Reviewer ’s report  
 
Title: SEXUAL INITIATION AND ASSOCIATED FACTORS AMONG FEMALE YOUTHS 
IN WEST SHOA, AMBO  TOWN, ETHIOPIA: A COMMUNITY -BASED CROSS -
SECTIONAL STUDY.  
 
Version: 2 Date: 28 Sep 2017  
 
Reviewer: Dr. Andras  
 
Reviewer's report:  
 
While the content and the findings of the article are very important, the text does not meet the 
standards required for a scientific publication. There are several problems with the English of the 
text, including many spelling and grammatical errors. Most disturbing is that a lot of spaces are 
missing between words. Poorly formulated sentences are hindering the reader to understand and 
process the content of the text. There are some parts where the fo rmulation leads to wrong or 
over-simplified statements. Although I give a list of some of these and giving suggestions on 
addressing them, I want to emphasize that it is just some of the places that need to be amended, 
and an overall, very careful editing is needed to improve the text.  
It is disturbing that there is no pagination and no running head in the manuscript.  
 
TITLE AND ABSTRACT  
The problem already starts with the title, which has one content issue, one language issue, and 5 
(!) spelling errors. If the paper is aimed to tackle early sexual initiation, why is it not reflected in 
the title? The "factors linked with it" formulation is clumsy, and hard to understand. 
Capitalization, hyphenating, and a lack of article for the noun "study" are erroneous . The authors 
may consider the following title: "Early sexual initiation and associated factors among young 
females in West Shoa, Ambo town, Ethiopia: A community -based cross -sectional study".  
In the abstract, the sentence "In addition, the timing of firs t sex is affected by a variety of factors 
and this makes the consequences of youth sexuality much more serious" is problematic. You 
should be more specific about what factors you mean, and what serious effects they may have. 
(There are several protective f actors, which may make youth sexuality - this is also a problematic 
formulation - well-informed, based on conscious decision, and a good experience.) I would 
consider saying something like: "There are some factors as X, Y, and Z, which proved to be 
associa ted with the risk of premature sexual activity in young people. If youths are exposed to 
these factors, this may have serious consequences on their health."  
The sentence "Data was entered, cleaned by using Epi -Info version 3.5.1 and exported to SPSS 
versi on 16.00 for analysis" is not needed in the abstract.  
"(AOR=2.75, 95% CI; 1.74, 4.34)" should be "(Adjusted Odds Ratio [AOR] = 2.75, 95% CI: 
1.74-4.34)" and so forth; from the second mentioning, the AOR abbreviation does not have to be 
resolved.  
In the abstract, you say "In general, educational status, age group, peer pressure, alcohol 
consumption and watching pornographic materials were predictors for the sexual initiation." In 
the "Result" (should be "Results"!), however, you stated educational level i s not influencing 
sexual initiation.  
You say: "Therefore, building life skill, an active effort to promote sexuality education, 
establishing and strengthening youth center/club should be intensified, particularly for young 
women, in making informed decisi ons about sexuality issues to reduce youth reproductive health 
problems." -  Should be skillS; what should be strengthened in youth centerS/clubS?  
 
INTRODUCTION  
Page 4, rows 52 -56: "In addition, adolescents take part in sex activities because of the factors 
such as peers, unlicensed erotic video films exposure and the desire for economic gain (8). Due 
to this, a substantial proportion of youths are participated in  their earlier sexual activity."  
A more proper formulation of this part might be: "In addition, adolescents' engagement in sexual 
activities may be influenced by several factors, such as peer pressure, exposure to unlicensed 
erotic material, or possible economic gains (8). Due to these effects, a substantial proportion of 
young people are initiated into sex prematurely."  
Page 5., rows 4 -5: "Any sexual activity before marriage is regarded as the [sic!] reproductive 
health problem in adolescent." - is not justified with any references, and it sounds quite 
problematic. Do you think, that sexual activity in marriages - for instance, if the woman is a 
victim of domestic violence - does not pose health problems?  
Page 5, rows 6 -10: "Studies showed that the pro portion of premarital sexual practice among 
youths in Oromia region (31%) is higher compared to national (19%) (9). however, factors that 
contribute to early sexual practices were not as such dealt in -depth within the study area." 
Instead of this formulati on, I suggest saying: "So far conducted studies demonstrated that the 
proportion of premarital sexual activity among [how old?] young people in Oromia region was 
31%, which is significantly higher [?] than the national average (19%). However, factors that 
influence early sexual initiation in Oromia youths have not yet been studied in detail."  
Page 5, row 14 and later mentions: I would refrain from using the term "sexual commencement" 
and keeping the terminology "sexual initiation" (maybe alternating with " sexual debut" or "first 
sexual intercourse").  
In general, the introduction does not make it clear whether you will deal with overall sexual 
initiation, or with early sexual initiation. For the latter, you don't provide definition. I give some 
suggestions for that later.  
Another point the introduction does not clarify: why did you just studied women? (Early) sexual 
initiation of young men is not influencing their health? What is your rationale for just including 
women in this study?  
 
METHODS  
What are "keb eles" (p. 6., rows 14 -15) and "Gots" (p. 6., row 41)? If the text says there are three 
kebeles, it does not seem to be necessary to name them 01, 02 and 03 - or at least, there is no 
explanation why will it be needed.  
Page 6., row 38: "Finally, 675 sample  sizes were used." - This sentence does not make sense. Do 
you mean that finally 675 subjects took part in the study?  
Page 6, rows 51 -54: "In cases where no eligible respondent found in the chosen household,  the 
data collectors have gone to the next house hold to the right direction until they got eligible 
female youths." - What does "right direction" mean?  
If Tables 2 and 3 are within the text, why are Tables 1 and 4 at the end of the manuscript and 
duplicated?  
Page 7, row 7: "We adopted the questionnai re from EDHS, 2011 (6)." For those not familiar with 
the EDHS, you should add a couple of sentences on what is this questionnaire, what are the 
questions, etc.  
Page 7, rows 18 -23: Correct abbreviation for statistical probability is p.  
Page 7, rows 37 -38: It is not unequivocal who wrote letters of support to who.  
Page 7, rows 44 -46: The formulation "were not forced" has a very bad connotation. I would 
reformulate the sentence to indicate respondents were free to decline participation, a nd we made 
it sure that if they decide so, their so far administered data will not be stored.  
 
  
RESULT (CORRECTLY: RESULTS)  
Page 8, row 9: Under "forty questions" do you mean "forty questionnaires"?  
Page 8, rows 11 -13: Correctly: "The mean age of the resp ondents was 16.74 years (SD = 2.1, 
range: X -Y)." X and Y are the ages of the youngest and oldest participant.  
Page 8, row 16 -16: What is "Orthodox followers"?  
Page 8, row 24 -26: Pocket money was not mentioned so far. If you analyse it, you should outline  
in the introduction what is the rationale for that. What does pocket money mean in Ethiopian 
context? What may be the difference between girls who have pocket money and who don't? 
Please also give the equivalents of the Birr values in Euro.  
Page 8, rows 28-29: I would change the subtitle "Sexual involvements". First, you give 
prevalences for sexual initiation; why under 18 years is important? One of the most important 
parts of the article is Table 2, where you summarize what was the reason for the partici pating 
women to have sex for the first time. I would give more details in the text what were exactly the 
reasons, and how did you find these out. What does "maturity" mean? For me it suggests that 
some young women believed if they have sex they will look m ore mature, am I right? What does 
"need for marriage", or "getting gift" mean? Do you know more about what does "forced sex" 
mean?  
Page 9 -11, peer pressure and non -sexual risk behaviours: I suggest reformulating these parts, and 
beside descriptive statist ics, compare the occurrence (or the lack) of these behaviours among 
those who had early sex (before the age of 16) and who had sex later, or not at all. It would be 
very informative to see whether peer pressure, drug or alcohol use, and exposition to 
porno graphy is different across these groups. I'd also make it more explicit that the latter three 
are not referring to time of first sex, but to general occurrence.  
Page 11: You shouldn't make a difference between predictor variables according to their p -value, 
because not the size of the p -value but the effect size what tells whether the given predictor 
variable change the odds for sexual initiation. However, since you make multiple comparisons, it 
would be important to control the significance values for Ho lm-Bonferroni procedure. Since all 
adjusted odds ratios and their confidence intervals are given in Table 4, they shouldn't be 
repeated in the text one in one. Instead, I would outline how the predictor values change the odds 
for sexual initiation (e.g., " Those young women who chewed Khat were found to 1.3 times more 
likely to already have been engaged to sexual intercourse than those who did not consume 
Khat"). You should also outline what were the potential confounders for which you controlled 
the odds ra tios.  
 
  
DISCUSSION  
Page 12, row 9: What is G. C.?  
Page 12, rows 20 -21: What is DHS2011, and what should be the value there?  
Page 12, rows 28 -29: Instead of "In our finding" - "We have found that"  
Page 12, third paragraph: You shouldn't repeat exact values of odds ratios  
Page 13, rows 10 -11: Under "Substance users were more than once" you mean those who have 
tried a given substance more than once?  
Page 14, rows 14 -15: "Therefore, firming the norm  of virginity, which delays sexual intercourse, 
should be advocated." The word "firming" sounds problematic. Again it is something which may 
be relevant to Ethiopian culture - but in a meta -analysis of North American sexual health 
promotion trainings it wa s found that instead of pressing virginity and telling adolescents to 
delay sexual activity, it was more useful to teach kids life skills that help them making informed 
decisions. You may find it useful to consult this article 
(http://www.tandfonline.com/d oi/abs/10.1080/00224490209552120 ) and integrate its conclusion 
with your discussion. For the same reason, I'd be more careful in stating "restricting video". It 
sounds unrealistic, and the problem couldn't be solved with that, if Internet will be more broa dly 
available in Ethiopia.  
 
GENERAL COMMENTS  
A general problem with the article is that in the abstract you talk about "early" sexual initiation, 
but then "early" and overall "sexual initiation" is mixed up. You even do not define what is the 
input variab le in the regression models - am I right that you compare the odds of those who had 
EVER have sex to those who hadn't?  
You may have reasons for this - maybe premarital sex as illegal in Ethiopia, or regarded as a bad 
thing? However, I would be more specif ic than "sexual initiation", and rather concentrate on 
"early" sexual initiation. Getting initiated to sex in late adolescence may be regarded as normal 
in many cultures, and may be an integral part of entering into adulthood. It is a question how to 
defin e "early" in this context, but most researchers agree that sex before the age of 16 counts 
early initiation. You may find useful to consult these literatures: 
http://www.tandfonline.com/doi/full/10.1080/13625180701617621 ,  
http://www.sciencedirect.com/scien ce/article/pii/S1054139X10001047 ,  
https://bmcpublichealth.biomedcentral.com/articles/10.1186/1471 -2458 -8-136,  
http://www.euro.who.int/__data/assets/pdf_file/0003/303438/HSBC -No.7 -Growing -up-unequal -
Full-Report.pdf?ua=1 .  
I suggest that you include these co nsiderations to the article, make references to the literatures I 
mentioned above, and recalculate the statistics using 15 years or less as a threshold for "early" 
initiation.  
I understand English is not the first language of the authors, however the tex t needs to be 
carefully re -read and edited, preferably by a native speaker first.  
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.  
 
Yes 
 
Are the conclusions drawn adequately supported by the data shown?  
If not, please explain in your comments to the authors.  
 
Yes 
 
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 am able to assess the statistics  
 
Quality of written English  
Please indicate the quality of language in the manuscript:  
 
Not suitable for publication unless extensively edited  
 
Declaration of competing interests  
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