Reviewer's report
Title:Intravaginal practices and Lactobacilli colonization among women and risk
of sexually transmitted infections in Accra, Ghana
Version:1Date:9 February 2015
Reviewer: Heidi Jones
Reviewer's report:
The authors implemented a study to measure the prevalence of intravaginal
practices in women attending an ObGyn clinic in Accra and to evaluate
associations between these practices and the presence of lactobacilli. The
authors need to clarify a number of points before the reader can truly assess
what the study adds to the literature.
Major compulsory revisions
A number of the methods used are not quite clear and need to be made clearer.
Please address the following points:
1. Who do the women who participated represent? As this study is meant to
measure prevalence, it is important to establish how representative the women
who are included in the study are for women who attend this clinic in general.
The reader can only get a sense of this if they know the answers to the following
questions: What were the eligibility criteria for participation? During what time
frame were the women recruited? Were all women who attended the clinic during
that time frame approached? How many women were invited to participate but
refused? How many women who were invited were ineligible? What were the
main reasons they were ineligible?
2. Describe the questionnaire in a bit more detail – how was it designed? What
questions did it include? Was it self-administered in English or did an interviewer
read it to women? How long did the questionnaire take? What was the time
frame for the questions on intravaginal practices (e.g. were women asked about
practices they did in the last week? last month? After last intercourse? Were they
asked how often they do these practices?)
3. Laboratory methods – how were STIs diagnosed? Did all women receive a
gonorrhea test or was this based on whether it was clinically indicated? syphilis?
what information was recorded during the pelvic exam? How was trichomoniasis
diagnosed? Candida? Additionally, since the study used gram stains, did they
also use Nugent scores to detect BV? It is unclear exactly what tests and
outcomes were measured based on the microscopy and gram stains. Please
clarify.
4. The ‘Microscopic examination’ section, line 126, is confusing as it suggests
that the result from microscopy was used to determine whether women used
intravaginal practices, but the rest of the text suggests this was measured by
self-report on the questionnaire.
5. In general, the microscopy and culture/biochemical assays section needs to be
clear on what information was standardized to be recorded by the lab technicians
for this study.
6. The data analysis section would be stronger if the authors spent time
describing their main exposure of interest (self-report of intravaginal practices)
and their outcome (lactobacilli). In general, they should consider differentiating
between women who use water only versus those who use other products when
they look at the associations between the practices and vaginal flora.
Additionally, they should include measures of how frequent the practices were (if
questions included this information). When they asked about use of water was it
clear that they were asking about women inserting water in the vagina to clean it
(as different from cleaning the external genitalia)?
7. The authors should have one section that presents the results and a separate
section that discusses the results in the context of the literature (currently they
have merged Results and Discussion into one section).
8. Figure 1 is a little off-topic although information on what other infections were
present are of interest, Ideally, the authors would include the prevalence of other
infections in Table 2, which should include 2 columns - those with lactobacillus
present and those with lactobacillus absent (and a chi-squared test for statistical
significance).
If the cross tabulations suggest an association, the authors should develop a
logistic regression to see what predicts the presence of lactobacilli, and include
presence of other infections as well as reporting on intravaginal practices to see
whether intravaginal practices remains significantly related to lactobacilli after
controlling for these other infections.
The link between some forms of intravaginal practices (such as use of
commercial douches) and vaginal flora has been well-established in the
literature, but nevertheless may be of interest in the context of Ghana and the
intravaginal practices reported in this context. However, the authors need to
strengthen the methods and the results section for further review.
Minor essential revisions
1. After major compulsory revisions have been completed, the manuscript would
greatly benefit from editorial review for language usage, grammar and typos.
I hope these comments are helpful in strengthening the manuscript.
Level of interest: An article of limited interest
Quality of written English: Needs some language corrections before being
published
Statistical review: No, the manuscript does not need to be seen by a statistician.
Declaration of competing interests:
I declare that I have no competing interests