Title: Barriers to Health in Women of Reproductive Age Living With or at Risk of Non-
Communicable Diseases in Nigeria: A Photovoice Study
Version: 1 Date: 02 Oct 2022
Reviewer:  Monica Ewomazino Akokuwebe
Reviewer's report:
Reviewer’s Comments
1. How do you identify women of reproductive age living with or at risk of NCDs in Nigeria?
[Line 1 to Line 2]
2. I think without MMR, women are faced with NCDs. Kindly look for materials on women and
NCDS globally and in sub-Saharan Africa to aid you in writing the background of the Abstract.
[Line 30 to Line 31]
3. Photovoice framework or gadget…. incomplete statement. Is the photovoice a CBPR method?
Please clarify very well here in the abstract. [Line 37]
4. I do not see the relationship between this paragraph and women/ NCDs. [Line 59 to Line 68]
5. This sentence is not correct…there is an increased prevalence of NCDs in Nigeria, and it
varies across gender. [Line 69 to Line 71]
6. You see this sentence is contradicting the sentence above [Line 72 to Line 74]
7. Women of reproductive age are a group of women that are aged 15-49 years or 15-59 years
depending on the country. For Nigeria, it is 15-49 years. So, these women can be at risk with
NCDs and also not be at risk with NCDs. Some of these women might not have given birth or
may have given birth. So NCDs affect women of all ages 15-49 years. Generally, women can
be at risk of NCDs irrespective of their age. So, you must look for studies that are carried out
on women and NCDs. It is very important. [Line 75 to Line 76]
8. Are you also looking at women who are pregnant? The whole background is muddled or
mishandled. [Line 79 to Line 80]
9. I do not agree with you…. a lot of studies on NCDs and women …. NCDs are generally non-
contagious diseases…you can also add the 4 or 6 NCDs affecting women and their risk factors
(traditional or non-traditional risk factors) or (biomedical or non-biomedical risk factors). [Line
80 to Line 81]
10.  Is this the focus of your study? Then change the title to this and remove NCDs. [Line 83
to Line 84]
The aims of this study must align with the thematic sub-headings used in the results/findings.
[Line 86 to Line 91]
11.  This is not a study design. The study design is cross-sectional, and the study employed
a qualitative method, employing Photovoice, a community-based participatory research
method…. [Line 95 to Line 97]
12.  Clarify in-depth details on how it was used [Line 98]
13.  Review the objective here in line with the title of this study [Line 99 to Line 100]
14.  Is this related to your objective? [Line 101 to Line 103]
I do not agree with you…. both states are made as national representative states that have
lower rates of maternal mortality burden…..there are other states such as Osun state have the
highest level of poverty and maternal mortality ratio…what about those states across Niger
Delta or Northwest or Northeast with a heavy burden of maternal deaths. However, in Nigeria
the prevalence of health insurance coverage is 4% (Nigeria Demographic Health Survey,
2018) ….so health insurance coverage in individual states was not stated except you look for
community-based studies that have been conducted on health insurance coverage in each state.
Though, such health insurance coverage studies for each state are very few. But my question is
this, this is not the focus of this study…always remember you are looking at NCDs and their risk
factors among women of reproductive age (15-49 years). Be focused and stay on the suggestions
above [Line 113 to Line 115]
15. Women cannot be stratified but the LGAs can be stratified, or the States can be stratified….
check this very well. [Line 121 to Line 122]
16. Where did you get these results? Move them to the section for Results. [Line 127 to Line 128]
17.  Combine all these in one paragraph …..I thought your study on NCDs will be the major
discussion here…..think about it [Line 111 to Line 166]
18. Women of reproductive age start from 15 to 49 years. 18 years to 49 years will be given
a written consent form to fill out while women aged less than 18 years (> 18 years) are given
accent forms to fill…kindly check this. The form for women to sign and release their photos
should be in separate forms. [Line 168 to Line 172]
19.  Where are the socio-demographics of these women? [Line 174 to Line 175]
20.  I was thinking that taking pictures of food items across major markets in the selected LGAs
in Abuja and Lagos… let's see the differences…. take pictures of women and see what they
likely go for most in terms of food items, drinks, and water…NCDs are caused by two things:
(1) lifestyles or non-biomedical factors and (2) medical/bio-medical factors … [Line 190 to Line
192]
21. Start with the minimum wages (#18,000) for the low-income level… [Line 263 to Line 264]
22.  Wrong...is this your objective? [Line 347 to Line 349]
23. This is your aim…. know this [Line 351]
24.  This is just one of them…. what about others? [Line 259 to Line 260]
25.  This does not reflect the discussion on women of reproductive age and NCDs in Nigeria.
[Line 364 to Line 382]
26. Are there no strengths of this study? Is this a limitation? I do not think so [Line 384 to Line
388]
26. I did not see any valid discussion on the title and objectives of this study…even the results
are so wrong…. women and NCDs. Your findings must follow this:
1. Sociodemographic of women aged 15-49 years
2.  What are the common or major reported NCDs among women aged 15-49 years?
3. What is the prevalence of NCDs among women in Lagos and Abuja? What is the prevalence
of NCDs in Nigeria (Abuja and Lagos can be used as a national representative study for this,
as they have heterogeneous populations)
4.  Wrong and very wrong…..women and NCD ….right [Line 398 to Line 399]
27. They were never studied or researched in this study…..so this sentence is not supposed to
be in the conclusion [Line 402 to Line 403]
28. Include the Accent form for women aged less than 18 years because women of reproductive
age are 15-49 years [Line 420]
29. Not reviewed but the women read the accent and consent forms together with the approval
form of the usage of photos taken for this study with the assistance and supervision of a research
team member. [Line 421]
30. Nigerian women aged 15-49 years and NCDs are the focus and aim…. You have to separate
this study from the project. The objective of the previous study is far different from the present
study you are understudying. You must understand that clearly, …. The core objective of the
project was to investigate direct and indirect causes of maternal morbidity and mortality among
women of reproductive age (15-49 years) while the core objective of your present study is to
examine NCDs and risk factors among women of reproductive age (15-49 years) …Please, I
stand to be corrected. Your photovoice methods must show women aged 15-49 years with NCDs
and/or with or without risk factors [Line 430 to Line 431]
Selected Readings
Budig, K., Diez, J., Conde, P. et al. Photovoice and empowerment: evaluating the transformative
potential of a participatory action research project. BMC Public Health 18, 432 (2018). https://
doi.org/10.1186/s12889-018-5335-7.
Trübswasser, U., Baye, K., Holdsworth, M., Loeffen, M., Feskens, E. J. M., & Talsma, E. F.
(2021). Assessing factors influencing adolescents’ dietary behaviours in urban Ethiopia using
participatory photography. Public Health Nutrition, 24(12), 3615–3623. Cambridge University
Press.
Klingberg, S., Adhikari, B., Draper, C. E., Bosire, E. N., Tiigah, P., Nyirenda, D., &
Mukumbang, F. C. (2021). Engaging communities in non-communicable disease research and
interventions in low- and middle-income countries: a realist review protocol. BMJ open, 11(7),
e050632. https://doi.org/10.1136/bmjopen-2021-050632
Ghosh, U., Bose, S., Bramhachari, R., & Mandal, S. (2016). Expressing collective voices
on children's health: photovoice exploration with mothers of young children from the
Indian Sundarbans. BMC health services research, 16(Suppl 7), 625. https://doi.org/10.1186/
s12913-016-1866-8
Camille A. Sutton-Brown (2014) Photovoice: A Methodological Guide, Photography and
Culture, 7:2, 169-185, DOI: 10.2752/ 1751452 14X1 39999 22103165
Aribike, O., Okafor, I., Roberts, A., & Odugbemi, T. (2019). Are Nigerian Women Pro-Active
about Noncommunicable Disease Prevention? A Quantitative Survey. Annals of global health,
85(1), 38. https://doi.org/10.5334/aogh.2355
Gonfa, F. T., Lemu, Y. K., & Koricha, Z. B. (2021). Predictors of Women's awareness of
common non-communicable diseases screening during preconception period in Manna District,
Southwest Ethiopia: implication for a wellness check-up. BMC health services research, 21(1),
56. https://doi.org/10.1186/s12913-021-06067-2
Yaya S, Uthman OA, Ekholuenetale M and Bishwajit G (2018) Socioeconomic Inequalities in
the Risk Factors of Noncommunicable Diseases Among Women of Reproductive Age in Sub-
saharan Africa: A Multi-Country Analysis of Survey Data. Front. Public Health 6:307. doi:
10.3389/fpubh.2018.00307
Prevalence and determinants of non-communicable diseases risk factors among reproductive-
aged women of Nepal: Results from Nepal Demographic Health Survey 2016
Noncommunicable Diseases and Maternal Health: Noncommunicable Diseases and Maternal
Health – Maternal Health Task Force (mhtf.org)
Sikder et al.: Care-seeking patterns for fatal noncommunicable diseases among women
of reproductive age in rural northwest Bangladesh. BMC Women's Health 2012 12:2.
doi:10.1186/1472-6874-12-23