypothesis? State it clearly in the abstract.  
 
 
"Quality" is in your title but not in the abstract - how is quality measured? Or change the title to 
reflect what your primary outcome is  
 
 
Add "Mozambique " to keywords  
 
 
Intro  
 
Line 87: use of depo - is this monthly or 3 month depo? Some debate as to whether and when 
depo can be classified as a long acting method (although remaining in Tier 2)  
 
Line 98: this is out of pocket cost to clients, correct? Services  are never free, someone is paying. 
- clarify this is cost to clients  
 
Study objective: clarify your primary outcome. It seems you are measuring quality with client 
reported content of consultation, client satisfaction, and client knowledge. Link this to B ruce 
framework and use it to organize methods and results.  
 
What proportion of birth are in -facility in Mozambique? Is Immediate post partum contraception 
a big part of contraceptive provision or does most contraceptive provision happen at the primary 
care level? Just curious about health system context.  
 
 
 
Methods  
 
Line 130: delete "were forced", just say "we excluded"  
 
Line 133: I'm not clear on the use of "recapitulation" - is this a repeat or refresher training?  
 
Line 144 -149: I got confused here - N=417; 3 rounds, 15 health centers. So n=136 each round 
divided among 15 health centers? If the goal is to measures change at the health center level is 
this a sufficient sample? Or what am I missing?  
 
Line 147: .."to de tect whether quality of care changed over time AT THE FACILITY LEVEL" 
correct? Line 167 -171: you are powered to detect dissatisfaction - which is very rare. Is this the 
primary outcome? This needs to be made clear in the abstract and study objective sectio ns. Why 
did you choose dissatisfaction as the primary outcome, given all the problems with satisfaction 
measures in previous work? This is a major question I have about this paper.  
 
Line 191 -204: you spend a lot of space on the PCA, but it is not clear whi ch questions are 
included in the first component. I'm also not entirely clear on how reducing from 4 is useful - is 
the first component 1 question? I got confused here. Shorten this section and clearly explain how 
this helps the analysis (vs showing you kn ow a statistical technique).  
 
The title of the paper includes quality, and in the methods the study is powered for satisfaction, 
now in the results the authors lead with consultation - I got confused again about what the 
primary outcome is.  
 
Table 2. I lik e "by feet" but we say "on foot" or "by foot", which does not make sense because 
you use both feet to walk or run, but English often makes no sense.  
 
Line 251: for the follow up clients, did you look at depot continuation? Depo can be a good 
method…. Also,  now slicing and dicing N=417 between 3 rounds, 15 centers AND new and 
continuing clients - I worry you don't have the sample for this.  
 
Results  
 
Table 3: you can delete the "No" rows - since yes and no add up to 100% to save space.  
 
Please shorten the tex t of methods so you are not repeating the information in the Tables. 
Highlight key findings and refer reader to table for the rest.  
 
Line 255: Satisfaction. This is the primary outcome, correct? You do not really explain how it is 
measured in methods. And present this first if it is the primary outcome, and present "quality" if 
that is the focus. If the focus is satisfaction, change the title.  
 
Table 4 and Satisfaction results. It seems clear that this measure is not getting at what we want to 
know - this i s the typical issue with satisfaction measures. The only one with any real variation is 
"would you recommend the service to others". Can you comment on this and why this is the 
primary outcome? And which item is the outcome or some sort of scale or index, or? 
 
Lines 264 -270, Knowledge: are these knowledge or are they opinions/ myths (seems so to me). 
And where does the PCS fit in here? I got confused  
 
Line 276 -299: integrate the findings about difference by round into the sections about each 
outcome - it wa s confusing here and would make more sense to present when you are presenting 
the content, knowledge, and satisfaction results.  
 
Lines 301 -308: delete this paragraph, or justify how you can compare the 3 rounds with such 
small cell sizes  
 
Lines 310 -326: Here is the principal component: as a linear variable? How many of the 4 
questions are included? Or what am I missing here? I'm not sure this is the appropriate analysis  
 
Lie 323: I am not familiar with using AIC to compare models with diffe rent outcomes (only 
different covariates and can handle different sample sizes)…but I may be wrong .  
 
Line 328: help the reader interpret your results - specify which direction these relationships are 
in "..significant NEGATIVE predictor.." etc. throughout   
 
Table 5. If the outcome is the principal component, tell us what it includes. Also, help reader 
interpret the linear regression results - a 1 unit change in outcome is what exactly here? Please 
justify the use of this analytic approach. What am I missin g? 
 
Discussion  
Lines 336 -337 Use the Bruce and Jain framework  - make clear in methods as you describe your 
outcomes and measurement, and use the framework to organize the results. And where is 
satisfaction, which is the primary outcome?  
 
In the discussion  it sounds like method choice and information are the outcomes, but you 
powered for satisfaction…  
 
Line 393: I am not convinced that a) this study focuses on quality or b) that you measure quality.  
 
What about the satisfaction results - and a discussion o f whether satisfaction is a useful measure 
of quality. See for example, Darney, B. G., Saavedra -Avendano, B., Sosa -Rubi, S. G., Lozano, 
R., & Rodriguez, M. I. (2016). Comparison of family -planning service quality reported by 
adolescents and young adult wom en in Mexico. International Journal of Gynecology & 
Obstetrics, 134(1), 22 -28. doi:http://dx.doi.org/10.1016/j.ijgo.2015.12.003  
 
 
Tables & figs  
 
See above for some comments on tables.  
 
Figures: if you are using R you can make much nicer graphs/figures.  
 
Fig 3 : it is hard to see the don't know category - (in black and white it all looks like No). An 
alternative is to present only the correct response proportions  
 
 
 
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.  
 
Unable to assess  
 
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 manus cript or would you recommend an 
additional statistical review?  
If an additional  statistical review is recommended, please speci fy what aspects require further 
assessment in your comments to the editors.  
 
I am able to assess the statistics  
 
Quality of written English  
Please indicate the quality of language in the manuscript:  
 
Acceptable  
 
 
Declaration of competing interests  
Please complete a dec laration of competing interests, considering the following questions:  
 
1. Have you in the past five years received reimbursements, f ees, funding, or salary from an 
organisation that may in any way gain or lose financial ly from the publication of this 
manusc ript, either now or in the future?  
 
2. Do you hold any stocks or shares in an organisation t hat may in any way gain or lose 
financially from the publication of this manuscript, either now or in the future?  
 
3. Do you hold or are you currently applying for any patents  relating to the content of the 
manuscript?  
 
4. Have you received reimbursements, fees, funding, or salary from an organization that 
holds or has applied for patents relating to the content of the manuscript?  
 
5. Do you have any other financial competing interests?  
 
6. Do you have any non -financial competing interests in relation to this paper?  
 
If you can answer no to all of the above, write 'I declare that I have  no comp eting interests' 
below. If you r reply is yes to any, please give details below.  
 
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