Reviewer’s report
Title: 
Use of community-based interventions to promote Family Planning use
among Pastoralist women in Ethiopia: Cluster randomized controlled trial
Version: 
1 
Date: 
21 Aug 2020
Reviewer's report:
Thank you for the opportunity to review this paper, which presents the results of
a cluster RCT evaluating a community-based program to increase FP use among
pastoralists in Afar region, Ethiopia. Overall, this seems to be a well-done study
with useful results, but more work is needed on the organization of the paper to
improve clarity. My specific comments are below.
Major comments:
1. Background: This section includes important background on the problem, the
Ethiopian context, and the male involvement literature, but it would help to
organize it so that there is one main point in each paragraph. Currently it is
somewhat repetitive. For example, paragraph three starts off discussing the RIF
(is this study part of that project?) and low FP use among pastoralists in Afar
(also mentioned in paragraph two) and then goes into the literature on male
involvement. 
2. Methods: Please provide more information about the control group. In the
Background you mention that the faema are a long-standing group, which I
assume would have been operating in the control areas. Is it that these groups
were operating, but were not trained on any FP content? In your intervention
description, you also mention that you made health facilities in intervention
areas ready to provide FP methods. Were FP services available in the control
areas? I see in Figure 1 that the control arm received "existing intervention from
the government", and it would be helpful to understand more about what that
entailed.
3. Methods, Study Design: It would be helpful to clarify in this section if you
used longitudinal data collection or cross-sections at baseline and endline.
4. Methods, Study Setting: Is that correct that only 44% of people in Afar are
female? Or is it 44% of people are married women or women of reproductive
age? 44% seems low if it is the female population overall.
5. Methods, Study Setting: It would be helpful to know more about these three
districts selected for the study, e.g. are they representative of Afar as a whole in
terms of demographics? How about in terms of FP and other health service
availability?
6. Methods, Interventions, p. 6, lines 170-173: It would be helpful to know more
about the process used for developing and testing the FP messages used as part
of the intervention.
7. Methods, Interventions: Rather than organizing the information by
intervention component (education by faema leader, video-assisted message, and
HEW/health worker interventions) it would be helpful to organize it by arm.
Right now it is difficult to understand which parts of this intervention were done
in each arm. For example, under the section on health education by faema
leaders, did the "educating women in FP" arm only get the sessions with the
female faema leaders, and the "male involvement in FP education" arm received
the sessions with the female faema leaders + the sessions with male faema
leaders? Your Figure 1 lays out the interventions by arm, but it would help to
include information about the logic of the different intervention packages in each
arm. For example, why wasn't "assistance from HEW" included in the male
involvement arm?
8. Methods, Outcomes: Please clarify whether your primary outcome is any FP
use (including traditional methods) or modern contraceptive use. You mention
both in lines 233-236.
9. Methods, Outcomes: I'm not sure "intention" is the best term for your
secondary outcome. The term "intention" makes a reader think of the standard
DHS measure of intention to use FP in the future among non-users. Your
description of this secondary outcome sounds more like attitudes or community
norms around FP use.
10. Methods, Randomization: I am not sure that you could really call participants
"blinded" to the intervention type. I understand that you didn't specifically tell
them which intervention arm they were in, but they would have known that they
were receiving FP information and that it was being provided only to women or
to both women and men.
11. Methods, Data Collection: You mention here that repeated cross-sections
were used for follow-up. Why was this needed since the baseline and endline
were only 9 months apart? Was there a high level of migration that meant that
women who completed the baseline were no longer in the same households
during endline? Did you use the same random sampling strategy at endline as
you used at baseline? This should be described in more detail. This is also a bit
confusing because in Figure 2 you show no attrition between baseline and
endline.
12. Methods, Data Quality Control: You mention both the interviewer-
administered surveys and the logbooks here. Were the logbooks used in your
analysis, or only the surveys? If only the surveys, I think you can delete mention
of the logbooks throughout this paper.
13. Methods, Statistical Analyses: I understand that you weren't able to do the
GEE analysis that you originally intended, but have you considered using
multiple regression of your cluster-level data to adjust for some of the
differences in cluster-level socio-demographics? I know that you're concerned
about the small number of clusters, but there are statistical methods you can use
(possibly cluster wild bootstrapping?).
14. Discussion: Please revise so that you start your discussion section with a
summary of your findings, followed by an in-depth discussion of each finding of
interest in relation to existing literature, and finally followed by a discussion of
the study limitations. It looks like your limitations paragraph is currently first.
15. Discussion: You have included in your Discussion similar findings from
other interventions, but it will help to delve into the similarities and differences
between your intervention and the others that support your findings rather than
just listing the findings from each study. Currently, much of the discussion is
about couple-level interventions and those that supported spousal
communication, but from the intervention description you've provided, it doesn't
seem like there was much emphasis on couple communication. Instead, it sounds
like the intervention provided information to women and the male involvement
arm focused on messages about male responsibility. It will help to explore in
more depth what your findings tell us about these different intervention
modalities.
16. Discussion: Some of your statements in the Discussion section do not seem
to be supported by the data you present. For example, you state that "overall
women empowerment could be positively influenced by women's education on
FP", but you do not present measures of empowerment in this paper. Another
example is that you state, "education including women's education on FP is a
good intervention to improve FP use by increasing the health-seeking behavior
and health status of pastoralist women", but we don't really have data on their
health-seeking behavior (e.g. we don't know how many women in each group
went to a health facility) or their health status. You also mention financial
freedom for women in several places, but this does not seem to be supported by
the data.
17. Discussion: It would be helpful to discuss in more depth why you think the
male involvement arm resulted in higher FP use than the women's education
arm. In the last paragraph on p. 14 you discuss the role of religious leaders - do
you think this was the primary reason for higher FP use in the male involvement
arm?
18. Conclusion: I think it will help to zoom out a bit more to make your
conclusion more applicable outside of Ethiopia. For example, instead of
specifically mentioning the "faema structure" you can use more general
terminology like "community-led support groups". 
Minor comments:
1. Background, p. 3, lines 69-72: It looks like this sentence "It should be noted
that lack of awareness…" should be cited with #9.
2. Methods, Study Setting: It seems like lines 143-150 belong in the Background
section since you have described women in Afar in paragraph 2 in the
Background section.
3. Methods, Data Collection: This section has quite a bit of information, and I
think some can be deleted. For example, you describe your outcome variables
again here, but this can be deleted since there is a full section on this above. I
also don't think you need to provide all of the statistics for your "intention"
construct - I think the Cronbach's alpha is sufficient. 
4. Methods, Data Quality Control: This section includes quite a bit of
information that does not seem to be related to data quality. For example, you
describe the video intervention again and the DSMB and adverse event
monitoring, and I don't think this needs to be included in this section.
5. Methods, p. 6, line 169: HEW should be defined here.
6. Results, p. 10, line 373: Please clarify what is meant by "husband knows for
the current use of FP".
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
No
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 declare that 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?
No
Is the use of statistics and treatment of uncertainties appropriate?
Yes
Is the presentation of the work clear?
No
Are the images in this manuscript (including electrophoretic gels and blots) free
from apparent manipulation?
Yes