Reviewer's report
Title: Risk Perceptions, Sexual Behaviours and Cultural Practices related to HIV
and AIDS in Bunda, Ukerewe and Serengeti Districts, Northern Tanzania
Version: 1 Date: 28 January 2011
Reviewer: Jerry Okal
Reviewer's report:
Major Compulsory Revisions:
The author in his arguments seems to understate the role of culture in
understanding of the socio-cultural dimensions of HIV/AIDS that is needed for an
effectiveprevention approach. To delve into this the paper will establish how culture is a
determinant of health and a means to communicate and encourage behavior
change for HIV/AIDS prevention through various forms (eg theatre, music,
dance, traditional medicine, etc.) Further examination on this will give the reader
a better sense of the implications of culture on sex behavior but also draw
important implications for prevention and interventions; and determine how at risk
populations receive and interpret health messages. Bringing this up, in my
opinion would give the reader a good background of cultural practices and risk
taking behavior of the researched community.
It appears that culture remains little understood especially in the epidemiology of
diseases such as HIV/AIDS and other STIs among the general population.
Thus, the author could do well to explain how culture and disease risk intersect to
explain increased vulnerability and further state how elements of HIV prevention
are applied and interpreted among these population groups. In my opinion the
primary focus of the paper should be to define how cultural practices interfere
with safer sex practices this requires highlighting these cultural elements in more
detail. Thus, additional data and supporting information on practices such as wife
inheritance, same-sex practices, death cleansing, wife sharing etc should be
teased out and be the gist of the paper.
We quite agree with the observations of this reviewer about culture remains little understood in the
epidemiology of HIV/AIDS and other STIs.However, the gist of this article is not portray culture as a
determinant of health but rather to emphasise the importance of understanding sexual behavior and other
social economic and cultural parameters in context in order to design effective HIV/AIDS interventions.
We did not intend to study Sexual Culture which we believe is another broad area of study.
Having said that I feel the title of the
paper may need to be revised if the authors choose to take this path.
We have not chosen the path proposed by the reviewer because the gist of this article is different.
Furthermore, there is no possibility of collecting additional data as this was a one time consultancy-no
possibility of getting additional funds. However, we have changed the title to suit our area of
concentration.
If the paper
is to remain as it is then the relationship of risk, sexual behaviours and cultural
practices should be well defined and argued.
Yes, the emphasis in the article has shifted to sexual behaviour in context-the content and meaning of
sexual behaviour are in focus. Risk perception has been downplayed and cultural practices have been
addressed as traditional practices which not necessarily hinder AIDS control efforts but rather act as
foundation on which effective health education interventions should be built on.
Finally, the author needs to review
the abstract carefully (the results section of the abstract is rather confusing) and
main parts of the paper require careful review for comprehensibility, far too often
repetitions of concepts are made and flow of ideas lacking. Ensure that the
quotes and texts are consistent with the the arguments fronted.With these
changes the paper will make important contributions to the literature.
The results section of the Abstract has been carefully reviewed. Results have been more systematically
presented and in more details. Repetition of concepts have been avoided and the flow of ideas is more
logical. The quotes and texts are consistent with the arguments fronted.
Discretionary Revisions
1. How was confidentiality of study participants maintained by the study team?
What was the content of the information sheet given to participants.
2. The last paragraph of the abstract needs clarification: the authors state that
"The study revealed that both pre and extra-marital sex were common in study
communities which are predominantly Christian and polygamous. Cultural
practices were also reported to exist including death cleansing through
unprotected sex. Other risk sexual behaviors, cultural practices and their
contexts are presented in details and discussed. Reported preventive measure
against HIV was low levels of condom use with both regular and casual partners.
Some HIV-infected people were reported to deliberately infect others and
draconian measures were proposed against them." I highly doubt this is
comprehensible seems like a broad claim.
3. Last paragraph of the background section is unclear and is left hanging how is
the information on planned AMREF interventions tied to previous HIV
interventions in Mwanza region. Please show the relationship.
4. Apply standard in house referencing style.
5. Can the authors illustrate how convenient sampling strategy was carried out in
the methods section ? How was balance for age/gender ensured? Were study
participants compensated in any way?
5. In my opinion the first two paragraphs of the results section should be under
the methods section as it is the description of participant characteristics.
6. Please tell your reader more about the themes under discussion, tease data
and relate information to the quotations. The section on "risk perceptions of HIV
and AIDS" in my view require critical review.
7. Can the authors state limitations of the study?
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 I have no competing interests
Reviewer's report
Title: Risk Perceptions, Sexual Behaviours and Cultural Practices related to HIV
and AIDS in Bunda, Ukerewe and Serengeti Districts, Northern Tanzania
Version: 1 Date: 15 February 2011
Reviewer: Ami Moore
Reviewer's report:
Title—Risk perceptions, sexual behaviors and cultural practices
This paper covers an important issue. However, there are significant issues that
need to be addressed. Also, there are several errors. Below are my comments.
Abstract
Background
The authors hoped to achieve the following: “informing development of new and
modifying existing interventions”. I am not sure if this goal was achieved because
of all the issues with the manuscript.
Methods
The authors stated that they formulated hypotheses, but I did not see any within
the paper. Am I missing something?
The statement has been dropped as there was no hypothesis which was formulated
Background
1. Are the authors absolutely certain that “little is known on how African societies
understand sexually transmitted infections (STIs) including HIV”? There are
studies that have indicated that not only Africans understand HIV, but they are
also changing behaviors. Thus, evidence suggests that HIV incidence has fallen
in 22 sub-Saharan African countries (see UNAIDS report on the global epidemic
(2010)). Perhaps, if the authors believe that in some rural areas these changes
are not occurring, then they need to be specific.
The said statement has been dropped. What the reviewer is claiming is true. We have included recent
material from UNAIDS report on the global epidemic, 2010.
Additionally, some of the cited
works that they mentioned are outdated (Larson, 1989; Munguti et al. 1997, Pool
& Washija, 2001. In my opinion, significant progress has been made in the fight
against HIV and AIDs in Africa in the past 5 years or so. Thus, the authors might
want to check more recent works.
We concur with reviewer’s comments-we have dropped outdated work and included more recent work.
2. The authors should provide at least one citation for the following statements:
“Epidemiological studies on HIV and AIDS for instance, have tended to view
sexual behaviours as a set of isolable and quantifiable encounters and to treat
risk as correlated primarily with the number of partners” and “These findings are
usually explained superficially and at times have caused controversy as some
scholars have argued that the findings are value biased against African
societies”.
The said statement has been removed from the article.
Methods
1. The first paragraph gives a description of the setting and this should not be in
the methods section.
We think that a description of the setting is trying to situate a study ( the study area) and this is part of the
methodology
2. The selection of participants is ambiguous to me. The participants were drawn
from the bigger sample of people who took part in “the questionnaire survey” (by
the way, this should read ‘survey’). I gathered that the participants for this survey
were randomly selected. If so, why were FGD participants conveniently selected?
What is the purpose of mixing the two groups? If there is any methodological
justification, the authors need to clearly state this.
This section has been revised. Under Study design and sampling procedure selection of study
participants has been made explicit that purposive sampling design was adopted.
Results
My main and general concern here is the way the findings are presented. The
authors should try to ground these in a theoretical framework instead of just
primarily stating what the participants have said.
Findings of this study emanated from the data which is the product of grounded analysis (see Methods
section). In this article we cite actual data in verbatim quotes as a prerequisite of findings to be
independently and objectively verified.
However, below are my specific
comments.
1. I believe that it will be good if the authors would specify the percent of
participants who reported specific behaviors, beliefs, etc., instead of using
phrases such as “many”and “a few”. For instance, on page 10, second and third
sentences: “Many study participants perceived themselves to be at risk of getting
infected with HIV because either they or their partners may not be faithful in
relationships. A few who did not consider themselves to be at risk said that they
and their partners are faithful to each other (e.g. they do not have sex out of
wedlock/steady partners)”. What percent is many and what percent is few?
We agree with reviewer’s comments. Percentages have been computed and given.
2. Additionally, it would be good if the authors give some background information
about the persons that they quoted. For example, instead of saying “one FGD
participant remarked”, they should add information about the age, gender, marital
status, occupation, etc. This will give the reader some kind of context.
Reviewer’s comments are valid. We have included informants’ age, sex, occupation and place at the end
of each quotation.
3. Page 18. Out of the blue, the authors talked about “the 96 interviewees not
being able to correctly point out all the necessary steps involved in the correct
use and disposal of a condom apart from the common knowledge of saying that
is used for safe sexual intercourse”, what about the other sample (517)? Also, an
important information that one gathered from this page is the lack of knowledge
of proper use of condoms. How prevalent is this?
We have withdrawn the said statement from an article. However, this came from 96 interviewees who
were asked that question. The 517 participants of FGDs were not asked that question.
Errors
1. Pages 2, 11, and 21: ‘Risk sexual behavior’ should read sexual risk behavior
or risky sexual behavior. Please check throughout the manuscript to make sure
this has not been overlooked in other pages.
Corrected.
2. Page 15, last sentence under heading ‘Cultural circumcision practices”: HVI
should read HIV.
Corrected.
3. Page 31, reference # 17. The title of the paper is: Papers that go beyond
numbers (qualitative research) and not “How to read a paper: Papers that go
beyond numbers (qualitative research).
The correct title of the paper is: ‘How to read a paper: Papers that go beyond numbers (qualitative
research.’
Level of interest: An article of importance in its field
Quality of written English: Acceptable
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
Reviewer's report
Title: Risk Perceptions, Sexual Behaviours and Cultural Practices related to HIV
and AIDS in Bunda, Ukerewe and Serengeti Districts, Northern Tanzania
Version: 1 Date: 3 February 2011
Reviewer: Henrike Korner
Reviewer's report:
This is an interesting paper and important for the development of socially and
culturally appropriate and interventions and prevention programs in this particular
context. The research question is well defined and clearly stated, and qualitative
research methods are relevant and appropriate.
The strength of this paper is that the risk practices of individuals are explored in
the specific social and cultural contexts in which they occur, and the meaning
which are attributed to these practices. There are, however, some issues that
need some more detail and clarification to improve the paper.
Methods:
Can the authors describe the three study communities in some more detail.
Some issues become clearers as the reader gets to the Results (e.g. Christianity
as the predominant religion, polygamy) but it would be good for the reader to
know more about the context.
The context is given that we were contracted (as consultants) by Sida –District Development Programme
Musoma office, Tanzania to undertake KAP research on HIV and AIDS so as to obtain data to inform
development of new and/or modifying existing interventions in the three districts of Bunda, Ukerewe ans
Serengeti which they support.
The three study communities communities have been described in details under Methodology section.
Questions/issues the authors may want to
consider: the relationship between Christianity and polygamy and other cultural
practices that seem incompatible with Christianity; why is the distinction between
fishing and non-fishing villages important (mobility, wealth?); socio-economic
status of these villages (are they poor or relatively affluent); what are
‘sub-villages’, do these villages have tribal structures, or any form of hierarchy,
etc.
One of the intriguing findings of this study is the existence of polygamy and Christianity and other cultural
practices which are incompatible. We have no comments on this finding.
The distinction between fishing and non-fishing communities is important in this study because we
wanted to compare sexual behaviours of the two communities in relation to HIV and AIDS given the
findings from previous studies that fishing communities were more prone to HIV infection due to
epicurean and extravagant lifestyle of fishermen.
In Tanzanian government structure sub-villages (harmlets) are smaller administrative entities which form
a village. It is a collection of several households.
Villages have loose traditional structures in the sense there are tribes (ethnic groups) and clans with their
leaders but their powers are limited to tribal/traditional functions. The overall powers are vested upon
Village Executive Officer who is an employee of the government and the village chairman who is elected
by the villagers.
Can the authors explain why they conducted both in-depth face-to-face
interviews and focus group discussions. What was the purpose of each? What
similar/different topics were explored in these interactions?
We conducted both FGDs and interviews to enhance methodological triangulation. The purpose of
interviews was to obtain individual perceptions, attitudes and practices in relation to HIV and AIDS as
opposed to FGDs which where meant to elicit the same but more at group level. The topics explored
were more or less the same as described under the present sub-section -methods for data collection.
page 8, lines3-4: ‘Homogeneity, seating arrangements ... were observed.’ Can
the authors provide details how these aspects of the focus groups were
observed.
Homogeneity of FGD participants: We invited people who had more or less the same socio-economic and
educational background.
Seating arrangement-These words have been removed. However, seating arrangement for FGD require
participants to sit in a semi-circle so that the moderator/facilitator could easily see them (eye cointact) and
a note taker could record non-verbal responses (body language).
Results:
I find it somewhat problematic to single out HIV-infected people deliberately
infecting others as a separate ‘theme’. First, because the data that the authros
present are really only second-hand knowledge from participants who allege to
have ‘observed’ this behaviour by others. This says actually more about HIV
stigma in these communities than about risk behaviour and cultural practices.
Secondly, infection is only possible if individuals do not protect themselves
appropriately. Sexual practices are a two-way street. I think it would be better to
integrate these findings under the other headings, or under a heading ‘HIV
stigma and risk’.
This theme has been withdrawn.
The section ‘Men who have sex with men’ needs some more in-depth treatment.
There is only one example, and that relates to sex between father and son. Is
male-to-male sexual contact a common practice in these communities? Is it
generally accepted or is it stigmatised?
This section has been withdrawn.
page 15 last sentence of first paragraph: This sounds as if HIV tests are carried
out before traditional marriages or in any other circumstances described in this
paper. This sentence can probably be deleted because HIV testing is not
mentioned in relation to any of the other sexual practices described in the paper.
Otherwise, can the authors comment on HIV testing.
The said sentence has been withdrawn.
Discussion and conclusions:
The conclusions are generally sensitive to the cultural practices which the
authors discussed in their findings and raises important issues for the
development of prevention programs.
However, the comment about no major differences in risk perception among
those who had partners involved in extra-marital relationships and those who
said they had not’ (p. 20) is problematic. First, this difference is not evident from
the data as they are presented. Second, we cannot assume that participants
knew whether their partners had extra-marital relationships or not. Alternatively,
the authors could comment on participants who said that they had extra-marital
relationships compared to those who said they did not.
We agree with reviewer’s comments. The said conclusion has been withdraw. Moreover, the Conclusion
section has been tremendously improved.
General comments and revisions:
The authors frequently talk about the transmission of HIV and AIDS (e.g. page
11), or risk factors for HIV and AIDS. This should be amended to ‘transmission of
HIV’. (AIDS cannot be transmitted.)
Corrected.
para. 2 last sentence: ‘... as many scholars have argued’ – this needs references
This statement has been withdrawn.
p. 5: ‘Epidemiological studies on HIV and AIDS ...’ – needs references
This statement has been withdrawn.
page 13 line 1: ‘part-time sex with a concubine ...’: This is not clear and needs
some explanation. What is ‘part-time sex’ (casual sex?)?
This has beeb corrected. By part time sex we mean casual sex.
What do the authors
mean by ‘concubine’ (casual partners?)? Is this something that is practised by
men only or by men and women? Maybe the authors can provide some
examples from the interviews to make this clear.
This has beeb corrected. By concubine we mean casual partner. It can be both a man or a woman. In this
context we mean a man.
Recommendation:
Major compulsory revisions