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PEER REVIEW HISTORY
BMJ Open publishes all reviews undertaken for accepted manuscripts. Reviewers are asked to
complete a checklist review form (http://bmjopen.bmj.com/site/about/resources/checklist.pdf) and
are provided with free text boxes to elaborate on their assessment. These free text comments are
reproduced below.
ARTICLE DETAILS
TITLE (PROVISIONAL)
AUTHORS
Between compliance and resistance: exploring discourses on family
planning in Community Health Committees in Mozambique
capurchande, rehana; Coene, Gily; Roelens, Kristien; Meulemans,
Herman
VERSION 1 - REVIEW
REVIEWER
REVIEW RETURNED
GENERAL COMMENTS
Carol Dawson Rose
University of California, San Francisco
US
18-Sep-2014
This paper discusses an important concept: the discourse between
community health and people in the community, with a focus on
critiquing policy decisions related to family planning in Mozambique.
According to the abstract this manuscript presents a qualitative
analysis of focus groups, informal conversations/interviews and
observations utilizing phenomenology as the methodological
approach. The analysis reveals conflicting discourses among
community members whose charge is to implement a national family
planning policy. I do find some methodological issues with the paper
and as a result of these concerns I believe the paper needs to be
revised toward increasing the study rigor.
Comments/
1. Background clearly presented. Literature presents the need to
expand access to family planning services and the
country/government approach in Mozambique that included
community health committee members (community members). The
authors stated goal in the last section of the background is
presented/written as “contribute to:
a. Understand how CHC’s implement FP promotion;
b. Recommend changes to CHC programs to increase (perhaps
improve) their outcomes;
c. Understand the different interpretations and perspectives on FP
and the complexities involved in the triangle of health practitioners,
CHC’s members, and users.
I am not sure what the study aim is; also, this is the first time the
issue of practitioners is mentioned as a focus and not sure who
“users” refer to? At the outset it is unclear what the focus of the
study is from the way it is presented.
2. Study methods. There is no mention of ethical review or informed
consent. I believe these should be presented in the methods.
Otherwise the methods are clearly stated at this point.
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I am unclear why “informal” conversations were included in the
methodology. Is there a citation for the use of these conversations
as part of the method? This is not part of standard qualitative
methodology.
3. Data analysis. I have some comments about data analysis.
How was phenomenological approach used as an analytic approach
in the analysis? From my understanding of this method it is also
used in the data collection approach: e.g. multiple interviews,
eliciting narratives from participants. Yet this approach is not part of
the author’s presentation. This needs clarification from the author. I
agree, your perspective of examining commonalities and
differences, and relationships are all part of the phenomenology
approach but from which data? The focus groups?
Triangulation of data increases the reliability of qualitative data,
however, in the last paragraph of the analysis section it is presented
that the study data sources also included literature review and policy
documents. These components are not mentioned earlier in the
study methods or data collection piece. What literature, what policy?
Did you code it?
Who coded the data? Was it a team experienced in qualitative
research methods? And how do you code the data. The line “finally
coded” does not provide enough details about how these data were
reduced.
4. Results. As a reader I need a presentation of the data. For
example out finding included several different themes such as:
composition and training of committees, functioning of committees,
and diversity of positions of FP. I think the paper would be
strengthened by presenting the authors interpretation of how these
“themes” relate to our understanding of how CHC’s implement
promotion of FP.
While, I found the quotes and some of the interpretation of the
results, interesting and related to the focus of your study, the amount
of explanation of your interpretation of these results is inadequate.
Show me your analysis and interpretation.
5. Discussion. The discussion is about CHC’s taking on the role in
the community and the challenges of community member and
identity and not as much about taking on the role of promoting FP. I
think the discussion is quite interesting in terms of how health
promotion and FP promotion as a community-engagement policy
could be derailed by inadequate attention to who is in the
community, cultural differences, knowledge, the top down approach
of the way the community members are engaged in this initiative in
the first place. However, I don’t find a natural flow of what the study
authors intended through to the discussion. The pieces of the paper
from background to results to discussion do not “hang together”. Or
in other words, the story is not clear.
6. Finally, the last two paragraphs, which aren’t paragraphs but
rather bullet point lists, read as awkward. I an unclear if this is how
you direct authors to conclude their manuscripts, As a reader these
lists don’t make sense as presented. A more robust discussion
where you engage your findings and the literature about :1 “the
users beliefs and reluctance of IUDs and sterilization as seen as
problematic” is needed. Just making that statement where is the
author engagement with the literature on this topic?
Quality of Written English Very Acceptable.
Statistical Review, this manuscript does not report on statistical
findings.
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I declare that I have no competing interests in this manuscript.
The reviewer also provided a marked copy with detailed comments.
Please contact the publisher for full information about it.
REVIEWER
REVIEW RETURNED
GENERAL COMMENTS
Starr Hilliard
Tulane University School of Medicine
New Orleans, LA, USA
26-Feb-2015
Throughout the paper, the in-text citations are not formatted
correctly. As stated in the BMJ Open submission guidelines,
“Reference numbers should be inserted immediately after
punctuation.” The number should appear immediately after the
period, without a space, and formatted as a superscript.
There is no discussion of participant consent in the methods section.
Page 2 lines 8 + 37: Why is the phrase "Family Planning"
capitalized?
Page 2 line 35: I believe that the plural possessive should be used "CHC members' activities"
Page 2 line 35: The phrase “influenced promoting FP” reads
somewhat awkwardly to me. Possibly change it to “influence
promotion of FP.”
Page 3 line 6: I would remove “a” from before peri-urban because I
think the sentence reads better without it.
Page 3 line 12: There is a typo and “the results” is repeated twice.
Page 3 line 14: The phrase “actual rural” is confusing. I think that I
understand what you are trying to say, that while Boane is rural,
there are other areas of Mozambique that are far more so. I would
choose a better word or phrase than “actual.”
Page 3 line 37: Why is “Total Fertility Rate” capitalized?
Page 3 line 38: I would recommend adding a short descriptive
phrase after the number 5.9, maybe something like “children per
woman.” This is merely my personal preference and it can be left as
is if you wish.
The first sentence of the second paragraph of the introduction
states, “In order to expand access to FP services, many developing
countries have implemented community-based approaches
particularly in rural areas where access to modern contraception is
limited.” This statement needs citations to support it. There is an
extensive literature on the use of community-based approaches in
resource-limited areas and I would recommend that you cite a few of
those studies here.
In the next sentence, “Additionally, very limited number of trained
personnel is available in rural areas,” it is unclear if you are referring
to Mozambique or developing countries in general.
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Page 3 lines 51-53: The phrase “equity-increased service use” is
confusing.
Page 4 line 12: Is the word “sections” supposed to be “sessions”?
Page 4 line 19: Why is the word “Community” capitalized?
Page 5 lines 3 + 8: I would recommend using a comma instead of a
period when expressing large numbers. For example, using 134,000
instead of 134.000.
Page 5 line 25: Change “collect” to “collecting”
Page 5 line 27: The phrase “this method allows to uncover aspects”
reads awkwardly.
Page 5 line 39: The sentence states, “Eight to ten participants of
both genders were present at each FGD.” According to Table 1, two
FGDs in Ndlavela included only women. Therefore, the previous
statement is false. In addition, the third group from Ndlavela only
included one man of nine total participants. Given that some of your
findings are based on the comparison of men vs. women (page 9
“However, female CMs were less favorable than male members to
promote more than 5 children), I think that you should add the
almost lack of male participants in Ndlavela to your study limitations.
Page 5 line 56: If possible, it might be good to try to NOT use the
word “experiences” twice is one sentence. I think that this is an
important sentence in describing your approach to data analysis, but
that as it stands, it does not read smoothly.
Page 6 line 5: “Understood” should be “understand” in order to align
with the present tense of the previous two verbs.
Page 7 line 16: I would recommend changing “by” to “of.”
Page 7 lines 36-39: The explanation of the type of training that the
CMs received is not clear. This is an important part of the results
section, because it helps the reader to understand what your
findings mean. I recommend including a more detailed description of
the type of training the CMs received and if/how the training differed
between the two study sites. What did the training consist of? What
did the “oral instructions” consist of? Be more specific.
Page 8 line 17: The phrase “most astonishing” reads more like it
belongs in the discussion section. I feel that this is an important and
interesting finding and that the analysis is spot on.
Page 8 line 19: The sentence, “In Boane, most female CMs agreed
‘breastfeeding’ includes giving liquids to babies,’” seemed out of
place. It appears to be the only sentence about breastfeeding in the
paper. What does this finding mean? How does it relate to family
planning? The sentence does not seem to fit with the paragraph
above it or the paragraph below it.
Page 8 line 31: Please describe the “traditional contraceptive
methods [based on traditional local practices].” What are they?
Provide a more detailed description and possibly examples.
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Page 8 line 36: Do you mean to say that some “CMs promoted
injections, pills and condoms”? In the previous statement, you say
the opposite.
The quote at the bottom of page 8 is actually associated with the
second to last sentence of the paragraph, not the last sentence.
Page 9 line 5: What does it mean that “some meetings with health
workers were postponed”?
Page 10 line 29: There should be a comma after “traditional.”
Page 11 line 5: Why is the word “Committees” capitalized?
I think that the discussion is very well thought out and well written.
VERSION 1 – AUTHOR RESPONSE
Reviewer Name Carol Dawson Rose, Associate Professor, University of California, San Francisco,
USA
Institution and Country University of California, San Francisco US
Please state any competing interests or state ‘None declared’: None declared
This paper discusses an important concept: the discourse between community health and people in
the community, with a focus on critiquing policy decisions related to family planning in Mozambique.
According to the abstract this manuscript presents a qualitative analysis of focus groups, informal
conversations/interviews and observations utilizing phenomenology as the methodological approach.
The analysis reveals conflicting discourses among community members whose charge is to
implement a national family planning policy. I do find some methodological issues with the paper and
as a result of these concerns I believe the paper needs to be revised toward increasing the study
rigor.
Comments/
1. Background clearly presented. Literature presents the need to expand access to family planning
services and the country/government approach in Mozambique that included community health
committee members (community members). The authors stated goal in the last section of the
background is presented/written as “contribute to:
a. Understand how CHC’s implement FP promotion;
b. Recommend changes to CHC programs to increase (perhaps improve) their outcomes;
c. Understand the different interpretations and perspectives on FP and the complexities involved in
the triangle of health practitioners, CHC’s members, and users.
I am not sure what the study aim is; also, this is the first time the issue of practitioners is mentioned as
a focus and not sure who “users” refer to? At the outset it is unclear what the focus of the study is
from the way it is presented.
Author answer: We agree with the comment. Indeed, the focus was implicit in the introduction and we
added more amendments. The three points are not the focus of the study, but the contribution this
study may add to the literature. The word “practitioners” will be replaced by the term “health workers”.
The first time we wrote the word practitioners was on page 3, paragraph 2. In the new version we use
only the word health workers.
CMs are expected to work in close relation with health workers in order to push users/clients to use
family planning services. Here, by users, we refer to clients of family planning. While the health
workers provide counselling sessions/practices at health care facilities, the committee members are
responsible for mobilising members of their community – family planning clients – to use and to look
for family planning services.
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This study aims to explore how members of community health committees act and address family
planning. Because committee members have a responsibility in the implementation of family planning
policy, we posit that: 1) CMs interact with family planning clients and health workers; 2) CMs may
converse and act upon family planning according to their socio-cultural background, and 3) CMs may
have different knowledge, expectations and perspectives which might interfere with family planning
initiatives.
2. Study methods. There is no mention of ethical review or informed consent. I believe these should
be presented in the methods. Otherwise the methods are clearly stated at this point.
Author answer: The new version took into account this omission in the study methods. Meanwhile,
based on Mozambican National Bio-ethical Committee for Health National’s recommended items, we
followed a specific informed consent agreement. Participants gave informed consent to be part of the
sampling. They were made aware of: the purpose of the study, the inclusion and exclusion criteria,
the procedure of the research, the voluntary nature of research participation, the procedure used to
protect confidentiality, the right to end their participation in the research at any time and finally, the
risk and benefits of the research.
I am unclear why “informal” conversations were included in the methodology. Is there a citation for the
use of these conversations as part of the method? This is not part of standard qualitative
methodology.
Author answers: In the literature concerning qualitative methods, there is no consensus if informal
conversations should or not included in the methodology. Some methodology manuals simply do not
mention if informal conversation should be or not be cited in the methodology section.
Meanwhile, in the case of our study, we included informal conversations in the methodology because
the use of this type of interview was helpful in foregrounding aspects of sociability, and reciprocity.
During the observation, when CMs were carrying domiciliary visits, informal conversation assisted in
better understanding clients’ motivations/expectations of promoting FP.
For instance, it was through informal conversation were some CMs were more open to talk about the
expectation of receiving a payment. As Bernard (2006: 211) argues, informal interviewing is a
technique characterised by a total lack of structure or control. We are open to receiving suggestion
whether or not we remove informal conversations from the in-text.
3. Data analysis. I have some comments about data analysis.
How was phenomenological approach used as an analytic approach in the analysis? From my
understanding of this method it is also used in the data collection approach: e.g. multiple interviews,
eliciting narratives from participants. Yet this approach is not part of the author’s presentation. This
needs clarification from the author. I agree, your perspective of examining commonalities and
differences, and relationships are all part of the phenomenology approach but from which data? The
focus groups?
We agree with the comment. Largely, phenomenology is used as methodology for multiple interviews
and narratives. Phenomenology is also used as an analytical approach. Generally speaking,
phenomenological analysis aims at clarifying the meaning of phenomena from the lived experience. In
the field of Sociology, there are different perspectives within phenomenological approach. For
instance, there are specificities from the contribution of Schutz, Berger and Luckmann, Garfinkel,
Cicourel, etc). We followed Berger and Luckmann.
One important thing not mentioned was this study is part of a broader research entitled “Plural
discourses and concepts related to contraception in Maputo province, Mozambique”. That study has
combined several techniques such as multiple in-depth interviews, FGDs, observation, and group
interviews with several actors.
In this article, we were only interested in discussing the concept of CHCs in implementing FP policy.
We used all data related to CHCs from FGDs. With CHCs, we held FGDs, informal conversations and
observation during the domiciliary visits as techniques to obtain information. In this article, following
Berger and Luckmann’s phenomenological analytical approach, we focused on the world life of CMs,
how this world life originated and is taken for granted by CMs. Also taken into account are how CMs
members formulate the idea of FP, how the knowledge produced is shared and how CHCs, using
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their knowledge, implement FP initiatives.
The phenomenology of Berger and Luckmann applies to crucial concepts in order to grasp the social
reality. Thus, we explicitly and implicitly adhered to notions such as knowledge about FP; the identity
of the members of CHCs; socialization (training of the committees); social roles, particularly when
CMs take responsibility in addressing and acting regarding FP; language – when specific language is
used according to the situation, and normality/abnormality when CMs define what is problematic
within the FP.
As methodology, we also applied phenomenology when we considered the examination of
commonalities, differences and relationships from the data of FGDs and observation of CMs’ activities
when conducting domiciliary visits. We compared what CMs said during FGDs discussions against
how they typically acted during their daily activities.
Triangulation of data increases the reliability of qualitative data, however, in the last paragraph of the
analysis section it is presented that the study data sources also included literature review and policy
documents. These components are not mentioned earlier in the study methods or data collection
piece. What literature, what policy? Did you code it?
Author answer: Thank-you for the comments. It was a fault we did not earlier mention the literature
review and policy documents in the study methods. We used policy documents as a secondary data
source for triangulation. We coded the policy documents. Code understood here is a word or short
phrase that symbolically assigns a summative salient, essence-capturing, and evocative attribute for a
portion of language-based or visual data. Thus, we read, underlined, coded, and analysed the content
of the Estratégia do Planeamento Familiar (National Family Planning Policy; the Plano Estratégico do
Sector de Saúde 2014-201 (Health Sector Policy of 2014-2019); and Termos de Referência para o
Estabelecimento e funcionamento dos Committees de Saúde (Terms of reference for implementing
and functioning of committees’ health. The literature review focused upon topics related to the
community-based approach, and family planning. The new version took into account the comment.
Who coded the data? Was it a team experienced in qualitative research methods? And how do you
code the data. The line “finally coded” does not provide enough details about how these data were
reduced.
Author answer: I have already answered the questions: “who coded the data” and “how do you code
the data” Please refer to the beginning of this letter. To answer the question: “Was it a team
experienced in qualitative research methods?”, I would say, researching is a process of learning.
Since 2005, RC has been working with qualitative studies.
RC has learned there is a need to develop personal attributes for coding such as induction, deduction,
abductions synthesis, evaluations, logical and critical thinking. Apart from the cognitive skills, there
are personal attributes such as, being able to deal with ambiguities, to exercise flexibility, and to be
rigorously ethical.
Meanwhile, it is important to consider that coding is not a precise science. Even with the contribution
of the team members for discussing and analysing data, it is primarily an interpretative action.
Undeniably, we agree the line “finally coded” does not provide enough detail. In the new version, we
made amendments to address this.
4. Results. As a reader I need a presentation of the data. For example out finding included several
different themes such as: composition and training of committees, functioning of committees, and
diversity of positions of FP. I think the paper would be strengthened by presenting the authors
interpretation of how these “themes” relate to our understanding of how CHC’s implement promotion
of FP. While, I found the quotes and some of the interpretation of the results, interesting and related
to the focus of your study, the amount of explanation of your interpretation of these results is
inadequate. Show me your analysis and interpretation.
Author answer: We agree with the comment. The new version includes your suggestions about
presenting the data and the interpretation of how these themes relate to our understanding of how
CHC’s implement promotion of FP. Concerning the second comment, if the reviewer could indicate
which interpretations are inadequate it would greatly assist us to reformulate the analysis. Meanwhile,
in order to indicate the analysis and interpretations in the new version, we have highlighted the
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amendments in yellow.
5. Discussion. The discussion is about CHC’s taking on the role in the community and the challenges
of community member and identity and not as much about taking on the role of promoting FP. I think
the discussion is quite interesting in terms of how health promotion and FP promotion as a
community-engagement policy could be derailed by inadequate attention to who is in the community,
cultural differences, knowledge, the top down approach of the way the community members are
engaged in this initiative in the first place. However, I don’t find a natural flow of what the study
authors intended through to the discussion. The pieces of the paper from background to results to
discussion do not “hang together”. Or in other words, the story is not clear.
Author answer: Thank-you for the comments. Perhaps because we were more influenced by the
analytical approach, we focused more on CMs taking the role in their communities as well as the
challenges and identities of CMs. Admittedly, we have neglected promoting the role of FP. We have
rephrased the discussion section so to include CHC’s role in implementing FP.
6. Finally, the last two paragraphs, which aren’t paragraphs but rather bullet point lists, read as
awkward. I an unclear if this is how you direct authors to conclude their manuscripts, As a reader
these lists don’t make sense as presented. A more robust discussion where you engage your findings
and the literature about :1 “the users beliefs and reluctance of IUDs and sterilization as seen as
problematic” is needed. Just making that statement where is the author engagement with the
literature on this topic?
Author answer: We agree with this comment. Indeed, the way it was presented is awkward. We have
made amendments and revised some literature on beliefs and myths about contraceptives. It was a
weakness we did not particularly engage with the literature about beliefs and misconceptions about
contraception. In the new version, we have taken this into consideration.
Quality of Written English Very Acceptable.
Statistical Review, this manuscript does not report on statistical findings.
I declare that I have no competing interests in this manuscript.
Reviewer Name Starr Hilliard, MS
Institution and Country MD Candidate 2018
Tulane University School of Medicine
New Orleans, LA, USA
Please state any competing interests or state ‘None declared’: None declared
Please leave your comments for the authors below
Throughout the paper, the in-text citations are not formatted correctly. As stated in the BMJ Open
submission guidelines, “Reference numbers should be inserted immediately after punctuation.” The
number should appear immediately after the period, without a space, and formatted as a superscript.
Author answer: Thank-you for this remark. The new version took into account the instructions for intext citations of BMJ Open. This article was transferred from Family Planning and Reproductive
Health Care to BMJ, and during this process, we forgot to change the style of in-text citation.
There is no discussion of participant consent in the methods section.
Authors answer: We state ethical approval only at the end of the article without presenting in the
methods section. The new version has included it.
Page 2 lines 8 + 37: Why is the phrase "Family Planning" capitalized?
Author answer: It was our error. Indeed the word family planning in this context does not need to be
capitalised.
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Page 2 line 35: I believe that the plural possessive should be used - "CHC members' activities"
Author answer: Thanks for the observation. We agree.
Page 2 line 35: The phrase “influenced promoting FP” reads somewhat awkwardly to me. Possibly
change it to “influence promotion of FP.”
Author answer: We agree and amendments were made in the new version.
Page 3 line 6: I would remove “a” from before peri-urban because I think the sentence reads better
without it.
Author answer: We removed “a” before the word peri-urban.
Page 3 line 12: There is a typo and “the results” is repeated twice.
Author answer: We agree and have edited the sentence.
Page 3 line 14: The phrase “actual rural” is confusing. I think that I understand what you are trying to
say, that while Boane is rural, there are other areas of Mozambique that are far more so. I would
choose a better word or phrase than “actual.”
Author answer: The sentence is revised in the new version.
Page 3 line 37: Why is “Total Fertility Rate” capitalized?
Authors answer: It was a typo. There is no need for using capitalisation, and we have revised.
Page 3 line 38: I would recommend adding a short descriptive phrase after the number 5.9, maybe
something like “children per woman.” This is merely my personal preference and it can be left as is if
you wish.
Author answer: We agree; it sounds better and more clear. The new version has included the
“children per woman”.
The first sentence of the second paragraph of the introduction states, “In order to expand access to
FP services, many developing countries have implemented community-based approaches particularly
in rural areas where access to modern contraception is limited.” This statement needs citations to
support it. There is an extensive literature on the use of community-based approaches in resourcelimited areas and I would recommend that you cite a few of those studies here.
Authors answer: Indeed, there is extensive literature on the use of community-based approaches.
Below, I present some of the literature and in the text, we included some experts.
Christopher, J.B., Le May, A., and Ross, D.A. (2011). Thirty years after Alma-Ata: A systematic review
of the impact of community health workers delivering curative interventions against malaria, and
morbidity in sub-Saharan Africa. Human Resources for health, 9:27.
Perry, H, & Zulliger, R. (2012). How effective are community health workers? An overview of current
evidence with recommendations for strengthening community health workers programs to accelerate
progress in achieving the health-related Millennium Development Goals. Johns HopkingBloomberrg
School of Public Health.
Abbot, A. & Luke, N. (2011). Local hierarchies and distributor (non) compliance: A case study of
community-based distribution in rural north India. Health Care Women Int. 32(3), 225-242.
Award, A., & Abahussain, E. (2010). Health promotion and education activities of community
pharmacists in Kuwait. Pharm World Sci 32: 146-153.
Ray, S., Madzimbamuto, F., & Fonn, F. (2012). Activism: working to reduce maternal mortality through
civil society and health professional alliance in sub-Saharan Africa. Reproductive Health Matters, 4049.
Mubyazi GM, Hutton G. Rhetoric and reality of community participation in health planning, resource
allocation and service delivery: A review of the reviews, primary publications and grey literature.
Rwanda Journal Health Sciences2012;1(1):51-6.
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Babalola, S., Sakolsky, N., Vondrasek, C., Mounlom, D., Brown, J., & Tchupo, J. P.(2001). The impact
of community mobilization project on health-related knowledge and practices in Cameroon. Journal of
Community Health 26 (6).
In the next sentence, “Additionally, very limited number of trained personnel is available in rural
areas,” it is unclear if you are referring to Mozambique or developing countries in general.
Author answer: We refer to both Mozambique and other developing countries. We have revised the
sentence.
Page 3 lines 51-53: The phrase “equity-increased service use” is confusing.
Author answer: We have reformulated and replaced by the phrase: “improve access and coverage to
basic health services”
Page 4 line 12: Is the word “sections” supposed to be “sessions”?
Author answer: It was a typo. We refer to sessions and not sections.
Page 4 line 19: Why is the word “Community” capitalized?
Authors answer: It was a typo. There is no need to capitalise the word community
Page 5 lines 3 + 8: I would recommend using a comma instead of a period when expressing large
numbers. For example, using 134,000 instead of 134.000.
Authors answer: In the new version, we considered 134,000.
Page 5 line 25: Change “collect” to “collecting”
Author answer: We agree; indeed it sounds better using the word collecting.
Page 5 line 27: The phrase “this method allows to uncover aspects” reads awkwardly.
Author answer: Thanks for the observation. In the new version the sentence was rephrased.
Page 5 line 39: The sentence states, “Eight to ten participants of both genders were present at each
FGD.” According to Table 1, two FGDs in Ndlavela included only women. Therefore, the previous
statement is false. In addition, the third group from Ndlavela only included one man of nine total
participants. Given that some of your findings are based on the comparison of men vs. women (page
9 “However, female CMs were less favorable than male members to promote more than 5 children), I
think that you should add the almost lack of male participants in Ndlavela to your study limitations.
Author answer: Agreed. The way the sentence was written gives the idea there was equal gender
representation which was not the case and contradicts the information of table 1. We should state
“Eight to ten participants were present at each of the FGDs.” We have removed “both genders”.
Indeed, we are not inferring those eight to ten participants were equally represented by both genders
in each locale. There were differences between Boane and Ndlavela in terms of gender
representation.
In Boane, gender equity in the Committee was achieved but family planning was viewed as a
woman’s concern.In Dlavela however, this was not possible to have gender equity. At the outset of
the Committee’s formation, gender equity was taken into account. Ultimately, it included only one man
as all the other male members gradually withdrew. This withdrawal was said to be caused by the
committee’s activities. Promoting contraception was considered a woman’s affair
Considering the lack of male participant in Ndlavela, we also view this as a study limitation. In the new
version, we have taken it into account. See the table placed in the abstract.
Page 5 line 56: If possible, it might be good to try to NOT use the word “experiences” twice is one
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sentence. I think that this is an important sentence in describing your approach to data analysis, but
that as it stands, it does not read smoothly.
Author answer: Sentences have been revised. See the new version.
Page 6 line 5: “Understood” should be “understand” in order to align with the present tense of the
previous two verbs.
Author answer: Sentences have been revised according to the suggestion. See the new version.
Page 7 line 16: I would recommend changing “by” to “of.”
Author answer: Sentences have been revised according to the suggestion.
Page 7 lines 36-39: The explanation of the type of training that the CMs received is not clear. This is
an important part of the results section, because it helps the reader to understand what your findings
mean. I recommend including a more detailed description of the type of training the CMs received and
if/how the training differed between the two study sites. What did the training consist of? What did the
“oral instructions” consist of? Be more specific.
Author answer: More information about training is included in the new version.
Page 8 line 17: The phrase “most astonishing” reads more like it belongs in the discussion section. I
feel that this is an important and interesting finding and that the analysis is spot on.
Author answer: Sentences have been revised according to the suggestion. The phrase “most
astonishing” was removed from the result section.
Page 8 line 19: The sentence, “In Boane, most female CMs agreed ‘breastfeeding’ includes giving
liquids to babies,’” seemed out of place. It appears to be the only sentence about breastfeeding in the
paper. What does this finding mean? How does it relate to family planning? The sentence does not
seem to fit with the paragraph above it or the paragraph below it.
Author answer: The sentence means: Although CMs blamed family planning users for prejudice
against natural contraceptive methods such as breastfeeding, this study also found contradictions
among some CMs. Some CMs themselves believe this natural method includes giving liquids to
babies. Exclusive breastfeeding is one of the natural contraceptive methods and thus is one
component of family planning. For some CMs and clients, exclusive breastfeeding does not make
sense. They think it should include other giving liquids to babies. We decided to remove the
sentences in the new version because we have presented other examples of misconceptions.
Page 8 line 31: Please describe the “traditional contraceptive methods [based on traditional local
practices].” What are they? Provide a more detailed description and possibly examples.
Author answer: Here by “traditional contraceptive methods [based on traditional local practices]”, we
mean indigenous contraceptives, such as herbs, amulets, and charms that are believed to prevent
pregnancy. This form of indigenous contraception is widely known and its prevalence often rivals that
of western methods. For instance, respondents mentioned seeds and/or roots of specific plants are
used to boil and drink in order to avoid pregnancy. Another traditional method consists in preparing
the first pad (used in the first day of menstruation) mixed with plants and a stuffed snail’s carcass
which is kept in a closed place – often buried.
To be more precise, we replaced the word traditional by indigenous contraceptives in the new version.
More information about indigenous contraceptives can be found in an earlier study by Agadjanian
(1999). Agadjanian, V. (1999). Women’s choice between indigenous and western contraception in
urban Mozambique. Women and health 28 (2), 1-17.
Page 8 line 36: Do you mean to say that some “CMs promoted injections, pills and condoms”? In the
previous statement, you say the opposite.
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Author answer: The sentences should be written in this way: “In both study sites, for those CMs who
agreed to promote modern contraception they were largely open to disseminate injections, pills and
condoms”. This means that although in the previous sentences there was not consensus about the
type of contraceptive should be used, there were some who promoted modern contraceptives such as
injections, pills and condoms yet rejected other alternatives like the IUD and sterilisation. We agree
that the way it was written was unclear. We have rephrased the sentence.
The quote at the bottom of page 8 is actually associated with the second to last sentence of the
paragraph, not the last sentence.
Author answer: Some changes of the position of the sentences were made in the text in order to
better position the quote expression.
Page 9 line 5: What does it mean that “some meetings with health workers were postponed”?
Author answer: Here we refer to regular meetings health workers had with CMs for monitoring
purposes. CMs work and/or report their activities and the need for brief instructions about how to
proceed in case means CMs often need additional information on promoting family planning.
Sentences were revised in the new version to be more precise.
Page 10 line 29: There should be a comma after “traditional.”
Author answer: We agree. The sentence has been revised.
Page 11 line 5: Why is the word “Committees” capitalized?
Authors answer: The word has been corrected. It was a typographical error.
I think that the discussion is very well thought out and well written.
I think that the findings are interesting and will add to the literature on community-based approaches
and specific ways in which to improve them. The in-text citations need to be reformatted. A few
statements in the introduction require further support by additional references. There are other minor
edits that need to be addressed. The discussion is well-written and interesting to read.
Author answer: Thank-you for the comment. The in-text citation was reformulated. Additional
references were included to the sentence in the introduction. The final version was edited.
VERSION 2 – REVIEW
REVIEWER
REVIEW RETURNED
GENERAL COMMENTS
CarolDawson Rose
University of California, San Francisco
US
13-Apr-2015
The authors have done a nice job of reworking the manuscript.
I do think there is one place to add a citation and some other small
comments. Thank you for allowing me to review your important
work.
The reviewer also provided a marked copy with detailed comments.
Please contact the publisher for full information about it.
REVIEWER
REVIEW RETURNED
GENERAL COMMENTS
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VERSION 2 – AUTHOR RESPONSE
Review for BMJ Open.
The authors have rewritten a manuscript that is very responsive to the reviewer’s comments. This
paper discusses an important concept: the discourse between community health and people in the
community, with a focus on critiquing policy decisions related to family planning in Mozambique.
According to the abstract this manuscript presents a qualitative analysis of focus groups, informal
conversations/interviews and observations utilizing phenomenology as the methodological approach.
The analysis reveals conflicting discourses among community members whose charge is to
implement a national family planning policy.
Author answer: Thank-you for the comment.
Comments/
1. Background clearly presented. Literature presents the need to expand access to family planning
services and the country/government approach in Mozambique that included community health
committee members (community members). The authors stated goal in the last section of the
background is presented/written as “contribute to:
- understanding how CHCs implement promotion on FP,
- understanding the different interpretations and perspectives of FP and the complexities
involved in the triangle of health workers, CMs and clients.
- recommend changes to CHC programs to improve their outcomes,
Page 5: the concept of problematic everyday life explains? Citation? Not sure what author
means in this sentence.
Author answer: We agree with the comment.The new version took into account this omission. We
included a citation and reformulated the sentence. We applied the concept of problematic everyday
life suggested by Berger and Luckmann (1966). We followed the phenomenology of both scholars,
which is the framework used in this study. They stress that the reality of everyday life encompasses
two kinds of sectors: 1) problematic everyday life, and 2) unproblematic everyday life.
According to both scholars, the reality of everyday life presents itself as a reality interpreted by the
individuals. In the context of our study, ccommittee members benefited from a brief training on family
planning providing them with basic knowledge. They were made aware of their “modus operandi,”
intended to promote contraception at the community level in what was implicitly considered an
unproblematic sector.
However, whenever a committee member deal with refusal of modern contraceptives or conflicting
views among committee members, health workers and policymakers, the counselling sessions were
viewed as problematic.
CMs have practical knowledge and a variety of instructions to deal with everyday life situations. As
well, they have information to deal with and implement family planning issues. However, CMs’
knowledge and day to day practice allow them to identify problems and/or interruptions. When this
happens, they are able to take on any problematic situation.
Another example of a problematic situation is obstacles encountered by CMs during the promotion of
family planning. These include quality of training, lack of payment, recognition by health workers, and
diversity of positions among CMs. All these challenges mean CMs constantly must deal with
problematic situations.
2. Study methods. Thank you to the authors for including a description of “informal conversations” and
including a discussion of how these data from conversations were folded into the analysis.
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Author answer: Thank-you for the comment.
On page 5 when the authors refer to the concept of problematic every day life, I think this needs a
citation.
Author answer: The new version took into account this omission. Thanks.
3. Data analysis. The authors have completed a skillful and adequate reworking of their methods.
Author answer: Thank-you for the comment.
4. Results. No further comments.
Author answer: Noted
5. Discussion. When the authors speak about how in “Ndlavela there was a stronger trend toward
pursuing the CHCs’ role than in Boane. These differences can be associated to training, sociocultural
background, differences in knowledge as well as geographical location.” I wonder if these findings
also provide support for theories of community participatory efforts (Nina Wallerstein and Meredith
Minkler) and the fact that CMs were given a higher value by staff at health centers in Ndlavala
compared to Boane, engagement and listening to the community may strengthen programs and
community member investiment.
Author answer: Thank-you for this reflective commentary. Unfortunately we could not access
Wallerstein and Minkler’s book entitled “Community-Based Participatory Research for Health: From
Process to outcomes, 2008”. However we did read Wallerstein N & Duran, B.’s article “CommunityBased Participatory Research Contributions to Intervention Research: The Intersection of Science
and Practice to Improve Health Equity, Am J Public Health 2010”. Thus, we are more inclined to
assume the findings of this study may also provide support for Community-based participatory
research (CBPR). This support may be achieved by bridging the gap between science/theory and
practice through community engagement and social action to increase health equity (see Wallerstain
and Duran 2010). Our study is an attempt to explore and disseminate interventions across two
communities in South Mozambique. By supporting such theories, it is our intention to address power
imbalances; facilitate mutual benefit among the community, health workers, policymakers, and
academic partners (by supporting theories).
Additionally, this study is intended to promote reciprocal knowledge incorporating community
practices into the research. Without a presuming to generalise, our study provides an illustrative
research example identifying barriers and challenges within the intervention and implementation of
family planning policy. It also discusses how Community-based participatory research can address
such challenges by fulfilling committee members’ expectations and improving training and
supervision.
For communities receiving inadequate services, this study provides a modest voice in research.
Hopefully, by giving voice to such communities, this may later lead to achieving success for the family
planning policy. However, we must also take into account that the real challenge is to develop and
sustain effective strategies to eliminate disparities in population health status as well as the health
system as a whole.
In this article, we add to the literature on intervention and implementation of family planning. This is
accomplished by identifying barriers and challenges to building bridges between theory and
community-based practices and policy. The success in Ndlavela is a telling example. CMs were given
greater respect by health workers. This was demonstrated by, when necessary, postponing regular
meetings, recognising their contributions, and by listening to them when they voiced expectations.
This should be considered a strong strategy for diverse communities to implement family planning
policy and improve health equity.
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For instance, in Mozambique’s peri-urban and rural areas, health workers are viewed as individuals
with strong symbolic power and/or high social status because of their occupation. Therefore, CMs
being recognised by health professionals could be another step forward in achieving the involvement
of community health members. By doing this, combining knowledge and action for social change
could improve community health participation and ultimately eliminate health disparities. However,
many barriers exist – conflicting views, differences in committee members’ sociocultural background,
and recognition from health workers at healthcare service centres. When such variances are
disclosed and addressed through CBPR approaches, this can lead to building programs and
community member involvement. However, the effectiveness of family planning policy continually
requires adaptation to local settings and consideration within complex systems involving all
partners.We made amendments in the table (in abstract) entitled Strengths and limitations of the
study. We also made alterations in the discussion section, and finally, we included more one
reference.
Wallerstein N & Duran, B. Community-Based Participatory Research Contributions to Intervention
Research: The Intersection of Science and Practice to Improve Health Equity. Am J Public Health
2010; 100(Suppl 1): S40–S46.
Quality of Written English Very Acceptable.
Statistical Review, this manuscript does not report on statistical findings.
I declare that I have no competing interests in this manuscript.
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Between compliance and resistance:
exploring discourses on family planning in
Community Health Committees in
Mozambique
Rehana Dauto Capurchande, Gily Coene, Kristien Roelens and Herman
Meulemans
BMJ Open 2015 5:
doi: 10.1136/bmjopen-2014-006529
Updated information and services can be found at:
http://bmjopen.bmj.com/content/5/5/e006529
These include:
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