PCLM-D-25-00083

Waterlogging, Health and Healthcare Access in Southwest Bangladesh

PLOS Climate

Dear Dr. Clech,

Thank you for submitting your manuscript to PLOS Climate. After careful consideration, we feel that it has merit but does not fully meet PLOS Climate’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

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We look forward to receiving your revised manuscript.

Kind regards,

Zerina Lokmic-Tomkins, PhD, MSc

Academic Editor

PLOS Climate

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Additional Editor Comments (if provided):

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Does this manuscript meet PLOS Climate’s publication criteria ? Is the manuscript technically sound, and do the data support the conclusions? The manuscript must describe methodologically and ethically rigorous research with conclusions that are appropriately drawn based on the data presented.

Reviewer #1: Yes

Reviewer #2: Yes

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2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

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3. Have the authors made all data underlying the findings in their manuscript fully available (please refer to the Data Availability Statement at the start of the manuscript PDF file)?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception. The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: No

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4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS Climate does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

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5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: My main concern is that the study is quite broad, and the ontological issues are not adequately addressed in either of the main models:

The model evaluating the effect of waterlogging on illness or health does not differentiate between types of illness, likely including chronic conditions that are unrelated to waterlogging. This lack of specificity may introduce bias, potentially exaggerating the observed association.

The model assessing the impact of waterlogging on healthcare service utilization does not distinguish whether the services were sought due to waterlogging-related illnesses or for unrelated pre-existing conditions. The phrase “conditional upon illness reporting” does not resolve this issue. In reality, while service utilization may increase due to a rise in waterlogging-associated illnesses, it may simultaneously decrease for individuals with chronic conditions, or for maternal and child health needs, due to access barriers during flooding. Failing to distinguish between these scenarios may dilute the attribution of healthcare utilization to waterlogging. Separate analyses for waterlogging-related illness and other pre-existing conditions would yield more meaningful inferences.

A fundamental ambiguity remains: Is the study aiming to assess the impact of waterlogging on healthcare utilization due to waterlogging-related illness, or regardless of the cause of illness? This distinction is crucial. If the nature of the illness is not considered, healthcare utilization may appear to decrease simply because waterlogging prevents people from accessing care, even if their condition is unrelated to flooding.

When evaluating the impact of waterlogging on health, it is important to clearly define the types of illnesses considered. It would be inappropriate to include pre-existing chronic illnesses in a model examining waterlogging-related health effects. Waterlogging is more plausibly associated with acute conditions such as gastroenteritis, vector-borne diseases, skin infections, injuries, drowning, and—under certain conditions—hypertension (e.g., due to saltwater intrusion in coastal areas), as well as mental health challenges. Including chronic conditions like diabetes, cardiovascular disease, or kidney disease in the analysis could bias results. Was data on the type of illness available? If so, how was it used to reduce the risk of misclassification and potential bias?

Minor Concerns:

Regarding the wording in the methods section (under “Conceptual approach and data structure”):

The sentence “we could expect people exposed to waterlogging to enjoy a greater probability of using healthcare services” should be revised.

The word “enjoy” implies a positive or desirable experience, which is ethically inappropriate in this context. A more neutral phrasing is recommended.

Regarding the selection of households based on pregnancy and children under two years of age:

While this makes sense for studying maternal and child health service utilization (e.g., antenatal and postnatal care), individuals with chronic conditions also require regular access to services (e.g., for diabetes, dialysis, or cardiovascular disease). The rationale for limiting the sample to households with pregnant women or young children needs to be explained, especially since the study aims to examine the general association between waterlogging and healthcare utilization.

Additionally, illness within the past 30 days may mostly capture acute conditions and not chronic conditions. If pregnancy and children under two were among the inclusion criteria, there should be a subgroup analysis or at least descriptive findings related to this population, regardless of statistical significance. I was surprised that the population distribution table does not include any information on these groups. This is not a criticism of the study design, but rather a suggestion to enhance the generalizability of the findings.

Finally, please clarify how Out-of-Pocket Expenditure (OOPE) was measured.

Given the reliance on self-reported data, responses may be inaccurate or imprecise. What steps were taken to minimize response bias or random reporting in participants' answers regarding OOPE?

Reviewer #2: Dear Authors,

Thank you for the opportunity to review your manuscript examining the impact of waterlogging on health service utilization and household out-of-pocket expenditures in Tala upazila, Bangladesh. This is a timely and policy-relevant study that shines light on an underexplored dimension of climate-driven flooding and its consequences for health-care demand. I offer the following detailed feedback:

Overall Assessment

The research question is clearly motivated by the increasing frequency and severity of waterlogging events in low-lying coastal areas.

Your cross-sectional survey of 596 households (1,266 respondents) provides an adequate sample to estimate associations between exposure and health outcomes.

The sequential probit models for (a) reporting illness and (b) seeking formal care are conceptually sound and correctly specified.

Statistical Analysis

Strengths:

Appropriate choice of probit regression for binary outcomes.

Inclusion of key confounders (age, gender, education, wealth quintile, chronic illness status).

Presentation of coefficients with robust standard errors, 95 % confidence intervals, and p-values.

Sensitivity checks excluding outlier spending households, with stable waterlogging effects.

Suggestions:

Consider reporting marginal effects in addition to coefficients for more intuitive interpretation.

If possible, explore heterogeneity by wealth or gender (interaction terms), while noting potential power limitations.

Acknowledge any potential clustering at the household or community level and, if data permit, adjust standard errors accordingly.

Data Availability

Current Statement: “The data will be provided in a file with the manuscript upon acceptation.”

This does not meet PLOS Climate’s requirement for immediate, unrestricted data access.

Please deposit the de-identified household survey dataset and all analysis code in a public repository (e.g. Zenodo, Dryad, Figshare) and update your Data Availability Statement with DOI or persistent link.

Methodological Clarity

Please provide additional detail on how waterlogging exposure was measured (e.g. survey item wording, verification).

Clarify response and non-response rates, and whether any weighting was applied to adjust for sampling design.

Ethical Considerations

You note IRB approval; please include the approval number and name of the ethics committee for completeness.

Confirm that all participants provided informed consent and that data were anonymized prior to analysis.

Discussion & Limitations

The discussion is balanced in acknowledging self-reporting bias and lack of supply-side variables (clinic distance, capacity).

You may wish to expand on potential mechanisms linking waterlogging to increased illness reporting (e.g. vector-borne diseases, sanitation breakdown).

In summary, this manuscript makes a valuable contribution to understanding climate-related health risks. After addressing the data-sharing requirement and clarifying the few methodological details above, I recommend it for publication in PLOS Climate.

Best regards,

Wisdom Adzigbli

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Reviewer #1: No

Reviewer #2: Yes:  Wisdom Adzigbli

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Waterlogging, Health and Healthcare Access in Southwest Bangladesh

PCLM-D-25-00083R1

Dear Dr. Clech,

We're pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you'll receive an e-mail detailing the required amendments. When these have been addressed, you'll receive a formal acceptance letter and your manuscript will be scheduled for publication.

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Kind regards,

Zerina Lokmic-Tomkins, PhD, MSc

Academic Editor

PLOS Climate

Additional Editor Comments (optional):

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

Reviewer #2: All comments have been addressed

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2. Does this manuscript meet PLOS Climate’s publication criteria ? Is the manuscript technically sound, and do the data support the conclusions? The manuscript must describe methodologically and ethically rigorous research with conclusions that are appropriately drawn based on the data presented.

Reviewer #1: Yes

Reviewer #2: Yes

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3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

--------------------

4. Have the authors made all data underlying the findings in their manuscript fully available (please refer to the Data Availability Statement at the start of the manuscript PDF file)?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception. The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

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5. Is the manuscript presented in an intelligible fashion and written in standard English?<br/><br/>PLOS Climate does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

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6. Review Comments to the Author<br/><br/>Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: (No Response)

Reviewer #2: Thank you for the thorough revision. All major concerns raised in the previous round including clarification of the downscaling workflow, the new sensitivity analysis with the 20 km product, and the expanded discussion of urban-heat implications have been fully resolved. The study is now technically sound and the conclusions are firmly supported by the data.

The dataset deposited in Zenodo and the updated code repository (now including a clear README and environment.yml) meet PLOS’s data-availability requirements and support full reproducibility. Overall, the manuscript is written in clear, standard English and makes a valuable contribution to the understanding of regional climate projections in data-sparse mountain regions. I look forward to seeing it published.

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7. PLOS authors have the option to publish the peer review history of their article (what does this mean? ). If published, this will include your full peer review and any attached files.

Do you want your identity to be public for this peer review? If you choose “no”, your identity will remain anonymous but your review may still be made public.

For information about this choice, including consent withdrawal, please see our Privacy Policy .

Reviewer #1: No

Reviewer #2: Yes: Wisdom Adzigbli

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