Reviewer ’s report  
 
Title: Dual Contraception Method Utilization and Associated Factors among Sexually Active  
Women on Antiretroviral Therapy in Gondar City, northwest, Ethiopia: a cross sectional study  
 
Version: 0 Date: 19 Nov 2019  
 
Reviewer: Hadii M Mamudu  
 
Reviewer's report:  
 
Title  
 Dual Contraception method utilization and associated factors among sexually active women on 
antiretroviral therapy in Gond ar City, northwest, Ethiopia: A cross sectional study  
 
Summary  
This paper attempts to evaluate the use of hormonal, intrauterine device or permanent modern 
contraceptive methods along with condoms among HIV positive women of reproductive age on 
antiretroviral therapy in selected hospitals within Gondar City, Ethiopia,  as well as possible 
factors associated with the study outcome. The methodology of the paper consists of a cross -
sectional study with the use of systematic random sampling to select 563 participants. The major 
findings of the study were the low rate of wom en who used dual contraceptive methods and the 
factors linked to the study outcome were older women, urban residents, educational status and 
HIV disclosure.     
 
Overall Comment  
This is an important research, which was well conceived that can inform the lit erature and target 
programming efforts and the methodology was clearly explained. The contributions to theory 
and practice would appear to be the increase in knowledge and evidence on the use of dual 
contraception method in the country setting. The results  would be helpful to public health 
practitioners and policy makers to create programs and restructure the system to reach the target 
audience.  
 
 
While reading the background section, for a reader who is unfamiliar with concepts such as dual 
contraception, t he authors do not present any helpful explanation of dual contraception or 
justification for why dual contraception is included in the study in the first place.  At first glance, 
my definition of dual contraception would have been two different types of co ntraceptive 
methods without paying much attention to which specific method. The author should have 
discussed the effectiveness and reliability of such methods as well as the emphasis on dual 
methods and not just highly effective methods for women who are o n antiretroviral therapy. I 
cannot judge how well this paper builds on past research, in other words are there other research 
studies that have reported low utilization of dual contraceptive methods which need to be cited? 
However, I suggest that the follo wing concerns should be addressed in a revision. My major 
concerns are addressed below:  
1. The literature review is quite brief and does not provide sufficient background for the study 
for the emphasis on dual contraceptive methods or its efficacy.  
2. Acro nyms should be well defined at the beginning before being used and when they are 
already defined, there is no need to re -define them.  
3. There is no consistency in the way citations are credited. It is not clear which citation style is 
being used.  
4. Ther e are numerous grammatical errors  
 
Specific Comments  
Abstract  
1. Within the background section, Human Immune Deficiency Virus (HIV) acronym should 
be defined before being used elsewhere within the abstract.  
2. Within the conclusion section, rather than usi ng 'older age group',… were associated with 
dual contraceptive use, this should be replaced with 'age'.  
 
Background  
1. The acronym HIV/AIDS was already defined in the first paragraph so just use the 
acronym in the second paragraph.  
2. The fourth sentence i n the second paragraph should be written as Ethiopia is one of the 
'countries' severely affected by the disease, 'with' over 100,000…  
3. The third paragraph should be 'show' not showed. What do you mean by 'appropriate care 
taken for desire for children'? on page 1.  
4. Within the fourth paragraph, we already know what HIV stands for , so there is no need 
to redefine it.  
5. Within the last paragraph on p.2, there should be a comma after virtual elimination.  
 
Methods  
1. Is there a conceptual framework that was used for the variables being studied?  
2. The authors did not provide any ethical review considerations within the methods section.  
3. The acronym ART should be defined.  
4. The reference on p.3 referring to Gondar City Administration Report should be cited 
under references.  
5. Within the study population paragraph, it should state all 'randomly selected sexually 
active HIV women of reproductive age (15 -49), who had follow up in the ART clinics were 
included in the study'.  
6. What do you mean by five and two degree graduate nurses on p.4?  
7. The definition of dual contraception should have been provided in the introduction 
section where it was first mentioned.  
8. The sexually active variable on p.4 should be defined as a client who engaged in sexual 
activity within one month prior to the survey.  
9. IQR on p.5 was not defined  
 
Results  
1. There was no title given to all the tables in the document. For table 1, there should be a 
total N=563 across the heading.  
2. Were there any assumptions testing or regression diagnostics conducted for the 
multivariate logistic regression model?  
3.  The second sentence under the socio -demographic section should read thus: 'The 
remaining participants provided incomplete responses a nd were rejected from the analyses'.  
4. For the income results that were reported, is this referring to income per day or per 
month? In addition, the presentation of that sentence is not grammatically correct.  
5. The last sentence of the socio -demographic  section on p.5 should read as 'Majority of the 
participants belong to'  
6. Within the sexual and reproductive characteristics section on p.5, the word 'to' after 
regarding should be deleted  
7. Within the clinical factors section on p.6 , the last words 'we re get treatment' should be 
replaced with 'got treatment'  
8. p.8 lines 7 -9, delete 'were ever' and delete 'ever'  
9. IUCD on p.6 should be defined  
10. p.8 line 15, replace computed with conducted  
11. p.8 line 17, replace 'knowing of partner's HIV status' to  'knowledge of partner's HIV 
status'  
12. p.8 line 18, replace crudely associated with positively associated  
13. p.8 line 24 &amp; 25, the words 'Urban and Rural' should not be capitalized.  
14. On page 5,6 and 7, why are there table titles without the tables included?  
 
Discussion  
1. On page 7, replace 'the current study finding is higher compared to' with 'the percentage 
of women using dual methods is higher in our study compared to…'  
2. I could not understand this sentence and I believe it needs to be rewritte n: The observed 
variation between the current and previous local studies might be due to the difference in place 
of residence and marital status as majority, (85%, 86%) of our study participants were from 
Urban areas and married respectively.  
3. The wordin g of this sentence needs to be changed and a period added at the end: Our 
study finding was lower than …  
4. There is a grammatical error in this sentence on p.7: this high level of maturity helps 
them to understood…  
5. There is no need to capitalize Urban  in several sentences.  
6. On page 8, I was intrigued by the paper's findings that disclosing one's HIV status is 
important to the use of dual contraceptive, so I decided to look up the other studies that were 
stated to support their findings. My interpreta tion of these findings is that these women may be 
in committed relationships and have more freedom to negotiate the use of safe practices.    
 
Limitations  
1. Are there other variables associated with dual contraceptive use that could not be studied 
such as financial support, availability of services/supplies, etc.?  
2. The limitations to a cross -sectional research study should have been mentioned.  
3. The bias should be more specific e.g. is this a recall bias, sampling bias, social 
desirability, etc?  
4. Why i s it impossible to provide a generalization about those in the community? Is this 
due to the study area? This needs a little more explanation .  
5. The last sentence has a grammatical error: 'Plus, that, it is impossible to provide a 
generalization about t hose who are in the community'.  
 
 
 
Are the methods appropriate and well described?  
If not, please  specify what is required in your comments to the authors.  
 
Yes 
 
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 sh own?  
If not, please explain in your comments to the authors.  
 
Yes 
 
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  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:  
 
Needs some language corrections before being pu blished  
 
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, f ees, funding, or salary from an 
organisation that may in any way gain or lose fin ancial ly from the publication of this 
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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?  
 
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