Reviewer ’s report  
 
Title: Understanding what impacts on disclosing anal incontinence for women when comparing 
bowel screening tools: A phenomenological study  
 
Version: 0 Date: 14 Feb 2019  
 
Reviewer: Sue Ross  
 
Reviewer's report:  
 
Thanks for inviting me to review this interesting paper.  It addresses a common problem 
affecting women, anal incontin ence (AI), attempting to explore the usability of a new AI 
questionnaire which aims to contribute to the identification and care of women who develop AI.  
This research specifically addresses "women's experiences in disclosing AI when completing 
assessment  tools", including a new questionnaire, BSQ.  
 
My comments follow:  
1. Background  
1.1 The aim of the research "was to determine if we could accurately identify AI in women 
of reproductive age" (lines 82 to 85).  That does not seem an aim that could be addr essed by this 
phenomenology study.  Rather it aims to find out if women understand the meaning of the 
questions they are being asked in BSQ (compared to other more established AI questionnaires), 
and if there are other barriers to disclosing AI.  This is i n itself a useful contribution to the 
literature, because it seems the established questionnaires may be flawed and produce apparently 
discordant outcomes, while BSQ might be a useful tool.  The aim of the research should be 
revised accordingly.  
 
2. Method  
2.1 Lines 91 to 92 - In the abstract, inclusion criteria are more explicit: "parous women in the 
first trimester of a subsequent pregnancy".  Please include this description in the method.  
2.2 Lines 88 to 91 - There is not a reference to the development o f BSQ - perhaps this work 
is submitted or in press?  
2.2 Line 99 - "Journaling" is included in the description of interpretive phenomenology (line 
99), no results are given for journaling.  If journaling was used, then a section in the results and 
discussio n should be included.  If not, I suggest saying that this did not form part of the method 
used in this study, or else leave "journaling" out of the method altogether.  
2.3 Line 115 to 117 - BSQ was developed from two earlier questionnaires - what was that 
process?  
2.4 Line 117 - "No timeframe was included" in the BSQ.  It would be helpful to know what 
was the reason for this decision.  The actual phrase used in the BSQ is "Have you ever lost by 
accident?" for a variety of symptoms.  From the paper, it is unc lear how women would answer 
the items.  For example how would a woman describe her experience if she has once or more 
often lost poo 5 years ago but not at all over the past year?  If that past episode was distant in 
time but traumatic, would that put a wo man into the "consider referral" classification.  Many 
other scenarios are also possible, eg accidents because of an episode of diarrhoea, or in 
childhood.   
2.5 Lines 122 to 124 - The method indicates that the BSQ needed the assistance of the 
researcher t o understand aspects of BSQ and the other tools.  This is the nature of 
phenomenology (in understanding what the questionnaire/questions mean to women), but can the 
reader be certain that the tool is usable by a woman on her own?  
 
3. Results  
3.1 The Resul ts are clear and relevant, highlighting the good and less -good parts of the 
results.  In particular, the results highlight the fact that women felt they wanted a frequency scale 
for symptoms (perhaps preferring something more explicit than currently used i n the BSQ: from 
never to daily) for past and current experience (lines 163 -165).  This would help to address my 
concern above (2.4).  
3.2 The sub -headings in the results are confusing.  There are 3 major themes identified that 
described how women responded to disclosing AI: social expectations, trusted space and 
confusion.  These headings are used in the results, but are interspersed in the text by other 
headings that seem to be sub -headings.  For example, the heading "social expectations" (line 
171) seems t o have sub -headings of "keep it hidden" and "birthing process", and after 
"confusion" (line 214), "understanding" may be a sub -heading.  The use of different formatting 
for the sub -headings would make the results easier for the reader to understand.  
 
4. Discussion  
4.1 The discussion is interesting and comprehensive.  
4.2 A few errors have slipped into the paper:  Line 274 - should be "Leonard" (not Loenard).  
Line 277 -280 - these lines include some instances where the meaning (and grammar) need to be 
reviewe d and improved.  
4.3 The authors are correct that this qualitative research has identified useful findings to 
inform the further development of AI tools for use in pregnant women who are at risk of AI.  
4.4 How does it reduce study bias to use triaging anten atal midwives to invite women to take 
part in the study.  Those midwives may themselves be biased (for example recruiting women 
with more severe AI symptoms, to be helpful to the study team).  In addition, the researcher may 
be biased in her approach (as a  health professional) leading women to discuss particular 
concerns.  She may well have led women towards full disclosure when they might not have done 
so when using the questionnaires independently.  What did the researcher (and her team) do to 
ensure that  she did not lead the discussion towards specific symptoms or experiences?  
 
5. Conclusion  
The conclusion from this work should tie in with the study aim and results.  Such a conclusion 
might be as follows, because you identified three different types of barrier (woman, environment 
and language and other aspects of the questionnaire itself):  
This study piloted a new questionnaire for use in routine screening of women at  risk of AI.   
Your research identified barriers caused by (1) the women's own beliefs (feeling of stigma 
associated with AI), (2) needing a confidential place to talk about AI, and (3) wording and other 
aspects of AI questionnaires themselves.   
Addressin g these issues would help women to disclose their experience of AI, so that they may 
receive suitable counseling and treatment.  Further work is needed . . . to include women with 
and without AI etc  
Make sure that the aims and discussion properly map toge ther. 
 
Summary comments  
This is a useful piece of research.  The BSQ seems an interesting development from earlier 
questionnaires, aiming to move towards more easily -understood lay terms and expressions that 
will be accessible to pregnant women.  The autho rs are clear in noting that further work is 
needed to refine and develop the tool.  They are to be congratulated in writing this preliminary 
work as part of a more extensive program of work.  
 The BSQ was developed with women who had a history of AI.  It do es seem that this 
questionnaire that is relevant for those women.  However there is no evidence from this study 
about whether BSQ can differentiate between women with AI and those who have milder 
symptoms or no symptoms, or to identify women who will go on  to develop more severe 
symptoms.  That is likely one of the next pieces of work to be undertaken.  
The title of the paper could better describe the work that was done, and the value of the work.  
Are the methods appropriate and well described?  
If not, please specify what is required in your comments to the authors.  
 
 
 
Does the work include the necessary controls?  
If not, please specify which controls are required in your comments to the authors.  
 
 
 
Are the conclusions drawn adequately supported by  the data shown?  
If not, please explain in your comments to the authors.  
 
 
 
Are you able to assess any statistics in the manuscript 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.  
 
 
 
Quality of written English  
Please indicate the quality of language in the manuscript:  
 
 
 
Declaration of competing interests  
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