Reviewer's report
Title:Prevalence of sexual coercion and its association with unwanted
pregnancies among young pregnant females in Kampala, Uganda: A
cross-sectional study.
Version:1Date:1 June 2015
Reviewer: Chinelo Okigbo
Reviewer's report:
— Major Compulsory Revisions:
The authors assessed the prevalence of sexual coercion and unwanted
pregnancy among women aged 15-24 in Lubaga division, Kampala Uganda and
then assessed the association between the report of sexual coercion and
unwanted pregnancy. This is a very relevant study especially for stakeholders
who are tackling the sexual and reproductive health challenges faced by young
women in Kampala, Uganda. Despite the relevance of this paper, there are
several key revisions that need to be made to improve the quality of evidence
this manuscript hopes to provide. I will provide the recommended revisions
according to the different sections of the paper.
1) Title: The title of this manuscript does not appropriately reflect its content.
Omitting to include “facility-based cross-sectional study” in the title gives the false
impression that the data used in estimating the prevalence is from a household
survey. Though this is a minor revision, it is important to providing an adequate
snapshot of the manuscript content.
2) Authorship: Three out of the seven authors of this manuscript only provided
critical review of the manuscript. This, in my opinion, does not warrant
authorship; instead, the three authors should be acknowledged in the
“Acknowledgement Section”.
3) Abstract: See the section on “minor essential revisions”.
4) Background: The authors provided a good background for the rationale for this
manuscript. However, there is room for improvement. Specifically, I would have
liked to see the rationale/reasons for some of the bold statements made in this
section. One of such statements is “young women are at a higher risk of sexual
coercion”. Why is that so? Also, the authors need to provide citation for this
statement. Another such statement is “Children born to such young mothers may
die within the first month of life …” Why is this so? Is there any evidence
supporting such statements? In the abstract, the authors stated “Current
literature focuses mainly on its risk factors but less on its resultant deleterious
health effects.” I would have liked to see this literature gap explore more in this
section. Additionally, how does this study fill that gap?
Also, I need to hear more about the sexual coercion and how it differs or
encompasses sexual violence. It will also be good to see a theoretical conceptual
framework of how you are thinking about the relationship between coerced sex
and unwanted pregnancy. Are factors that predispose to both outcomes similar
or different? And lastly, the percentages provided in this section should be
rounded to the nearest whole number for ease of reading and understanding.
5) Methods/study setting: The last five sentences in this section do not belong to
this section; they should go under the Background section. Additionally, the
authors should ensure they are not being repetitive.
6) Methods/study design and sampling procedures: There is a need to
emphasize that this is a facility-based study as it has unique challenges
especially as it pertains to generalizability of study results to the entire
population. Additionally, the use of both quantitative and qualitative studies
(mixed methods study) is a strength of this study. The authors need to highlight
this strength in the background section where they talk about the literature gap
and the significance of this study as recommended (#4 above). Despite the
strength, the readers need to know more about what informed the qualitative
study and what role the qualitative piece plays in the entire study. Although the
authors attempted to do this in the “Strengths and Limitation” section, they did
not provide adequate information on the rationale and role of the qualitative piece
(see my recommendations for that section below). The authors need to provide
more information in this section. Specifically, were the women interviewed in the
qualitative piece part of the quantitative sample?
7) Methods/data collection and measurement: The first sentence in this section
provides information that the lead investigator collected both the quantitative &
qualitative data for the study. Who is the lead investigator? Is she or he part of
the author list? Give more details about the qualitative data collection. Who
conducted the interviews, were the interviews audio-taped, how long did the
interviews last, where did the interviews take place, were the interviews
conducted in local languages or English? Also, were all participants (both
quantitative and qualitative study participants compensated for their time?
8) Methods/definition of variables: Why are you presenting the secondary
outcome before the primary outcome? The definition of sexual coercion does not
include the time variable; I suggest you make that a separate sentence. Also, in
your description of the questions used in assessing sexual coercion you said, “If
one responded ‘yes’ to at least one of the above, the response was classified as
sexual coercion in the past twelve months.” It would have been nice to examine
the prevalence of the different forms of sexual coercion as they may require
different policy and programmatic interventions. One of the questions used in
assessing the ‘circumstance surrounding sexual debut’ is “Or did you force your
partner to have sex?” Did you code this as forced first sex? Forced first sex
usually applies to the victim and not the perpetrator. That question measures
‘perpetrator-ship’ and nor ‘victim-hood’, so why did you use it in this instance. For
the ‘knowledge of contraception’ definition, does it include knowledge of
traditional contraceptive methods or just the modern contraceptive methods?
9) Methods/data analysis: Under the quantitative data subsection, you said you
included variables if found to be predictive of the outcome at p<0.15. Why did
you 0.15 instead of 0.05? Provide more information on this. Also, you were
repetitive on stating the statistical package used in data analysis. Ensure you are
not being repetitive in all the sections of this paper. Also, what are the model-fit
indices that you assessed? Provide more information on that. In the qualitative
subsection, what type of coding did you do – deductive or inductive?
10) Results/characteristics of participants: Since you are presenting your own
data, make sure you include the decimal points in the percentages presented.
You did so in some and rounded the others; be consistent. Does the proportion
of those who reported non-consensual sexual debut include those who reported
they forced their partners? As I mentioned earlier, these are perpetrators and not
victims. So please provide more information. Also, it would have been nice to see
the descriptive characteristics of the IDIs and the KIs.
11) Results/prevalence: Provide the proportion with post-secondary education.
What about those with only secondary education? You mentioned pre- and post-
but not those with only secondary education.
12) Results/PPR: You provided the adjusted PPR for women who experienced
non-consensual sexual debut, how did you ensure that these are not measuring
the same sexual coercion? That is, did the coerced first sex occur more than 12
months prior to the survey since your outcome variable ‘coerced sex’ was
measured within 12 months of survey? If you did not make this distinction, I will
like to know how you controlled for the collinearity between these two variables.
13) Results/types of sexual coercion and their relations with unwanted
pregnancy: You provided the prevalence of the different types such as what you
called ‘deception’ and ‘transaction sex’. Are these really types of sexual
coercion? I would think that they are situations in which coerced sex can occur.
Not all transactional sexual activities are coerced. And not all deceptions involve
sex. So revised these words to be more meaningful. Also, I re-formatted your
qualitative quotes, see attached word document. After each quote, you provided
the descriptive characteristics of the respondent. This is great; however, your
words are redundant. A 17 year old is an adolescent. There is no need putting
both words in the same description. Revise this for all your quotes. For the key
informant interviews, make sure the abbreviation you are using is KII and not KI.
Also, provide the age, gender and cadre of the KII in the description. A general
comment about all your quotes are that they are just descriptive and do not
reflect any in-depth analysis of the qualitative data. The fourth quote in this
section is embedded with multiple themes such as the issue of persuasion, the
drugging, dropping out of school, lack of parental support and possibly victim
blaming. How prevalent are these in the context and how do they relate to each
other? It is not okay to just paste descriptive quotes without further analysis of
what the quote represents. In the paragraph before the ninth quote you said,
“Seven though about abortion but they had no money …” Are these seven
women out of the eight IDIs or of all the women surveyed?
14) Discussion: The first sentence of the second paragraph is repetitive as it is
the same as the first sentence in the first paragraph of this section. Just say that
your result is consistent with a previous study and provide the estimates from the
previous study. Also, in the second paragraph, you said that your definition of
sexual coercion differs from that in previous studies. It will be good to provide
information on what differs for better understanding. The last sentence in the
fourth paragraph talks about having multiple sexual partners reduces the use of
contraceptive methods. Having multiple sexual partners and using alcohol do not
directly translate to non-use of contraceptive methods. Revise this sentence to
clearly show the relationship between engaging in risky behaviors and
contraceptive use. Finally, the discussion section is lacking the men’s
perspective and the need to involve men in the fight to reduce the prevalence of
sexual coercion and unwanted pregnancy. This is a two-way street so you need
to think about how to involve the other half and not just focus on the women.
15) Program implications: You recommended comprehensive se education as an
intervention for sexual coercion. This will not tackle all forms of sexual coercion
such as rape and transactional sex. What other ways can these types of coercion
be prevented/reduced? Also, you recommended youth friendly centers. Has this
been proven to be effective? There is recent discussion that youth-friendly
centers do not increase access to reproductive health services for the youth as
initially theorized. I will like to see other recommendations on how to reduce
these high prevalences. There needs to be free/affordable legal services for the
victims. What about mass media education, getting these into the political
agenda, and having legal punishments (such as jail time) for convicted
perpetrators? I need to see more practical/easy-to-implement recommendations,
the ones you provided seem to be text-book recommendations that are difficult to
implement.
16) Strengths and limitations: As I stated earlier, although the use of mixed
methods is a strength of this study, you did not describe how the quantitative and
the qualitative aspects complement each other. It seems like you just found
quotes that supported your numbers. That is not how mixed methods study is
done. The NIH working group on “Best practices for mixed method research in
the health sciences” described the criteria that need to be met to conduct a
mixed methods study. These are not highlighted in this study. If you did not meet
these criteria, I will suggest you separate both methods and talk about them as
two different studies. The NIH document can easily be found online, just Google
the title provided. For the last sentence in this section, you should talk about this
more throughout the paper. You structured this paper as a prevalence paper, you
need to tell us right from the start that this is a facility-based prevalence study
and so excludes those who did not seek care at the facilities, those who did not
get pregnant from the assault, and those who aborted the pregnancies.
— Minor Essential Revisions: The author can be trusted to make these. For
example, missing labels on figures, the wrong use of a term, spelling mistakes
1) Abstract: This is a well-written section; however, there are a few minor
grammatical errors. The revisions are included in the word document containing
track changes and specific comments which I have attached.
2) Results: Minor edits are recommended as suggested in the attached
document. Make sure you define your acronyms in the text prior to using them.
For example, you did not define what YFS stands for.
3) Discussion: Minor edits are also provided here.
4) Conclusion: Revise this section to make sure you are not being repetitive and
to reflect the new recommendations you will make.
5) Acknowledgment: This is a very long sentence; please revise.
— Discretionary Revisions: These are recommendations for improvement which
the author can choose to ignore. For example clarifications, data that would be
useful but not essential
None recommended.
Level of interest: An article whose findings are important to those with closely
related research interests
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.