PONE-D-20-18978

Prevalence and associated factors of anemia among reproductive-aged women in Eastern Africa; a multilevel analysis of the recent DHS data.

PLOS ONE

Dear Dr. Teshale,

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.

SPECIFIC ACADEMIC EDITOR COMMENTS: An expert in the field handled your manuscript. We really appreciate their time and efforts. Although interest was found in your study, some major concerns and comments reduced this enthusiasm. There are comments about revising several statements to increase clarity; additional details about the methods need to be provided; there are questions about the data analyses; and the discussion should be rewritten to better focus on the main and novel findings. Please address ALL of the reviewer's comments in your revised manuscript.

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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: Yes

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

Reviewer #1: Yes

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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: Yes

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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: 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: The manuscript by Teshale and colleagues explored the prevalence and associated factors of anemia among reproductive-aged women in Eastern Africa. The authors used a weighted and large sample of DHS data. The authors found a high prevalence of anemia in east Africa with spatial variations. The authors delineated possible associated factors using appropriate statistical techniques. The following suggestions can strengthen the manuscript:

Abstract

1. Change “Anemia in reproductive age women” to “Anemia in women of reproductive age."

2. For culture appropriateness, “restrain to “low- and middle-income countries" as opposed to "developing countries."

3. Start a new sentence with “This study aimed to”

4. Change” …using the nine eastern African countries DHS data” to using DHS data of 9 eastern African countries,”

5. Defined DHS at the first mention or avoid abbreviation in the abstract.

6. Delete “and variables with p-value <0.05 in the multivariable analysis were declared as significant determinants of anemia."

Background

1. Line 50: delete "developing."

2. Line 50-57: For coherence, separate the effect of anemia women and their offspring separately.

3. Line 63-64: Add in 2011. As you know, the prevalence should be stated with a time period.

4. Remove "developing countries" to replace them with LMIC.

5. Please clearly state the objective of threw study in the last paragraph of the background before starting line 80.

6. In addition, please state your hypothesis

Method

1. Change "method" to "methods."

2. Cite line 90

3. Please write all “reproductive-age women" to "women of reproductive age."

4. Give the rationales for choosing the confounding factors to adjust for.

5. Line 115: The DHS uses a different categorization of wealth index, please use them as opposed to poorest/poorer

6. Line 124: Since the prevalence of the outcome of interest is very high (35%), the odds ratio can overestimate the prevalence ratio using logistic regression. Although the use of odds ratios is correct, authors should consider prevalence ratios analysis by employing either log-binomial or Poisson regression “see Barros, A. J., & Hirakata, V. N. (2003). Alternatives for logistic regression in cross-sectional studies: an empirical comparison of models that directly estimate the prevalence ratio. BMC medical research methodology, 3(1), 21. See use of log-binomial analysis in anemia prevalence" https://link.springer.com/article/10.1186/s12884-020-03064-x]

7.

8.

9. Describe the methods of sample weighting. Was additional weighting with the population of the country done?

10. Line 134: Authors should explain why started methods of model comparison such as AIC/BIC were not used

Results:

1. I recommend adding a geographical map depicting the distribution of anemia in East Africa.

Discussion

1. As stated on line 247-248, infectious diseases such as malaria and HIV substantially contribute to anemia in the population in LMICs. However, the authors never explored their effect in this study, and yet malaria and HIV data are available in the DHS records. For the recent similar study for the west and central Africa, see Ssentongo, P., Ba, D. M., Ssentongo, A. E., Ericson, J. E., Wang, M., Liao, D., & Chinchilli, V. M. (2020). Associations of malaria, HIV, and coinfection, with anemia in pregnancy in sub-Saharan Africa: a population-based cross-sectional study. BMC Pregnancy and Childbirth, 20(1), 1-11.

2. The should consider cut down the discussion to focus on the main findings and continue to provide 2-3 paragraphs explaining their results in light of other studies. The final section should be the clinical and public health implications and finally, the limitations. The authors do not have to discuss every result.

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Reviewer #1: Yes: Paddy Ssentongo, MD, MPH

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Anemia and its associated factors among women of reproductive age in Eastern Africa: a Multilevel Mixed-effects Generalized Linear Model

PONE-D-20-18978R1

Dear Dr. Teshale,

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,

Frank T. Spradley

Academic Editor

PLOS ONE

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

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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

**********

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

Reviewer #1: 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

**********

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

**********

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: The authors have addressed all my comments. The manuscript is clearly written and the statistics are robust.

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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.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

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: Paddy Ssentongo, MD, MPH