Title: Exposure to different types of mass media and timing of antenatal care initiation: Insights
from the 2016 Uganda Demographic and Health Survey
Version: 3 Date: 23 Oct 2021
Reviewer:  Aduragbemi Banke-Thomas
Reviewer's report:
Thank you for staking on board many of the comment sin my earlier review. I hope you can
be proud of the much-improved manuscript submitted. However, some more work is needed to
further improve the manuscript. Please try to address all the comments below and have another
thorough re-review of the manuscript, so that all can be done in the next round.
General comments
Please choose US or UK English. You are mixing the spellings All through. Choose one.
Do a thorough re-review of the manuscript for grammar, typographical and sentence
construction errors. I am still seeing a number in the manuscript. For example, “Different types
of mass media have been documented to have a significant associations with utilisation maternal
healthcare services in different parts of the world such as India, Nepal and South Asia [2, 4,
5]”. Please check.
Spell out all abbreviations on first use. For example, HIV, eMTCT etc.
Abstract
“Early initiation of quality antenatal care (ANC)…”. What is “quality” ANC? Is there ANC that
is not of “quality”? Please Remove quality in Front of ANC in all instances here and all through
the manuscript.
I believe I mentioned this in the first round. This is not about “impact of exposure to different
types of..”. Do you mean effect of exposure to…”. Impact is a big word!
This detail, “All our analyses were done using SPSS version 25 (Armonk, NY: IBM Corp)” is
not relevant for the abstract.
“TV” and “television” are both one word. Please spell out television in every instance in the
abstract and in the main manuscript. Do not use “TV”.
In line with the title of the paper, please align this statement “Exposure to TV and radio,
belonging to the Northern and Western regions, younger age and less household size were
associated with earlier ANC initiation” to focus on just media types, not age etc. In any case,
please do not simply repeat your results in the conclusion again!
Introduction
“Early initiation of quality antenatal care (ANC)…”. What is “quality” ANC? Is there ANC that
is not of “quality”? Please remove quality in front of ANC in all instances here and all through
the manuscript.
“Accessing timely and quality maternity healthcare…” Immediately define what timely means
as per the first trimester here and remove quality!
Please use maternal health services NOT maternal healthcare services!
“Accessing timely and quality maternity healthcare has been proven to lead to better pregnancy
outcomes”. Please focus on ANC and not other maternal health services.
Replace “…hefty…” and use a more technically appropriate word.
After defining ANC on first use, please don’t spell out antenatal care again. For example, here
“Antenatal care is an entry point to the utilisation of maternity healthcare services….”.
If you write this in the introduction, “Different factors including type of mass media exposed
to have been documented to promote the utilisation of maternal healthcare services”, it begs
the question what’s the point of your study then? Please remove and make the point on media
exposure affecting, but the gap is which type of media. This will be a stronger argument/
rationale.
All of this is irrelevant or unnecessary: “In 2012, Kisuule et al. looked at timing of ANC at a
national referral hospital and showed that 72.7% of the women did not know the right gestation
age at which ANC should be initiated [13]. However, the authors did not look at the association
of timely ANC initiation or knowledge with exposure to different types of mass media [13].
Bbaale analysed the 2011 UDHS and showed that only 17% and 47% of mothers initiated the
first ANC contact in the first trimester and attained at least four ANC contacts, respectively [14].
However, the author only included listening to radio as one of the variables but did not include
the other types of mass media [14]. Atuhaire et al. explored interrelationships between timing
of ANC initiation, postnatal care (PNC) and utilization of health facilities during childbirth and
further showed that initiating ANC early is an enabling factor for health facility utilization during
childbirth and timely PNC utilization [7]. However, the analysis was less focused on exposure
to the different types of mass media [7]. Mass media was made a composite variable combining
all the three types which does not give the effect of the different types of mass media on the
timing of ANC initiation”. Only flag ref 7 and 14 and summarise everything in one sentence.
This is to only say what is available in the literature and the gap identified. The actual results
of those studies can go to the Discussion.
Following the Above comment, please further reduce your introduction.
Please make the rationale for this paper clear. I believe I mentioned this in the first review.
Methods
“The primary outcome was early initiation of ANC defined as timing of first ANC contact within
the first trimester of pregnancy”. Too late to start defining the proper timing of the first ANC.
Please flag in the introduction.
Please check for the appropriate use of semi-colons. This is not appropriate “…factors included;
household…”. Check other instances.
“SPSS version 25.0 statistical software” Cite properly as done in the abstract.
“Two multivariable logistic regression models were made based on complete case samples with
the first one having mass media variables and the final one having other sociodemographic
independent variables that were found significant at bivariable level (p-value < 0.25)”. Not clear
at all. Why was < 0.25 used here?
Please describe how you handled missing data in your methods.
Please present consistently “…variance inflation factor (VIF) greater than 10”.
Results
“Missing 2109”. What does this mean? Are these all the missing cases? If yes, please state
clearly. More importantly, that’s a lot of missingness. Please describe how you handled missing
data in your methods.
Discussion
Needs a lot of work around structure and flow. Summarise main findings, interpret findings,
strengths and limitations, and then implications. Have one central idea per paragraph.
Not sure how Asp et al. relate. This sentence needs to be broken into two as they are two
different stories, “Although this is the first nationwide study that has looked at this topic, Asp
et al. explored the association between media exposure and birth preparedness in southwestern
Uganda, the study showed that women who read newspapers were more likely to have a  birth
and complication readiness plan while no association was observed with exposure to radio and
TV”.
This, “Overall, radio is the most popular media source compared with TV and newspapers/
magazines” is a major discussion point and needs to probably frame the first paragraph of the
discussion.
There are a number of unsubstantiated statements in the manuscript. Please reference
appropriately. For example, “. This could partly be attributed to the fact that most women reside
in rural areas where access to Newspapers or magazines is hard and not sustainable due to the
daily or weekly costs involved”. There Are many others. Please check.
“Different types of mass media have been documented to have a significant associations with
utilisation maternal healthcare services in different parts of the world such as India, Nepal and
South Asia [2, 4, 5]”. You cannot just write this sentence, without explaining those results and
linking Them to your study. This is the central thrust of your paper. Please expand on this.
You have to gently bring in the Internet discussion. It appears rushed and wrongly situated where
it is at the moment.
Linkage here, “The Northern region experienced a long civil war during and after which, several
interventions and humanitarian aid programmes majorly targeting maternal health services
and the fact that many people resided within internally displaced peoples’ camps with easier
maternity care access could partly explain the observed finding in the region [37]” needs to be
clearer.
This is not what means that findings Are generalisable “Furthermore, we used a nationally
representative sample with a high response rate of 97%for women. Therefore, the findings are
generalizable to all women in Uganda”. By this, I mean response rate! If I had a sample of two
women and both respond i.e. 100%. Does that make sense for me to assume generalisability
because of my 100% reference rate? In any case, you have a lot of missingness! Please think
about this Again and update accordingly.
Conclusion
This statement, “Late initiation of ANC precludes sufficient time to access the sufficient number
of ANC contacts thus missing opportunities for early intervention” cannot be substantiated by
your findings.
Please rework this section completely to align closely to your results.