Reviewer ’s report  
 
Title: Feasibility and acceptability of using Medical and Nursing Students to provide Implanon  
NXT at the community level in Kinshasa, Democratic Republic of Congo  
 
Version: 0 Date: 09 Oct 2018  
 
Reviewer: Research Square  Reviewer 1  
 
Reviewer's report:  
 
PEER REVIEWER ASSESSMENTS:  
 
OBJECTIVE - Full research articles: is there a clear objective that addresses a testable research 
question(s) (brief or other article types: is there a clear objective)?  
No - there are major issues  
 
DESIGN - Is the c urrent approach (including controls and analysis protocols) appropriate for the 
objective?  
No - there are major issues  
 
EXECUTION - Are the experiments and analyses performed with technical rigor to allow 
confidence in the results?  
No - there are minor iss ues 
 
INTERPRETATION - Is the current interpretation/discussion of the results reasonable and not 
overstated?  
No - there are minor issues  
 
OVERALL MANUSCRIPT POTENTIAL - Could an appropriately REVISED version of this 
work represent a technically sound contr ibution?  
Probably - with minor revisions  
 
PEER REVIEWER COMMENTS:  
 
GENERAL COMMENTS: Expanding access to long -acting reversible contraception, including 
implants, is an important question. This is an interesting study of a model for provision of 
Implanon NXT by medical and nursing school students during community -based campaign days 
in Kinshasa. The paper is well written and includes longitudinal data on Implanon NXT adopters 
within the first year of use. It also includes some limited data collected from t he students 
providing the method. Results indicate that many women chose to receive the method, that they 
thought the students did the insertions comfortably, and that continuation was high. However, the 
paper could benefit from more information on the con text and model for the intervention. There 
are many types of community -based distribution models, and this is a very particular one in the 
sense that it uses students and is being implemented near health facilities in Kinshasa. It would 
be helpful to provi de more information on the type of barriers such a model is designed to 
address (some of this information is under discussion but could be moved earlier and expanded 
to frame the paper). Overall, it also seems that the introduction could give more weight t o 
remaining questions around the service delivery approach (such as sustainability and linkages to 
the health system for follow -up, side effect management, or removals), since this is part of the 
model.   
 
More details are needed for the methods, such as th e number of sites or number of campaign 
days defining the recruitment period, or rules for follow -up (i.e., not after removal). The study 
uses a descriptive longitudinal design and should be presented as such. Statistical tests are not 
appropriate because the study was not designed to support comparisons. They can still be 
presented as they are interesting, but descriptively. Similarly, the study was not designed to 
produce estimates of continuation (or removal) rates. This, along with a statement regarding  the 
generalizability of the results, should be acknowledged under limitations.  
Footnote 1 on service statistics comparing uptake of Implanon NXT to uptake of other methods 
is important and referenced in the discussion as well. This should be included in the methods and 
results sections of the paper rather than as a footnote. On line 197, the authors reference 
qualitative data. This is not mentioned in the methods. Are these data fully presented elsewhere? 
Why are they not included in this paper?  
 
Related t o this, some of what is included in the discussion goes beyond the results (e.g., uptake 
vs. other methods, or reference to youth and new users). Some relevant literature may also be 
added to the discussion, including for example a recent review on bleedin g changes by Polis et 
al. As mentioned earlier, it would be helpful to discuss the generalizability of the results. One 
finding that I found interesting but was not highlighted in the discussion is that close to 38% of 
Implanon NXT acceptors had not used f amily planning before, which suggests this intervention 
model may help attract new users (it could even be more than 38% when looking at prior use of 
modern contraception). On the other hand, while the others noted challenges with stock -outs and 
with couns eling on early removal (which is an issue of free choice AND use), there are perhaps 
other areas of improvement. Some may agree that over a third of women finding insertion 
somewhat painful is not a concern, but others may disagree, and this deserves to be  discussed. 
Likewise, 1.8% of women became pregnant, which the authors indicate is due to improper 
screening and the fact that women were already pregnant before receiving the method. Was 
information collected on whether other women were screened for pregn ancy? While most 
women were comfortable with their provider, many were not aware that the provider was a 
student. For stock -outs, do the authors have information on how this compares to stock -outs at 
the facility -level? Overall, there are promising results , but it would be helpful to also 
acknowledge additional areas for improvement for a more balanced interpretation of the 
findings.  
 
 
REQUESTED REVISIONS:  
Please refer to comments above.  
ADDITIONAL REQUESTS/SUGGESTIONS:  
In the results section, the authors may consider starting with results related to experiences getting 
the method, then longitudinal findings. The objectives could be clarified and framed accordingly.  
If possible, it would be interesting to provide informa tion on prior use of modern contraception 
(as opposed to all types of contraception) and on prior use of LARCs for a better understanding 
of the population reached through this intervention.  
For line 210, the authors offer alternative hypotheses for change s in findings on satisfaction over 
time (more women highly satisfied vs. satisfied). The authors may consider running a sub -group 
analysis on the women with data at both time points to determine which hypothesis is correct.  
Some improvements could be made to the tables.  
Table 1: the header for data on parity is missing; employment data are shown twice.  
Table 3: There is a * but I did not see what it referred to.  
Table 5: some numbers are missing.  
I really liked Figure 1, but had trouble following some of t he numbers. At six months, 460 
surveys and 77 LTFU add up to 537 and not 531. At 12 months, 420 surveys and 27 LTFU add 
up to 437 and not 439.  
 
 
Note: This reviewer report can be downloaded - see attached pdf file.  
 
 
Are the methods appropriate and well described?  
If not, please specify what is required in your comments to the a uthors.  
 
No 
 
Does the work include the necessary controls?  
If not, please specify which controls are required in your comments to the authors.  
 
No 
 
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 specify what aspects req uire further 
assessment in your comments to the editors.  
 
Not relevant to this manuscript  
 
Quality of written English  
Please indicate the quality of language in the manuscript:  
 
Acceptable  
 
 
 
 
 
Declaration of competing interests  
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