PONE-D-19-30322

Spatial patterns of anemia among lactating mothers in Ethiopia: Data from Ethiopian Demographic and Health Surveys (2005, 2011 and 2016)

PLOS ONE

Dear Mr liyew,

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PLOS ONE

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: No

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

Reviewer #1: No

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3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). 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: No

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

PLOS ONE 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: No

**********

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: Reviewer’s Report

Spatial patterns of anemia among lactating mothers in Ethiopia: Data from Ethiopian Demographic and Health Surveys (2005, 2011 and 2016)

Anemia among human population is a major public health problem that affects populations in both rich and poor countries. Its primary cause is iron deficiency (IDA) and other various biological and non-biological factors. Anaemia is a common health problem in Ethiopia also where the latest DHS survey found around 24 percent women of reproductive age (WRA) were anaemic, ranges from a low of around only 16 percent to a high of close to 60 percent in different parts of Ethiopia. In the context, the spatial exploration of anaemia especially among lactating women is also an important issue and the authors have tried to study the concentration and clustering of one of the major health problems but the authors have missed somewhere and needs further improvement in the manuscripts. The constructive comments and suggestions are as follows-

1. Introduction section has started in right way with definition and cause of anaemia with most related to biological factors but missing non-biological factors. Next, anaemia as a public health problem has discuses in brief flowed by global scenario of Anaemia. Then adverse effect of maternal anaemia has been discussed before moving on scenario of anaemia in Ethiopia. Introduction section ends with reason for selecting lactating women for the study purpose.

2. Here, some important aspects found missing. Like, previous studies pertain to anaemia among WRA in Ethiopia, evidences and studies related to spatial pattern of anaemia among WRA in the study country. Reason for considering lactating women for study needs to be strengthened. Authors are also advised to do review of literature extensively as many relevant studies is available on anaemia among WRA in Ethiopia conducted on same data source at different point of time. Some studies are very recent with latest round of country DHS data.

3. Data source, sampling design and setting needs to be rewrite in appropriate manner. Whereas measurements should be different sections and can be written accordingly. It would have been better if researchers would have provided region wise sample over the three study period.

4. As the author mentioned “The haemoglobin level was measured for those eligible mothers after having consent and it was adjusted for altitude”. This needs to be clarified as DHS data for the country provide measured haemoglobin level and the adjusted haemoglobin for altitude. So, which one indicator authors have used in the study. The cut off used in this study has not been mentioned in the methodology section.

5. Spatial analysis section starts with autocorrelation analysis to spatial scan statistical analysis. Here, the concern is that in many section, authors have provided only the theoretical notions of such the method but missed to elaborate in accordance and need of the undertaken study. Like, how SAC has been executed in the study has found missing. Second, section on SAC mentioned somewhere “leads to rejection of null hypothesis and indicates the presence of spatial correlation”. Does the author have posed research question in same way?

6. Hot spot analysis (HSA) using Gettis-OrdGi* statistics is a appropriate way to check the variation in spatiality across the study areas but missed to the process undertaken in the study. It would be better if authors had been reviewed available study for spatial analysis of anaemia in Ethiopia by Kelemu T.K, et (2019) study using latest wave of Ethiopia DHS data. So, author is advised to go through the paper and restructure the section appropriately.

7. Overall methodology section needs to tightened and strengthened.

8. Results are very poorly interpreted, seems researchers are in hurry. So, results sections had to be written in well manner. Figures 3 can be interpreted region wise and changes over period would be better idea. Interpretation in figure heading is not the academic practices, so author is suggested to follow the rigour and pattern/outline to prepare the manuscript.

9. It would have been better to elaborate the section on emerging hotspot areas based on the data available for the areas before doing interpolation analysis to detect the primary and secondary clusters.

10. In spatial scan analysis, authors have tires to provide glimpse of significant clusters separately for each survey period but it they can provide reason wise prominent clusters, it would be better for planning and programme intervention at the regional level within Ethiopia.

11. Table 3 does not have catchy and reliable approach. It would have been better if the researchers would have been mentioned detailed with name or within each of the cluster with maximum and minimum concentration of anaemic lactating mothers. Second, researcher can match for enumeration areas which were found common during the period of 2005, 2011 and 2016, cluster wise. The format of table 3 provided in the text can be produced as supplementary table or appendix table.

12. Discussion section needs to rewrite as it is just findings of study only in very limited way. It is important to discuss the findings of the study with other previous and existing studies on the issues.

13. In the conclusion section authors have mentioned “Findings suggest that giving priority attentions would be important on water, and other nutrition-related interventions on the identified hotspot areas to prevent and control anaemia incidence among lactating mothers”. The concern is that from where these findings emerged as it is not found anywhere and anyway in the manuscript.

14. Maps and figures are also not readable as are very hazy. So authors are also advised to rework for figure and maps to make it clear before submitting it the journal.

Overall, the paper needs to revise with appropriate framework for the country undertaken for the policy and programmatic point of view.

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Reviewer #1: Yes: Rajesh Raushan

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Attachments

Attachment

Submitted filename: Reviewer Report.docx

PONE-D-19-30322R1

Spatial patterns of anemia among lactating mothers in Ethiopia: Data from Ethiopian Demographic and Health Surveys (2005, 2011 and 2016)

PLOS ONE

Dear Mr liyew,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’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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If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter.

To enhance the reproducibility of your results, we recommend that if applicable you deposit your laboratory protocols in protocols.io, where a protocol can be assigned its own identifier (DOI) such that it can be cited independently in the future. For instructions see: http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols

Please include the following items when submitting your revised manuscript:

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Please note while forming your response, if your article is accepted, you may have the opportunity to make the peer review history publicly available. The record will include editor decision letters (with reviews) and your responses to reviewer comments. If eligible, we will contact you to opt in or out.

We look forward to receiving your revised manuscript.

Kind regards,

William Joe

Academic Editor

PLOS ONE

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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

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Partly

Reviewer #2: Yes

**********

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

Reviewer #1: No

Reviewer #2: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). 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: No

Reviewer #2: Yes

**********

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

PLOS ONE 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: No

Reviewer #2: Yes

**********

6. 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: Spatial Patterns of Anemia among Lactating Mothers in Ethiopia: Data from Ethiopian Demographic and Health Surveys (2005, 2011 and 2016)

Although, the revised paper shows improvement than the previous one but, still there is need to work on it to improve the quality and strength of the paper to meet the criteria of the said journal. Important question is why the spatial hotspot is in those areas. Using data for three points of time to make it comparable also needs logically justification. Some other important comments are as follows-

1. Keep the use of term consistent- like somewhere author used maternal, somewhere lactating and somewhere breastfeeding mothers.

2. Line no 50 are not well connected with line no 49.

3. Authors need to rewrite the data source and sampling section and data measurement section. As these two are overlapping.

4. Authors missed to include anaemia measurement method in Ethiopia and the cut off as well used in the study for lactating mothers.

5. Still results sections needs improvement and there is mismatch on table no, figure no etc. like figure no. 1, 2, 3, 4 etc has mentioned twice with two different headings.

6. Figures are missing at all in the revised edited version.

7. Authors are proving only spatial hotspot and cold spot of the anaemic lactating women, if I am not wrong. But, important is why these are so, is important question and can be worth of the paper.

8. Maps and some tables, figures are missing at all in the revised paper.

9. Authors can have look on the paper related to their concerned issues. https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0197171

Thank you!!!

Reviewer #2: The authors have tried to address the issues raised in the previous review. However, authors still need to expand the discussion section by providing more explanation for the results and relating findings to previuos studies.

Also, weaknesses and strengths stated in the discussion section should be moved to a seperate section titled "Strengths and weaknesses"

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Reviewer #1: Yes: Rajesh Raushan

Reviewer #2: No

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files to be viewed.]

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Attachments

Attachment

Submitted filename: Reviewer Comments08 April 2020.docx

PONE-D-19-30322R2

Spatial Patterns of Anemia among Lactating Mothers in Ethiopia: Data from Ethiopian demographic And Health Surveys (2005, 2011,and 2016)

PLOS ONE

Dear Dr. liyew,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’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.

Please submit your revised manuscript by Jul 31 2020 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

• A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
• A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
• An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols

We look forward to receiving your revised manuscript.

Kind regards,

William Joe

Academic Editor

PLOS ONE

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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

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Partly

Reviewer #2: Yes

**********

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?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). 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

**********

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

PLOS ONE 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: No

Reviewer #2: Yes

**********

6. 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: Reviewer Report

Spatial Patterns of Anemia among Lactating Mothers in Ethiopia: Data from Ethiopian Demographic and Health Surveys (2005, 2011 and 2016)

1. In the conclusion of abstract section- Therefore, public health intervention activities designed in a targeted approach to impact high-risk populations as well as the geographic regions is vital to narrow anemia disparity in Ethiopia’- needs attention for correction the statement ‘is vital to narrow anemia disparity in Ethiopia’.

2. To date, the risk areas (hot spot) of anemia among lactating mothers in Ethiopia are not identified- so what are the other studies related to anaemia among lactating mothers would be important to justify the statement (Line 91).

3. Line No 115-120 is not required in the way it has been written. Authors are advised to look for section on data source from various published articles in journal of high repute.

4. In Line number 125, it would be better to mention the age range for ‘reproductive age women’.

5. ‘Data measurement’ heading is not appropriate.

6. In line no 164 as the author has used word ‘location data’. I think those were geo-referencing data. So its always good to use appropriate word.

7. Within the methodology section, spatial analysis section is improved and well written than the previous one.

8. Line no 214-218: “The prevalence of anemia during lactation was intermittently increasing across regions in Ethiopia. Even though it had decreased from 2005 to 2011 almost in all regions, its prevalence increased from 2011 to 2016 in all regions including the two administrative cities. The highest prevalence was observed in the Somali regional state (68%) and the Afar region (47%) in 2016”- The statement should be written very carefully. As line no 214 reflects that since 2005, anaemia among lactating mother is on increase. But, that is not the case as the authors are stating in the line no-215/216 that it had decreased between 2005 and 2011.

9. Don’t use like ‘in the following figure’ or ‘in the above figure/map, tables’ etc, as at many place in the manuscript, it has written like that,

10. As in table 2, keep number of digit identical after the decimal. As somewhere its two digit, somewhere, its three digit in second column. In column 4, keep three digits after decimal. Keep it identical for all the tables.

11. Line no 253- Can be written as all three consecutive survey periods. Because, all surveys has different meaning.

12. Line no 264- 270 needs to be written in well manner as the- In the above figure, HH (High-High) means high rates of anemia surrounded by similar characteristics; HL (High-Low) means high rates of anemia surrounded by low rates of anemia; LH (Low-High) means low rates of anemia cases surrounded by high rates of anemia cases; and LL (Low-Low) means low rates of anemia cases surrounded by similar characteristics. The red (HH) color indicates hotspot areas of anemia, the dark blue (LL) color indicates cold spot areas of anemia, and the dark yellow (HL ) and yellow (LH) colors indicate the outliers.-. Section needs rewrite as writing HL means…., LL means is not the standard writing style in result sections. This is not the right way to interpret the map. The authors can narrate what is emerging out from the said map, not like HL means High-Low. As the Map 5a, 5b, 5c are for three different time period so it would be better to do compare the regions. The colour combination should be part of methodology section.

13. Authors mentioning hot spot, cold spot etc in figure 4,5 6. Which needs proper interpretation like what are those spots, is there any change during the three survey period as authors have written about in very brief in discussion section.

14. ‘This implies, that the special attention of policy makers for anemia reduction should be in those high-risk areas of the country’- this statement needs correction/modification as per the study objectives.

15. ‘This spatial heterogeneity of anemia clustering was again observed prominently in Afar and Somali regions. This showed that the spatial clustering of anemia is more or less consistently higher in the Afar region in all EDHS surveys and the Somali region in the latest two surveys (2011 and 2016)’- Validate your findings with other available studies or is this new finding emerged from your study for the first time.

16. Policy suggestion or public health measures are missing, authors can think on those lines.

Overall, there is improvement in the paper than the previous one, but the scientific rigor in interpreting the results emerging from the map is somewhat missing. Discussion section still needs to strengthen. It would be better to reduce the number of maps wherever it’s possible. The paper still needs English editing as in the data and methodology section flow and consistency was missing as well. Authors can also think about the title of the paper.

Thank You!!!

Reviewer #2: (No Response)

**********

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.

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Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: Yes: Rajesh Raushan

Reviewer #2: No

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

Attachments

Attachment

Submitted filename: PONE-D-19-30322_R2_Reviewer Report-11062020.docx

Spatiotemporal Patterns of Anemia among Lactating Mothers in Ethiopia using data from Ethiopian demographic And Health Surveys (2005, 2011,and 2016)

PONE-D-19-30322R3

Dear Dr. liyew,

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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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. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately 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

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4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). 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?

PLOS ONE 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

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: Minor suggestions

1. Line no 127- Is four survey conducted or typed by mistake. I think it would be three surveys.

2. Line no- 208 can be written as Even though prevalence of Anaemia had decreased between 2005 and 2011.

3. Authors have used somewhere one and half decade. I think from 2005 to 2016, its 11 years. So, please do correct it.

Overall, the revised version seems improved and looks impressive and readable. So authors can take care of minor typo-error and other necessities of the PLOS ONE.

Thank You!!!

Reviewer #2: (No Response)

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Reviewer #1: Yes: Rajesh Raushan, PhD

Reviewer #2: No