Reviewer ’s report  
 
Title: Spanish Validation of Female Condom Attitude Scale and Female Condom Use in  Colombian Young Women  
 
Version: 0 Date: 07 Jun 2018  
 
Reviewer: Susan Witte  
 
Reviewer's report:  
 
This manuscript describes an important initiative to translate and adapt the Female Condom 
Attitude Scale for Spanish Language and to validate the scale using a sample of Colombian 
women. This is an essential contribution to the study of female condom use and acceptability. 
Promoting this device, one of only two dual barrier methods for STI and HIV prevention, is 
critical for women's reproductive health. There is tremendous utility in the findings, as this scale 
may now be immediately implemented in studies  of HIV and STI prevention and women's 
reproductive health within Spanish -speaking communities. There are some major concerns, 
however, that should be addressed prior to publication.  
 
While data analytic methods seem appropriate for the purpose of the pap er and appear to have 
been well -implemented, there is a significant issue related to the selection and screening criteria 
of the sample, and the study design not having included introduction of the device and 
opportunities for use. The overall scale questi ons are related to attitudes but also make an 
assumption about having used the device. For example "the female condom makes sex better for 
women," or "sex does not feel as good with the female condom." If a respondent did not have sex 
with the device, what  are they assessing?  
This makes it difficult to determine the relative strength of the findings as women were 
expressing attitudes towards a largely unknown and purely conceptual notion of the device.   
Nevertheless, authors find that the scale translates  well with strong alpha scores for most items 
and factor analysis identifies the same 5 factors of the original with the exception of a single 
item. While there is immediate utility and relevance to having this scale accessible for studies 
among women who may use the female condom for STI and HIV risk reduction globally making 
this study highly significant, there are also important limitations not yet acknowledged by the 
authors due to the study design.  
Authors may consider how to restructure the design de scription and discussion to address this in 
a more direct way to acknowledge that strength of having the validated scale, within the great 
limitations of the validation design.  Alternatively, if at all possible, it would strengthen the 
findings to redo th e test of validity using a design similar to Neilands and Choi, 2002.  
Below are additional specific recommendations to strengthen.  
Abstract:  
"Male and female condoms are the only dual -purpose devices to control such issues…"  
Recommend being more preci se about what authors mean here.  What do you mean "to control 
such issues?" Do you mean to reduce risk of unintended pregnancy? STIs? Both?  
 
N=387 in the abstract but some tables and figures throughout the manuscript have Ns that do not 
match this number . Footnotes are needed to explain differences in sample size(s) across analyses 
and presented graphics. Please check for continuity and consistency of sample size throughout 
the document.  
 
Background:  
Missing here is a brief discussion of the use of male a nd/or female condoms in Colombia. What 
is happening now? How might making female condom research and study more accessible 
improve the science of prevention in Colombia?  This would follow the epidemiology offered 
related to STIS and unplanned pregnancies in the first paragraph.  
 
Line 18: attitudes towards the female condom is noted as "one of the variables that best predicts 
consistent condom use…" There needs to be a more substantive discussion here regarding the 
variables associated with and predictive of use of the device.  More supporting literature is 
needed here to 1) identify other factors related to use of the device and 2) how these factors also 
relate to attitudes.  Similarly, the authors seek to examine the external validity (convergent and 
divergent validity?) of the scale with respect to other measures, but missing is a preliminary 
discussion regarding how/why this is important and how/why these measures are appropriate 
selections for this purpose.  Adding more information related to these fact ors and their 
relationships here and then later in the results and discussion following presentation relationship 
would strengthen the manuscript.  
 
State clearly that an additional purpose of the study is to evaluate experience with the device 
among the s ample of women. Experience is measured and reported upon, but it feels 
disconnected from the validation study. P. 6, line 23 authors say "as a parenthesis within the 
psychometric goal of the study." Consider centering it a bit more. It does not have to ove rshadow 
the validation of the scale, but given the limitations of the sample and our ability to interpret 
what the scale is measuring for women mostly unfamiliar with the device, it may be more central 
to the Results, Discussion and interpretation of findi ngs.  
 
Consider changing "Procedures" to "Methods":  
 
Why did authors select sociodemographics? Is there more background that could be provided to 
justify the choice of these demographics with respect to condom use or risk reduction?  
 
Results:  
Add discussion of findings related to convergent and divergent validity.  
 
This reviewer was not able to understand or make use/sense of the correlation matrix offered in 
Table XX. Can this be reformatted in a more traditional presentation so that the read er can see all 
relationships (please do not X out any).  
 
Why not examine relationship between knowledge and use of the fc and attitudes scale?  
 
Consider changing "Conclusion" to Discussion and incorporate a briefer "Conclusion" section at 
the end of the discussion.  
 
 
Discussion:  
 p. 7, line 25, "The relationships between the factors of the scale are consistent with the theory." 
What theory? Please backtrack to describe the theory informing the scale and integrate this into 
the Background, as well as the discussion of convergent and divergent validity factors/scales.  
 
Address here the issue of the item dropped. Why do authors believe this was necessary and with 
this population? Could it be related to the lack of experience with the device and/or sexual 
activity? This may also be added to limitations of the findings with regard to finalizing validity 
of the scale. Future research may be recommended to test validity of this version of the scale 
among sexually active women and to those who have been introduce d to the device.  
 
Is it possible on page 8 that these findings related to male versus female condom attitudes have 
everything to do with experience with a male condom but no experience with the female 
condom. This is important to address.  
 
Add a limitation s section in which the potential limitations are delineated or issues are explained, 
e.g. sample selection, online recruitment, and others noted above.  
It is finally at the very end of the manuscript that the discussion of convergent and divergent 
validity  come up. Please integrate throughout as requested in notes above.  
Add a Conclusion section that summarizes strengths and weaknesses of the manuscript 
contribution.  
Are the methods appropriate and well described?  
If not, please specify what is required in your comments to the authors.  
 
No 
 
Does the work include the necessary controls?  
If not, please specify which controls are required in your comments to the authors.  
 
Unable to assess  
 
Are the conclusions drawn adequately supported by  the data shown?  
If not, please explain in your comments to the authors.  
 
Unable to assess  
 
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.  
 
I recommend additional statistical review  
 
Quality of written English  
Please indicate the quality of language in the manuscript:  
 
Acceptable  
 
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, fees, funding, or salary 
from an organisation th at may in any way gain or lose financially from the 
publication of this manuscript, either now or in the future?  
 
2. Do you hold any stocks or shares in an organisation that may in any way gain or lose 
financially from the publication of this manuscript, eith er 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 t o 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?  
 
If you can answer no to all of the  above, write 'I declare that I have no competing interests' 
below. If your reply is yes to any, please give details below.  
 
I declare tha t I have no competing interests  
 
I agree to the open peer review policy of the journal. I understand that my name will  be included  
on my report to the authors and, if the manuscript is accepted for publication, my named report 
including any attachments I upload will be posted on the website along with the authors' 
responses. I agree for my report to be made available und er an Open Access Creative Commons 
CC-BY license ( http://creativecommons.org/licenses/by/4.0/ ).  I understand that any comments 
which I do not wish to be included in my named report can be include d as confidential comments 
to the editors, which will not be published.  
 
I agree to the open peer review policy of the journal