Reviewer’s report
Title: 
Measuring barriers to fistula care: investigating composite measures for targeted fistula
programming in Nigeria and Uganda
Version: 
3 
Date: 
16 Mar 2021
Reviewer's report:
Dear Respectable Editor 
I am grateful to give me the opportunity to review the manuscript entitled; Measuring barriers to fistula
care: investigating composite measures for targeted fistula programming in Nigeria and Uganda. The
authors used an informative title and structured abstract.
In the introduction section, the authors defined the magnitude of the problem (studies indicate that barriers
cut across psycho-social, cultural, awareness, social, financial, transportation, facility shortages, quality of
care, and political dimensions. The complexity of these barriers and relative rarity of the condition creates
measurement challenges for countries seeking to monitoring access to fistula care. Understanding the
layered barriers and intersectional vulnerabilities of poverty, gender, stigma, and geography faced by
women in need of fistula care may be useful in better targeting fistula services and designing programs to
reduce obstacles to care seeking and treatment). 
And the lack of knowledge (Quantitative fistula studies to date primarily focus on prevalence estimation
(epidemiology) or profile experiences for clinical care, with limited attention to measuring the range of
barriers to fistula care. No composite measure of barriers has been developed to our knowledge in the
context of fistula repair). 
Therefore, this explains why their study was designed (to develop and validate composite measures to
assess barriers to accessing fistula repair in Nigeria and Uganda). 
Methods section, the authors defined the study design and setting, participant sample and method, post-
repair client surveys, and domains of barriers to fistula treatment identified and analysis.
Results section, they clearly presented the demographics and fistula history, different factor analysis, and
barriers to Fistula Care Index. In addition to, distribution and reliability of indices and sub-scales, and
associations between indices and sub-scales.
Discussion section, Authors mentioned the strength of their study (first study to develop a set of measures
that quantitatively captures barriers to fistula care). 
They mentioned their study limitations and future suggested research and they compared their findings
with other findings (For example, a qualitative study found that obstetric fistula survivors in Addis Ababa
coped with their emotions through suicidal thoughts, avoiding family and community members, and
concealing their story and circumstances. As such, this sense of shame and compounded barriers often
leads to women resorting to different coping mechanisms including but not limited to managing the
condition at home, drawing limited social support mechanisms, seeking religious or spiritual guidance,
and alternative care).
Conclusion section, was clear reflecting the authors` results (The strong reliability and validity of the
multidimensional Barriers to Fistula Care Index, associated sub-scales (Limited Awareness, Social
Abandonment, and Internalized Stigma), and the Financial/Transport Inaccessibility Index introduce
options for integration of improved measurement and monitoring of barriers to care into fistula programs.
The psychometric properties of each construct suggest cognitive differences in how women perceive and
act on their fistula condition).
In addition, they used relevant references (I think the references section needs more revision by the
authors).
Finally, its interesting work of great value (including large number of patients) and can be accepted for
publication after minor revision (please the highlighted parts on the attached PDF file).
Regards 
Publons Reviewer Recognition
. Springer Nature can send verification of this review directly to Publons
(a subsidiary of Clarivate Analytics). If you would like to take advantage of this service, please click on
the “Yes” option below. Your name, email address, title of the reviewed manuscript, name of the journal,
and date of your review submission (the “Review Data”) will then be transmitted to Publons after the final
decision on the manuscript has been made. If you have already registered at Publons, they will notify you
of the receipt of this review and update your profile 
as per your settings and their policy. If you are not
registered with Publons, you will receive an email from them asking you to register in order for them to
be able to recognize your review on your new profile page. Publons may use the Review Data to generate
derivative metadata for the benefit of Publons and you as a reviewer, carefully considering the sensitivity
of such information. For example, Publons may verify your record as a reviewer by updating your profile
published on its webservice if you have registered for such service or help editors to identify candidate
reviewers. Please find the details of processing in Publons’ privacy policy
https://publons.com/about/terms
Yes
Declaration of competing interests
Please complete a declaration of competing interests, considering the following questions:
1
. 
Have you in the past five years received reimbursements, fees, funding, or salary from an
organisation that may in any way gain or lose financially from the publication of this manuscript,
either now or in the future?
2
. 
Do you hold any stocks or shares in an organisation that 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 competing interests' below. If your
reply is yes to any, please give details below.
I have no competing interests
Reviewer Publication Consent.
 I agree for my report to be made available under an Open Access
Creative Commons CC-BY License (
 http://creativecommons.org/licenses/by/4.0
) if this manuscript is
accepted for publication. Any comments that I do not wish to be included in the published report have
been included as confidential comments to the editor, which will not be published.
If you are not happy for us to publish this report, please contact the editorial office before completing
the review.
If you wish, you can include your name in your published report. Please note you must decide whether
to include your name at the start of the process and confirm this decision whenever prompted. If you
change your decision later, we will not be able to publish your name.
I agree to the terms of the CC-BY 4.0 license; please 
do not
 publish my name with my report. (default)
Is the study design appropriate to answer the research question (including the use of appropriate controls),
and are the conclusions supported by the evidence presented?
Yes
Are the methods sufficiently described to allow the study to be repeated?
Yes
Is the use of statistics and treatment of uncertainties appropriate?
Yes
Is the presentation of the work clear?
Yes
Are the images in this manuscript (including electrophoretic gels and blots) free from apparent
manipulation?
Yes