Title: Perceptions on violence against women and its impacts and response mechanisms among
community-based stakeholders: A qualitative study from Nepal
Version: 3 Date: 01 Jan 2023
Reviewer:  Ajay Acharya
Reviewer's report:
Comments:
The paper is well written. My comments are listed below.
Abstract:
• In the study aim, you wrote: “………regarding the prevalence and management of VAW and
its consequences in Nepal”. In my view, your study explored the factors that trigger IPV and
perceptions about IPV among the different categories of participants. It is less related to the
management and consequences of VAW.
• I suggest using the word Madhesh province rather than province 2.
Introduction:
• The introduction is great, and you have described the issues in detail. However, I feel some of
the introduction’s information can be shortened. For example, detailed explanations about the
cultural practices and initiates can better fit in the discussion section and are important when
you relate with your results. I also suggest using consistent terminology, either VAW or IPV.
Methods:
• It will be helpful to elaborate on the sample size calculation (how you came up with 24 health
facilities) and your sampling frame. Also, it will be good to explain the desegregation of your
study participants by the type of health facility. This is because if the district hospital is OCMC,
the perceptions and awareness of health service providers may be completely different from
others. I also wonder you have 24 health facilities and 15 IDIs with the health care providers.
Does it mean that you did not approach all the health facilities for the IDIs? Also, how many
health workers were approached and selected for IDIs?
• In a study setting, it will be good to provide more information about the local NGO (its name,
working area, expertise and so on)
• It is unclear why the health posts are excluded from recruiting the study participants. Many
health facilities in Nepal are health posts; the first contact point of IPV survivors is the health
posts in many cases.
• Are there any specific reasons for keeping figure 1. Rather than keeping figure 1, I would
suggest providing more information about Baghai (from where the FGD participants were). You
have mentioned that Baghai has a higher prevalence of IPV. Is there any area-specific factor for
the high prevalence of IPV?
• It will be good to explain how you developed IDIs and FGD guides . What factors were
considered (e.g., research question, previous studies) while developing these tools? How did
you test these tools?
• Are there any specific reasons why you chose FGD with women who had experienced IPV?
Many women survivors may not open up clearly while they are interviewed in the group settings
as there may be fear that the perpetrator may know that they are discussing these issues in the
group.
• Were the IDIs and KIIs interviewers trained? Also, was the translation done by the same
interviewers who did the transcription? Good to include how the validation was ensured – was
it done independently by a researcher who was not part of the interview?
• I suggest including triangulation of the study findings in the methods section. It will be helpful
to compare similarities and differences in the findings by the level and type of participants.
• Good to include the NHRC ethical approval number and the date of approval.
Results:
• I suggest including a short demographic of the study participants e.g. age, education, caste,
marital status, and others
• I would suggest considering quantifying the study participants. There can be two options – 1.
You can explain in methods how you define “most”, “few”, and so on OR in the results section,
you can elaborate as most of the participants (12 out of 15) ……
• I can see a good validation between IDI participants and the FGDs in the results section. If you
have results, you may adopt this approach for all the emerging themes. This may also apply to
the IDIs between different groups of participants.
• Are there any results that came from women survivors related to “Silence due to fear of
escalation of IPV” theme? Knowing how the health system responds to these survivors from
survivors’ perspectives is good.
• In line 413, you mentioned that “We found that many participants believed that domestic and/
or IPV is a normal family matter ……”. So many participants mean all the study participants or
is it just the FGD participants (violence survivor women)
• You have described the “Perception regarding counselling intervention” in detail in the results.
I can see that it is one of your study aims. I wonder if there are some in-depth results related
to counselling intervention, for example – counselling frequency, type of counselling and
counsellor, tools for counselling and so on.
Discussion:
• In line number 720, you wrote, “The current study has shown that one of the main reasons for
women not seeking help is because community members, the police, parents in law and both
men and women do not acknowledge violence as a crime and consider it a normal and acceptable
practice”. I did not see the in-depth information in the results section to confirm this statement
• Line number 734, you described the sanitization and training to health care providers. In your
results, I did not see any recommendations related to this.
• My main concern is about the strategies that you are suggesting. I feel that you are proposing
good strategies, but these need to back up by your results and the existing literature. As this is
a formative study preceding a planned intervention, it will be great to see if you have explored
more about your planned intervention and tested if your planned intervention is culturally and
contextually fit.
• I suggest adding more literature on the impact of individual counselling, the quality of
counselling and the importance of privacy and confidentiality in improving the quality of life
among women who are survivors of IPV.
• In my view, one of the main limitations of this study is the exclusion of health posts. Health
posts are generally the first contact point, and the perceptions from the health service providers
may be quite different than the health workers from OCMC. Similarly, although you covered
all eight districts of Madhesh province, I will be cautious about the generalization of results as
the population in different districts of Madhesh province varies differently, e.g., there are the
significant populations of Mountain and Tharu people where the social and cultural norms are
quite different. Another limitation is the type of method. As I explained, you chose FGD with
women who had experienced IPV. Many women survivors may not open up clearly while they
are interviewed in the group settings as there may be fear that the perpetrator may know that
they are discussing these issues in the group.
• You started your conclusion with, “VAW is a common problem in the southern part of Nepal
with poor sexual and reproductive health outcomes and poor quality of life”.However, I did
not see so many results around the Sexual and Reproductive health outcomes except multiple
pregnancies
• In conclusion, you said, “Most of the women interviewed faced physical violence……”. It is
most of the women who are survivors of IPV (FGD participants). Is this the case with women
seeking health services