Reviewer's report
Title:Factors Associated with Intimate Partner Violence Against Women in
Rwanda: A cross-sectional study
Version:2Date:23 April 2015
Reviewer: Kristin Dunkle
Reviewer's report:
Comments for Authors
This paper aims to fill an important gap in the literature on IPV by conducting a
detailed analysis of DHS data on IPV from Rwanda. Little literature on IPV in
Rwanda exists, but current trends in government, civil society, and donor-driven
priorities are leading to expanded investment in addressing IPV in Rwanda.
Creating an expanded evidence base to inform these efforts is of considerable
value.
These comments are therefore offered in the spirit of strengthening the analysis
and presentation of findings.
Major compulsory revisions:
In the introduction and discussion, the authors note a dramatic increase in the
prevalence of reported IPV between the 2005 and 2010 DHS, and offer a
detailed discussion of the accompanying changes in Rwandan society during this
time. Given this, the choice to analyse only 2005 data is odd, and the assumption
that the pattern and magnitude of correlates will not have changed does not
seem justified. This assumption only holds if all identified correlates have
increased in reported prevalence in tandem with reported IPV, which seems
unlikely. They mention that the 2010 data is missing key variables, but the only
specific variable currently mentioned is the male partner’s alcohol use, which is
certainly important, but not overriding. It seems to me that it would be simple
enough to analyse both datasets and the changes between them using shared
variables, and supplement this analysis with additional analysis of 2005 only.
This might yield valuable recommendations on variables that need to be included
whenever a DHS survey includes the module on violence. Alternatively, the
authors may wish to confine themselves on an analysis of 2005 only, but reduce
or eliminate discussion of changes in reported prevalence between 2005 and
2010 and stick to a brief mention in the introduction and justification of the choice
of 2005, with a more extensive discussion in the limitations section of the
drawbacks of using 10 year old data.
The second major issue is the choice of outcome variable for analysis. They
explore physical IPV and sexual IPV separately, rather than the more common
choice of multinomial regression comparing physical IPV only, sexual IPV only,
and physical plus sexual IPV to a baseline of no IPV (see many prior analyses of
DHS data and other prevalence and correlates study). The reason for this
approach is that physical and sexual IPV are not really separate outcomes either
in concept or reality. Both physical and sexual IPV tend to occur as part of a
broader pattern of violence and controlling behaviour from a male partner.
Globally, as in this data, sexual IPV rarely occurs with accompanying physical
IPV (60% of sexual IPV reported by married women here is accompanied by
physical IPV, as is 87.5% of the sexual IPV among divorced/separated women).
Thus in the current analysis, the comparison in each case contains many women
who do experience IPV. The inclusion of physical IPV in the model for sexual IPV
and vice-versa is almost certainly masking the true correlation with other
variables which would become evident with a true “No IPV” comparison group,
making the analysis both statistically and conceptually cleaner. Making this
change to the analysis is incredibly important for fully understanding correlates of
IPV (and properly exploring change over time, if the authors choose to do this).
The point the authors make about co-occurrence of physical and sexual IPV is
important, but is best made through descriptions of overlapping prevalence, not
in the modelling. And yes, the sexual IPV only group may be too small to observe
ay significant correlates, but this is normal, and not a problem given the reality
that sexual IPV rarely occurs in isolation from physical IPV. Exploring different
patterns of IPV through multinomial regression also allows also allows for some
exploration of dose response, is examining the magnitude of association with the
more severe physical+sexual IPV form of IPV versus physical or sexual alone.
Minor essential revisions:
The authors start with 1888 couples (in the abstract) but end with 1800-1810 in
the multivariable regressions. Where did the missing people go?
In the methods, the authors mention that 4,066 women were randomly selected
and agreed to complete the special DV questionnaire. How many were selected
and refused? Do we know anything about how those women who refused were
different? How do we get from 4,066 to 1,888 (or 1800) couples? How are the
1,888 (or 1800) women different from the others?
How many male partners were selected/invited and interviewed versus refused?
What do we know about how refusers were different? How was couples data
linked? Were there discrepancies between men’s and women’s data to handle?
How were they addressed?
Was permission obtained from the National Institute of Statistics Rwanda in
addition to the National Ethics Committee? In the context of Rwanda, that is
perhaps worth a mention.
The authors may also want to present their model building in phases, with a
sociodemographic model only, followed by a model with behavioural correlates,
etc. In any event, I recommend building models both semi-forward (adding
variables in conceptual blocks and then eliminating those not significant) over
pure backwards elimination as this makes it easier to see what’s going on and
choose a best subset.
The discussion will doubtless be revised to reflect revised findings. I’ll just note
here again that talking about rapid social change since the 2003 constitution
doesn’t really make sense when drawing on 2005 data and not including any
tracking over time.
The discussion of changes in the law, justice system, Abunzi system, creation of
One Stop Centres etc is interesting and informative, but not currently tied to the
findings presented. This sort of discussion needs to be made explicitly relevant to
interpreting and contextualising the findings presented or cut from the paper.
Figure 1 is not relevant unless the 2010 data is used in the broader analysis. It
may not be relevant in any event, because while it is interesting and valuable, it
is largely unrelated to the rest of the paper. The point about Rwandan prevalence
in comparison to other countries can be made in the text and save space.
Figure 2 would be much easier to read and interpret if the circles had text labels
instead of A, B, C etc. It would also benefit enormously from a numerical
description of each circle’s overall size, as well as the size of each cell.
Is it only the 1888 married/partnered women who go forward in the analysis? The
378 divorced/separated women clearly have also experienced IPV (and again,
what happened to the rest of the 4,066 women who reportedly completed the DV
module?)
In the tables, if presenting couples data, please be clear for all variables which
were reported by the woman, the man, or both (with previous explanation in
methods of resolving any discrepancies).
Why does table 1 have an N of 1,517 at the bottom? That’s a significant
difference from the 1800-1810 in table 2?
Please make sure to use the same variable labels and reference groups in all
tables.
It’s not necessary to present a 1 for the reference group when presenting the
odds ratio for a yes/no dichotomous variable (or any dichotomous variable),
unless the editors request it.
Why is being employed for cash vs in kind a more relevant reference group for
husband’s employment than not working? (The risk is that readers may think the
referent cherry picked to show significance, unless there is clear theoretical
relevance.)
In table 2, number of children <15 becomes <5 (a typo). Also, is there any
theoretical reason that 3 or 4 children should be different from every other
number of children? Or could this be a random artifact of running multiple
comparisons?
I know this is a lot of feedback but I hope the authors will take it in the spirit of
really wanting to see an excellent product from this important analysis, revise and
resubmit.
Level of interest: An article whose findings are important to those with closely
related research interests
Quality of written English: Acceptable
Statistical review: Yes, and I have assessed the statistics in my report.
Declaration of competing interests:
I declare that I have no competing interests.