Title: Risky sexual behavior and associated factors among reproductive age women in Eastern
African countries: A multilevel analysis of the recent demographic and health survey
Version: 0 Date: 01 Feb 2024
Reviewer's report:
Title: Risky sexual behavior and associated factors among sexually active women in Eastern
African countries: A multilevel analysis of the recent demographic and health survey
Submission ID: edc34754-f8e6-49d4-b1ed-dc623e5b0002
Dear editor in chief;
Thank you for considering me to review this manuscript.
General Comment:  The study was done on ‘Risky sexual behavior and associated factors
among sexually active women in Eastern African countries: A multilevel analysis of the recent
demographic and health survey' which is among the major public health problems in the East
African region. Besides, it was done using a large sample size which gives the study enough
power to enhance the validity of the findings. However, the study does have major caveats in
methodological approaches to consider it for publication as it stands now.
Specific comments
Abstract
1. Result:
1.1 The authors should indicate the directions of association of the exposure variables with risky
sexual behavior in the result part of the abstract.
1.2 Besides, some variables that are independently associated with risky sexual behavior in the
result part, for example, drinking alcohol, are not briefly summarized under the result part of
the abstract.
Conclusion
1.3 Line 47-48: Individual and community-level variables were associated with risky sexual
behavior. This is more general; the authors should conclude only for the variables they included
in the study which are independently associated with risky sexual behavior.
1.4 Line 49-50: Better to improve the healthy behavior of women by minimizing alcohol
consumption and strengthening HIV testing…. Alcohol consumption is not indicated in the
result part of the abstract
2. Introduction
2.1 The authors should have started the introductory part with the second paragraph (with the
definition of risky sexual behavior) rather than starting with describing sexually transmitted
diseases as the main objective of the study is not studying sexually transmitted diseases and
their determinants.
2.2 Only a single theme should be addressed in a paragraph; the authors have addressed more
than one theme in a single paragraph, for example, the second paragraph
2.3 The study gap the authors described is not convincing; ample studies have been done on
this area. What knowledge gap does the study fill? All the variables you mentioned statistically
associated with RSB are redundantly found associated with it.
3. Methods
Study population, sampling technique, and analysis
3.1 The authors should have unequivocally described the population. Who are sexually active
women? How many such women were included in the original survey? For how many of them
the outcome variable data are incomplete? For how many of them did you finally get complete
data and include in the study?
3.2 The sampling design of the surveys is what guides your data analysis technique. What is the
sampling design of the surveys? Was it similar for all the surveys? Please describe it
3.3 The analysis technique is not clear; why multilevel? How many levels of sampling are there
in the original survey? Is there a nesting of the lower lever variables in the upper-level variable?
How many levels did you consider for your data analysis? What is the lowest level grouping-
variable you considered to have an effect on the lower-level variables? How did you measure
that this grouping-variable does have an effect on the lower-level variables? Are the residual
errors of the variables in similar level correlated? How? Is the variance between the grouping-
variable is more than 50% of the total variance? How did you check that the variance between
the grouping-variable favors multilevel? Please clearly explain them in your analysis plan.
Study Variables
3.4 The way the exposure variables were selected is not clear.  It seems that some potential
exposure variables are missing from the study, for example, the relationship with the sexual
partner
3.5 The way some exposure variables were measured, for example, Community media exposure,
community literacy, and community poverty is not clear. Are they measured this way in the
original DHS survey? If not the authors should operationalize them.
4. Result
4.1 Some of the variables included in Table 2 and their description are not sociodemographic
variables. For example, test for HIV, drinking alcohol, knowledge of HIV, and ever heard about
STI. Therefore, the authors should correct the sub-topic
Model fitness and random effect analysis
4.2 An intra-class correlation coefficient of 29.73% is not that much informative about the
existence of variation between the clusters. Some scholars suggest that an ICC of # 50% suggests
the existence of variation. Besides, ICC only indicates a violation of the independence of
sampling from the different clusters. The authors should first conduct the log-likelihood ratio test
of multivariable logistic regression (without considering the levels) and the random intercept-
only model (null model) to check whether the cluster-level variance favors multilevel logistic
regression or not.
4.3 It is also better to use information criteria (AIC and BIC) to select the best-fit models as they
penalize the parameters that overfit the model
4.4 Tables 3 and 5 can be merged
5. Discussion
11.1 The authors should indicate the meaning of their findings before comparing them with
others' results
11.2 Some of the implications are merely authors' openions rather than being substantiated with
assertive pieces of evidence
12. Conclusion
12.1 The conclusion is not written in a way that guides policy makers and other stakeholders
and should be revised.
12.2 “…Individual and community-level variables were associated with risky sexual behavior.”
The authors should conclude for their specific variables which are independently associated with
RSB.