Reviewer's report
Title:"Why me? I don't fit the mould ... I am a freak of nature": a qualitative study
of women's experience of gout
Version:1Date:23 October 2015
Reviewer: Rebecca Grainger
Reviewer's report:
The authors present data addressing an important and overlooked topic – the
experiences of women with gout. This study uses qualitative methods to describe
the experiences of 13 women with gout to describe patient experiences of gout
and the key factors and major issues within these experiences. This is an
important piece of work and I congratulate the authors for their efforts. I do have
significant feedback for the authors which, if adequately addressed would
improve this work before it would be acceptable for publication.
Major compulsory revisions
1. The purpose of the study is given in the initial section of the methods. I would
recommend that a final paragraph is added to the background where a research
question is stated and the methods adjusted accordingly.
2. The methods are well described and the qualitative metholodgy is sound. I am
very concerned about the inclusion criteria for participants and the impact this
may have on the data, with significant implication for the themes identified in the
data.
Participants are eligible with a “self-report” of a diagnosis of gout. There can be
significant clinical uncertainty about a diagnosis of gout made with anything less
than a aspirate positive for Monosodiumurate crystals although this can be
assisted in a parimary care setting by use of diagnostic rules (Janssenns et al
2010
http://archinte.jamanetwork.com/article.aspx?articleid=225738&resultclick=1).
Where a major theme found in the data is “experience of onset, help seeking and
diagnosis” where many participants found distress in uncertainty, it would be
ideal to describe the experience of women with gout where there could be some
certainty about the veracity of the diagnosis. The authors could have recruited
with the criteria of “a doctor has told you you have gout” OR sort to verify the
diagnosis with participant permission to contact treating doctors. In the absence
of this approach it would be useful at least to describe the relevant factors around
gout in Table 1 e.g. years of gout symptoms, years since gout diagnosis,
treatments (including urate lowering therapy) (as a diagnosis of gout usually
requires some form of treatment)), percentage tophaceous, to give some idea to
reader about the nature of the gout diagnosis in the participants. If in fact the
participants did have MSU-proven gout, this would be very useful to know!
This to me is a critical failing of this manuscript, particularly where the theme of
diagnostic uncertainty, and its impact, are made so strongly – maybe there is
uncertainty because the diagnosis has not been made with sufficient certainty!
The discussion and conclusion require an additional section to discuss any
limitations of the data relating to the uncertainty about diagnosis given the
inclusion criteria being self-reported gout (see section above). This is of critical
importance for this work to be widely accepted and needs to be addressed
before acceptance for publication.
3. Other limitations of the study need addressing. The recruitment process
volunteering needs to be acknowledged and addressed – people with strong
feelings about their gout are more likely to volunteer and the views may not be
representative of all women with gout. This is especially relevant as the biggest
increase in incidence is in the elderly women, who are less than one third of the
current study (4/14 participants).
Minor Essential Revisions
1. The authors use quoted statements from other authors three times (lines 50,
64, 76). None of these statements have extra context as a quotation of the
original author. I dislike this form of writing as it is unnecessary. I would
encourage the authors to rewrite these sections, using their own words to
present the information and then simply give a reference.
The quotations which are stated to be newspaper headlines (line 65 onwards)
are an appropriate example of quotations. However neither examples are
actually headlines. The first is a by-line and the second the first line of copy from
the article (reference 8
http://www.theguardian.com/lifeandstyle/2010/jul/05/the-gout-myth-health and
reference 9
http://www.dailymail.co.uk/health/article-1263744/Growing-number-women-suffer-gout.html,
both accessed 23/10/15). I suggest this section needs re-writing to reflect the
actual source of the quoted material.
2. Two sentences from line 71 – 74 both have the subject “it” which is gout.
Perhaps use gout rather than “it” to increase clarity for the reader.
3. Line 57 – the sentence with a subject about challenges with diagnosis of gout
in women has two supportive reasons BUT one of the reasons actually relates to
treatment. This sentence does not make sense as it is written and needs
revision.
4. Line 85 – male does not need to be in parentheses
5. Line 163 – why are there two ? after Joanne – please address this
6. Line 356 mentions data related to men as being “in this study”. Since the
presented data is the data on women only, the separately published data on men
from the larger cohort should be referred to separately and referenced.
7. Line 337 – seems to be missing a capital T to start the sentence
Discretionary Revisions
1. I note that there were 13 participants with the representative quotes provided
coming from 9 participants. I also note that of the 16 representative quotes 6
come from one participant (Georgina). If equally representative quotes to support
identified factors were available from other participants, it may be worthwhile
using them, to ensure readers that the findings are truly representative of the
data.
2. Paragraph beginning line 334. The authors state that gout has an impact on
physical and sexual aspects of participants relationship and suggest that the
main impact was dislike of being touched as they were worried about pain. The
quote provided illustrated the impact in part but also went on to imply pain relief
from sexual intercourse. The authors have inferred that this is pain relief from
orgasm, which might be the participants meaning, but is not entirely clear to me
from the quote given. I would have preferred a quote that was more
representative of the more frequent experiences rather than the given quote,
which may actually be more illustrative of the concept of non-pharmacological or
alternative disease management/pain relief. On some level I felt this quote was
included because of the candid description of the participants intimate life rather
than because it illustrated the authors conclusions well.
Level of interest: An article of importance in its field
Quality of written English: Needs some language corrections before being
published
Statistical review: No, the manuscript does not need to be seen by a statistician.
Declaration of competing interests:
I declare that I have no competing interests