Adequate vitamin A rich food consumption and associated factors among lactating mothers visiting child immunization and post-natal clinic at health institutions in Gondar Town, Northwest Ethiopia

Addisalem Damtie Aserese; Azeb Atenafu; Mekonnen Sisay; Muluken Bekele Sorrie; Birhanu Wubale Yirdaw; Martha Kassahun Zegeye

doi:10.1371/journal.pone.0239308

Peer Review History

Original SubmissionOctober 11, 2019
19 Nov 2019 Decision Letter - Solomon Assefa Woreta, Editor PONE-D-19-28467 Adequate vitamin A rich food consumption and associated factors among lactating mothers visiting child immunization and post-natal clinic at health institutions in Gondar Town, Northwest Ethiopia PLOS ONE Dear Addisalem Damtie, 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. ============================== According to many literature Vitamin A play a pivotal role for grow and differentiation of cell and tissue. It has extra benefit in the healthy development of fetus and neonates. I would like to commend authors for conducting this very important topic. Abstract: The section seems well written has precisely and briefly illustrated the entire study. Introduction: This section has shown the scientific definition of vitamin A, the epidemiology of vitamin A, the prevalence and the vulnerable groups. However, the writing looks juggling from one topic to the other without clear coherence. It lacks consistency. There is not enough literature included to expound the objective. May be, good to incorporate literature that has been researched the topic at a national, regional and local level. Methods: I don’t see the relevance in this study to write down detail information about the study area. I recommend to make it brief and short with limited words. There are many similar studies has been conducted in various part of Ethiopia, Why you assumed 50 % prevalence of vitamin A rich food consumption to calculate the sample size? What is your rationale to implement a designed effect? What is your inclusion and exclusion criteria in this study? Result: This section appears to have incorporated information to address the objective and the analysis seems sound. However, there are few sporadic technical issues in the interpretation which has to be addressed accordingly. Discussion: This section looks very shallow and failed to make strong argument. As I have indicated in the introduction section, there is no sufficient literature that supposed to provide scientific clarification to each statistical analysis. Most of the argument has been made based on assumption which makes the argument very frail and less scientific. Your argument must be evidence based or supported by other literature. Oh the other hand, you have to address each objective included in this study in the discussion section. Each analyzed results should be properly discussed. Similarly, at the limitation of this study you indicated” the study was institution based, it may fail to show the consumption of specific community” What do you mean “consumption of specific community”? This and other similar statements needs your attention to properly articulate pass the right message. Overall, this section needs extensive overhaul. ============================== We would appreciate receiving your revised manuscript by Jan 03 2020 11:59PM. When you are 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. 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: A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). This letter should be uploaded as separate file and labeled 'Response to Reviewers'. A marked-up copy of your manuscript that highlights changes made to the original version. This file should be uploaded as separate file and labeled 'Revised Manuscript with Track Changes'. An unmarked version of your revised paper without tracked changes. This file should be uploaded as separate file and labeled 'Manuscript'. 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, Solomon Assefa Woreta Academic Editor PLOS ONE Journal Requirements: 1. When submitting your revision, we need you to address these additional requirements. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at http://www.journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and http://www.journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf 2. Your ethics statement must appear in the Methods section of your manuscript. 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We will update your Data Availability statement on your behalf to reflect the information you provide. Additional Editor Comments: According to many literatures Vitamin A play a pivotal role for grow and differentiation of cell and tissue. It has extra benefit in the healthy development of fetus and neonates. I would like to commend authors for conducting this very important topic. Abstract: The section seems well written has precisely and briefly illustrated the entire study. Introduction: This section has shown the scientific definition of vitamin A, the epidemiology of vitamin A, the prevalence and the vulnerable groups. However, the writing looks juggling from one topic to the other without clear coherence. It lacks consistency. There is not enough literature included to expound the objective. May be, good to incorporate literatures that has been researched the topic at a national, regional and local level. Methods: I don’t see the relevance in this study to write down detail information about the study area. I recommend to make it brief and short with limited words. There are many similar studies has been conducted in various part of Ethiopia, Why you assumed 50 % prevalence of vitamin A rich food consumption to calculate the sample size? What is your rationale to implement a designed effect? What is your inclusion and exclusion criteria in this study? Result: This section appears to have incorporated information to address the objective and the analysis seems sound. However, there are few sporadic technical issues in the interpretation which has to be addressed accordingly. Discussion: This section looks very shallow and failed to make strong argument. As I have indicated in the introduction section, there is no sufficient literature that supposed to provide scientific clarification to each statistical analysis. Most of the argument has been made based on assumption which makes the argument very frail and less scientific. Your argument must be evidence based or supported by other literature. Oh the other hand, you have to address each objective included in this study in the discussion section. Each analyzed results should be properly discussed. Similarly, at the limitation of this study you indicated” the study was institution based, it may fail to show the consumption of specific community” What do you mean “consumption of specific community”? This and other similar statements needs your attention to properly articulate pass the right message. Overall, this section needs extensive overhaul. [Note: HTML markup is below. Please do not edit.] 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 ******** 2. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: Yes ****** 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 ****** 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: I have read an article titled “Adequate vitamin A rich food consumption and associated factors among lactating mothers visiting child immunization and post-natal clinic at health institutions in Gondar Town, Northwest Ethiopia” by Damtie and collaborators with great interest. The article can help policy makers and researchers who wish to work on Vitamin A. I have some issues the authors may wish to consider before publication. 1. The English language needs extensive revision (detailed suggestions can be found with the attachment). 2. Line 56: Using abbreviation in abstract is not recommended. This abbreviation appeared for the first time here, and abbreviations should be written in full form when they appear for the first time 3. Line 134: As "VAD" appears for the first time it is good if it is written in full form. In general as this abbreviation only occurs at once in the entire manuscript, it is good to use in its full form. 4. Line 143: "strengthen fruit and vegetable" is not clear. 5. Lines 150-160: citation is needed. 6. Line 168: It is not clear why authors used 50% prevalence while they have previous study results. Of course those are community-based studies and may not apply for institutional-based study like this one. However authors have used them to compare the prevalence with current study. Authors may specify reason of using p-value of 50% and include lack of previous studies for comparison (if that is the case) as a limitation. 7. Lines 192-193: Authors mentioned that pretested questionnaire was developed from different sources mainly Hellen Keller International Food Frequency Questionnaire. Authors are encouraged to cite at least some of these sources. 8. Lines 193-194: Authors mentioned that the HK-FFQ was adapted to the local context. Did that mean the tool is validated? If so, the tool validation result may be cited or at least explicitly mentioned. Lines 213 to 214: Authors mentioned that the tool was pretested and necessary modifications made. What modification were actually performed? What was the reliability of nutritional knowledge questions from the pretest result. 9. Lines 220 to 221 is a repetition from line 205. 10. Lines 230 to 231: Variance inflation factor is more suitable for linear regression and authors may use standard error to check co-linearity in binary logistic regression. 11. Line 332: Authors should check the reference. The who report can not be cited for a study in India. 12. Line 336: Authors used both full form and abbreviation RDA twice both at line 105 and here. What is the need of abbreviating recommended dietary allowance if the full form is always written? 13. Line 368: This statement should be rewritten in a meaningful manner. 14. Lines 371 to 372: This statement should be reworked as assessment of intake of food before a week seems reason of social desirability. I suggest the authors to split the statement in to two. 15. Line 389: Authors may include the review protocol number. 16. Line 391: Authors may wish to disclose whether the consent obtained was written or verbal. Finally, the discussion seems straight jacketed. Authors may include additional references and suggest additional justification. Authors may also discuss factors which are not associated in the current study but were identified by previous studies. Factors which are not associated are also important. Good luck! ****** 6. 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: Henok Dagne Derso [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.] 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 us at figures@plos.org. Please note that Supporting Information files do not need this step. Attachments Attachment Submitted filename: Manuscript of vitamin A-commented.docx https://doi.org/10.1371/journal.pone.0239308.r001
Revision 1
10 Jan 2020 Author Response Dear Editor and Reviewer Sincerest thanks for your response and reviewers comments on our manuscript. We have modified the paper in response to the extensive and insightful editor and reviewer comments. We would be glad to respond to any further questions and comments that you may have. Response to Editor 1. Is the manuscript presented in an intelligible fashion and written in standard English? We tried to amend the English according to the comment 2. Line 168: It is not clear why authors used 50% prevalence while they have previous study results. Of course those are community-based studies and may not apply for institutional-based study like this one. However authors have used them to compare the prevalence with current study. Authors may specify reason of using p-value of 50% and include lack of previous studies for comparison (if that is the case) as a limitation • We used 50% prevalence to get the maximum sample size, since there is no study conducted among lactating mothers, we put it as a limitation 3. What is your rationale to implement a designed effect? What are your inclusion and exclusion criteria in this study? • We used design effect of 2 to consider the loss of effectiveness by the use of cluster sampling, instead of simple random sampling. • The inclusion criteria were lactating mothers visiting child immunization (EPI) and postnatal care (PNC) centers in selected health facilities during the study period in Gondar Town. • The exclusion criteria were lactating mothers who were severely ill during data collection period; we didn’t get such type of respondent. • We used median with IQR since the data is not normally distributed 4. The English language needs extensive revision (detailed suggestions can be found with the attachment). • We have extensively done the copy edit for our language usage. 5. Line 56: Using abbreviation in abstract is not recommended. This abbreviation appeared for the first time here, and abbreviations should be written in full form when they appear for the first time • It is modified accordingly to Helen Keller International Food Frequency Questionnaire 6. Line 134: As "VAD" appears for the first time it is good if it is written in full form. In general as this abbreviation only occurs at once in the entire manuscript, it is good to use in its full form. • It is modified accordingly to vitamin A deficiency 7. Line 143: "strengthen fruit and vegetable" is not clear. • This was to mean strengthen fruit and vegetable consumption, and corrected accordingly 8. Lines 150-160: citation is needed. • Thank you for the comment, we have provided the citation 9. Line 168: It is not clear why authors used 50% prevalence while they have previous study results. Of course those are community-based studies and may not apply for institutional-based study like this one. However authors have used them to compare the prevalence with current study. Authors may specify reason of using p-value of 50% and include lack of previous studies for comparison (if that is the case) as a limitation. • We used 50% prevalence to get the maximum sample size, since there is no study conducted among lactating mothers; we put it as a limitation for using in the discussion part 10. Lines 192-193: Authors mentioned that pretested questionnaire was developed from different sources mainly Hellen Keller International Food Frequency Questionnaire. Authors are encouraged to cite at least some of these sources. • We have cited the references accordingly; when we say different sources it is to mean that references like Food and Agriculture Organization (FAO) to measure woman’s dietary diversity 11. Lines 193-194: Authors mentioned that the HK-FFQ was adapted to the local context. Did that mean the tool is validated? If so, the tool validation result may be cited or at least explicitly mentioned. • For this study we didn’t do tool validation, since the HK-FFQ tool is internationally accepted tool for assessing vitamin A rich food intakes, the tool have 28 different food item questions. From the 28 food items we used 21 food items which are available in the study area and consumed by the society, the remaining 7 food items like, noodles, Amaranth leaves, sweet potato leaves, cod liver oil, coconuts, weaning food fortified with vitamin A, Margarine fortified with vitamin A were not included in the tool because they are not commonly consumed in the study area. Accordingly food frequency questionnaires can be adjusted to the local context. 12. Lines 213 to 214: Authors mentioned that the tool was pretested and necessary modifications made. What modifications were actually performed? What was the reliability of nutritional knowledge questions from the pretest result? • The modifications were mainly editorial like language translation of food items from English to Amharic. We didn’t perform reliability test for the nutritional knowledge questions, since it is the commonly used tool for assessing the nutritional knowledge of mothers 13. A line 220 to 221 is a repetition from line 205. • Modified accordingly 14. Lines 230 to 231: Variance inflation factor is more suitable for linear regression and authors may use standard error to check co-linearity in binary logistic regression. • Of course standard error is also used for checking multicollinearity, in our case standard error is also less than 4, and moreover, multicollinearity is a state of very high inter-correlations or inter-associations among the independent variables. It is therefore multicollinearity can also be detected with the help of tolerance and its reciprocal, called variance inflation factor (VIF). 15. Line 332: Authors should check the reference. The WHO report cannot be cited for a study in India. • Checked and modified accordingly 16. Line 336: Authors used both full form and abbreviation RDA twice both at line 105 and here. What is the need of abbreviating recommended dietary allowance if the full form is always written? • Modified accordingly 17. Line 368: This statement should be rewritten in a meaningful manner. • Modified to consumption of specific community 18. Lines 371 to 372: This statement should be reworked as assessment of intake of food before a week seems reason of social desirability. I suggest the authors to split the statement in to two. • Noted and modified 19. Line 389: Authors may include the review protocol number. • The protocol number for Ethical review was IPH/180/06/2011 20. Line 391: Authors may wish to disclose whether the consent obtained was written or verbal. • The consent obtained was verbal and included in the document 21. Finally, the discussion seems straight jacketed. Authors may include additional references and suggest additional justification. Authors may also discuss factors which are not associated in the current study but were identified by previous studies. Factors which are not associated are also important • Some amendments were made for the discussion part, the main problem was lack of literatures Attachments Attachment Submitted filename: Response for editor and reviewers.docx https://doi.org/10.1371/journal.pone.0239308.r002
18 Jun 2020 Decision Letter - Robin D Clugston, Editor PONE-D-19-28467R1 Adequate vitamin A rich food consumption and associated factors among lactating mothers visiting child immunization and post-natal clinic at health institutions in Gondar Town, Northwest Ethiopia PLOS ONE Dear Dr. Aserese, 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. Apologies for the delay in returning this manuscript to you. The global pandemic has delayed the review process. As you will see from the reviewer's comments below, while one reviewer is satisfied with your revised manuscript the other still has some concerns. I would add that I am personally not satisfied with the quality of the written English in the manuscript and strongly encourage you to get a copy editor to improve it. One of the journal's publication criteria requires the manuscript to be written intelligibly and in standard English. Please keep this in mind as you revise the manuscript. Please submit your revised manuscript by Aug 02 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, Robin D Clugston, Ph.D. Academic Editor PLOS ONE [Note: HTML markup is below. Please do not edit.] 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: Yes Reviewer #2: Partly ****** 3. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: Yes Reviewer #2: I Don't Know ****** 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 Response) 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: Yes Reviewer #2: No ****** 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: Authors fully addressed my comments in the revised manuscript. They have improved the write up and addressed major issues raised. Reviewer #2: authors have clarified several of the questions raised in the previous review, unfortunatly, the major problem in this paper is the discussion part (which was stated by the previous reviewer) that authors can overcome by including more references, and discussing their main findings related to their results and study population. the discussion can be improved, be more organized and enriched. Abstract (line 54) : can authors clarify ... the authors stated that about 631 study participants were included ... and in line 61: a total of 624 of lactating women participated... can author give the reason of the loss (-7) Background Needs to be organized… I suggest to the authors to start the first paragraph by line 111…117 Line 112 : not only vitamin A deficiency is the leading cause of morbidity and mortality, also zinc deficiency and both are the most leading causes… Line 113 : … vulnerable population segment by for those who have inadequate intake of vitamin A from food Line 114 : lactating women are the most… in addition to children under 5y old. Line 115 : … amount of micronutrients… I thnik here you have to put enough of vit A Line 118… line 122 can be deleted Line 129 : « …remains… » is there any measures taken nationnally ? Line 132 : … of reproductive age… what about lactating women ? is there any regional or national statistics ? Authors can reinsert here paragraph starting by line 98 before line 134 Line 138 to line 144 , this paragraph needs edits and rephrasing (children who born with low vitA reserves and from defiscient mothers are at greater risk to develop a vitA deficniency Line 202 : adapted questionnaire instead of pretested questionnaire Line 206 : .. and other litteratures, can the authors be more precise I suggest to authors that data quality assurance comes after data analysis Line 226 running frequency ???? Line 250 was obtained instead of secured Table 1 did authors collect information about household income ?? I think that the discussion needs a more in-depth , and authors have to present their major findings related to the population studied and not children aged between 6 to 23 months… to compare them to other studies conducted among lactating women (and explain in details the results obtained) Authors may add more statements in the end to highlight the implication and conclusions from this study ****** 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: Henok Dagne Derso 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. https://doi.org/10.1371/journal.pone.0239308.r003
Revision 2
27 Jun 2020 Author Response Dear Editor and Reviewer Sincerest thanks for your response and reviewers comments on our manuscript. We have modified the paper in response to the extensive and insightful editor and reviewer comments. We would be glad to respond to any further questions and comments that you may have. Response to Editor and Reviewer 1. Abstract (line 54) : can authors clarify ... the authors stated that about 631 study participants were included ... and in line 61: a total of 624 of lactating women participated... can author give the reason of the loss (-7) Seven lactating women discontinue the interview after starting due to their personal reasons 2. Background Needs to be organized… I suggest to the authors to start the first paragraph by line 111…117 Thank you for the suggestion and we have modified accordingly 3. Line 112 : not only vitamin A deficiency is the leading cause of morbidity and mortality, also zinc deficiency and both are the most leading causes… Yes it is not the only deficiency others also have their own great contribution. But in this paragraph we tried to be specific to vitamin A. We have modified 4. Line 113 : … vulnerable population segment by for those who have inadequate intake of vitamin A from food Modified accordingly 5. Line 114 : lactating women are the most… in addition to children under 5y old. Modified accordingly 6. Line 115 : … amount of micronutrients… I think here you have to put enough of vit A Modified accordingly 7. Line 118… line 122 can be deleted We believe it will give some insight 8. Line 129 : « …remains… » is there any measures taken nationally? There was a measure taken to prevent this problem by preparing guidelines for the prevention and control of micronutrient deficiencies at national level 9. Line 132 : … of reproductive age… what about lactating women ? is there any regional or national statistics ? We didn’t get data which represents lactating women at regional or national level 10. Authors can reinsert here paragraph starting by line 98 before line 134 Modified accordingly 11. Line 138 to line 144 , this paragraph needs edits and rephrasing (children who born with low vit A reserves and from deficient mothers are at greater risk to develop a vit A deficiency Modified accordingly 12. Line 202 : adapted questionnaire instead of pretested questionnaire Modified accordingly 13. Line 206 : .. and other litteratures, can the authors be more precise Modified accordingly 14. I suggest to authors that data quality assurance comes after data analysis Modified accordingly 15. Line 226 running frequency ???? Modified accordingly, it was not done for this research; we removed the statement from the paragraph. 16. Line 250 was obtained instead of secured Modified accordingly 17. Table 1 did authors collect information about household income ?? Not collected. We have collected the wealth index data 18. I think that the discussion needs a more in-depth, and authors have to present their major findings related to the population studied and not children aged between 6 to 23 months… to compare them to other studies conducted among lactating women (and explain in details the results obtained) Authors may add more statements in the end to highlight the implication and conclusions from this study Thank you for the concerns, the major limitation for this research was shortage of literatures. We tried to amend according to the comment. Attachments Attachment Submitted filename: Response to editor and reviewers.docx https://doi.org/10.1371/journal.pone.0239308.r004
4 Jul 2020 Decision Letter - Robin D Clugston, Editor PONE-D-19-28467R2 Adequate vitamin A rich food consumption and associated factors among lactating mothers visiting child immunization and post-natal clinic at health institutions in Gondar Town, Northwest Ethiopia PLOS ONE Dear Dr. Aserese, 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. As you will see below, one of the reviewers still requires some minor revisions to the paper. If you are able to complete these satisfactorily we should be closer to accepting your manuscript. Please submit your revised manuscript by Aug 18 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, Robin D Clugston, Ph.D. Academic Editor PLOS ONE [Note: HTML markup is below. Please do not edit.] 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 #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 #2: Yes ****** 3. Has the statistical analysis been performed appropriately and rigorously? Reviewer #2: I Don't Know ****** 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 #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 #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 #2: All questions raised in my previous review were addressed by authors. The paper looks better after the author's correction. I have made some suggestions to improve it more ... Methods I suggest to authors to add a paragraph about the HKI-FFQ as it is the main tool used in this paper at the Sampling method part (like it has been validated by WHO using serum retinol levels to provide reliable estimates of subclinical VAD. A brief description of the tool and then a paragraph about how authors have adapted the tool to local conditions ( what are questions that has been added or modified, steps ) Discussion needs some edits there is some suggestions : line 282 : our findings showed that the consumption of adequate vitamin A rich foods was…. Line 283 : lactating women should have a slightly higher vitA requirements compared to women who are not pregnant or lactating as vitA in mother’s diet are directly transferred into breast milk. Line 287 : our results are higher than those found in Danot, Rural Kenya, ethiopia.. Indeed, in the Damot sore district, the study revealed that only 12,5% ….. In rural kenya, only 13,5%..... While in India, the study revealed that … This difference in results can be explained by the effect of sample size, study settings , physiological state….. Please delete the time gap btw studies… Please delete paragraph 308…312 « no add value » Line 314 please modify unable to write and read by illiterate mothers (in all the manuscript) Line 316 : educational status by educational level Line 317 : because by may be explained by the fact that … Line 319 : a family size <= 3 had 4 times the most likely chance to… Line 320 : this may be due to a difficulty to provide…. Please change “mothers may give…. By « mothers may sacrifice their own quality/quantity of nutrition in order to protect their children. Line 324 : this may be due to that mothers with low socioeconomic status may not have access or can afford to buy food rich in vitA…there is a strong and consistent evidence that food insecure mothers are at higher risk of malnutrition. Limitation Another limitation of this study is serum retinol levels were not determined , which could not be done ( limited budget, lack of required facilities….) Conclusion Line 347: Based on the HK threshold values, 61% of lactating women have inadequate vitA food consumption (not 38,9%) and thus, was not a public health problem among our population. Line 349: having college educational level and above, ****** 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 #2: Yes:** Asmaa EL HAMDOUCHI [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. https://doi.org/10.1371/journal.pone.0239308.r005
Revision 3
22 Jul 2020 Author Response Dear Editor and Reviewer Sincerest thanks for your response and reviewers comments on our manuscript. We have modified the paper in response to the extensive and insightful editor and reviewer comments. We would be glad to respond to any further questions and comments that you may have. Response to Editor and Reviewer 1. I suggest to authors to add a paragraph about the HKI-FFQ as it is the main tool used in this paper at the Sampling method part (like it has been validated by WHO using serum retinol levels to provide reliable estimates of subclinical VAD. A brief description of the tool and then a paragraph about how authors have adapted the tool to local conditions ( what are questions that has been added or modified, steps ) � The HKI FFM asks respondents how many days in the last week consumed the foods listed on a predesigned FFQ. Only major sources of vitamin A are taken into consideration (t100 RE), though some attention are given to other foods. The tool has 28 different food item questions. From the 28 food items we used 21 food items which are available in the study area and consumed by the society, the remaining 7 food items like, noodles, Amaranth leaves, sweet potato leaves, cod liver oil, coconuts, weaning food fortified with vitamin A, Margarine fortified with vitamin A were not included in the tool because they are not commonly consumed in the study area. 2. Discussion needs some edits there is some suggestions : line 282 : our findings showed that the consumption of adequate vitamin A rich foods was…. Line 283 : lactating women should have a slightly higher vitA requirements compared to women who are not pregnant or lactating as vitA in mother’s diet are directly transferred into breast milk. Line 287 : our results are higher than those found in Danot, Rural Kenya, ethiopia.. Indeed, in the Damot sore district, the study revealed that only 12,5% ….. In rural kenya, only 13,5%..... While in India, the study revealed that … This difference in results can be explained by the effect of sample size, study settings , physiological state….. Please delete the time gap btw studies… Please delete paragraph 308…312 « no add value » Line 314 please modify unable to write and read by illiterate mothers (in all the manuscript) Line 316 : educational status by educational level Line 317 : because by may be explained by the fact that … Line 319 : a family size <= 3 had 4 times the most likely chance to… Line 320 : this may be due to a difficulty to provide…. Please change “mothers may give…. By « mothers may sacrifice their own quality/quantity of nutrition in order to protect their children. Line 324 : this may be due to that mothers with low socioeconomic status may not have access or can afford to buy food rich in vitA…there is a strong and consistent evidence that food insecure mothers are at higher risk of malnutrition. Limitation Another limitation of this study is serum retinol levels were not determined , which could not be done ( limited budget, lack of required facilities….) Conclusion Line 347: Based on the HK threshold values, 61% of lactating women have inadequate vitA food consumption (not 38,9%) and thus, was not a public health problem among our population. Line 349: having college educational level and above, � All the comments and suggestion has been addressed in the document. Attachments Attachment Submitted filename: Dear editor and reviewers.docx https://doi.org/10.1371/journal.pone.0239308.r006
30 Jul 2020 Decision Letter - Robin D Clugston, Editor PONE-D-19-28467R3 Adequate vitamin A rich food consumption and associated factors among lactating mothers visiting child immunization and post-natal clinic at health institutions in Gondar Town, Northwest Ethiopia PLOS ONE Dear Dr. Aserese, 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. Thank you for addressing all of the previous reviewers comments and resubmitting your revised manuscript. As originally communicated to you in my June 18th decision letter, I have one remaining concern with the manuscript and that is the quality of the written English. As previously indicated, the manuscript requires careful copy-editing before it can be accepted. I have copied the text from the journal's publication criteria below so you can better understand this policy: "PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. We may reject papers that do not meet these standards. If the language of a paper is difficult to understand or includes many errors, we may recommend that authors seek independent editorial help before submitting a revision. These services can be found on the web using search terms like “scientific editing service” or “manuscript editing service.” Please submit your revised manuscript by Sep 13 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, Robin D Clugston, Ph.D. Academic Editor PLOS ONE [Note: HTML markup is below. Please do not edit.] [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. https://doi.org/10.1371/journal.pone.0239308.r007
Revision 4
7 Aug 2020 Author Response Dear Editor and Reviewer Sincerest thanks for your response and comments on our manuscript. We have modified the quality of English in this paper in response to the given comments. We would be glad to respond to any further questions and comments that you may have. Attachments Attachment Submitted filename: Response to editor and reviewers.docx https://doi.org/10.1371/journal.pone.0239308.r008
13 Aug 2020 Decision Letter - Robin D Clugston, Editor PONE-D-19-28467R4 Adequate vitamin A rich food consumption and associated factors among lactating mothers visiting child immunization and post-natal clinic at health institutions in Gondar Town, Northwest Ethiopia PLOS ONE Dear Dr. Aserese, 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. As previously communicated, I am still not satisfied with the quality of the manuscript's written English and have made the following specific suggestions to help improve the manuscript. Line 24: …low-income countries and is a major… Line 30: An institution-based… Line 31: …March 2019, and included 631 study participants. (delete “were included in the study”) Line 74: “Vitamin A deficiency is a major public health problem, especially among low-income countries” Line 77: 5 years (insert space, add ‘s’) Line 79: …to replace loss that occurs through… Line 80: Please insert a space between the value and the unit Line 81: insert comma after the word foods Line 81: replace “which” with “that” Line 83: insert comma after the word products Line 86: Little attention has been given to the problem of vitamin A deficiency in breastfeeding as compared to preschool children because the clinical symptoms of xerophthalmia in women are rare. Line 91: …deficiency has been demonstrated in different African countries. For example, about 40%... Line 94: In Ethiopia, research has shown that vitamin A deficiency remains a public health concern, including a high prevalence of Bitot’s spots, with the highest… Line 99: replace “better” with “optimal” Line 100: Several causes of vitamin A deficiency in pregnant women have been identified, including inadequate consumption of vitamin A-rich foods, socio-demographic factors, economic status, duration of lactation (prolonged), amount of body fat, and hemoglobin concentration (2, 11, 12, 14, 20). Line 103: No need to start new paragraph here Line 104: Vitamin A deficiency has a wide range of consequences, with the most common manifestations including ocular lesions (e.g. xerophthalmia), mortality, failure to thrive, and poor reproduction (21). Line 107: Children born with… Line 109: No need to start new paragraph here. Change text: “Attempts to prevent and control vitamin A deficiency include promoting Line 110: remove comma between “mothers” and “and” Line 111: remove comma between “conditions” and “and” Line 111: “fortification of cooking oil with vitamin A” Line 113: …”launched a revised”. It would be helpful to include the data here. For example “In 20XX, Ethiopia launched a revised…” Line 117: “objective, which has made a great contribution to preventing vitamin A deficiency” Line 125: “750 km” Line 126: …health office report, it is estimated that there are currently… Line 136: No need to start new paragraph here Line 140. No need to start new paragraph here Line 143-146: Here you introduce the abbreviation HC for health center (line 143) but do not use it in line 145 and 146. Please be consistent with the use of this abbreviation, or do not introduce it. Line 149: Each of these definitions do not need to appear on a new line and can be consolidated into a single paragraph. Also, I do not recommend you using bold for the operational terms; maybe use italics so it does not conflict with the journal’s formatting guidelines. I recommend starting this paragraph like this: “The following operational definitions were used in this study. Adequate…” Line 163: Insert FFQ as abbreviation for food frequency questionnaire here Line 170: Please define what FFM stands for here. Spell it out. Line 170: “…last week they consumed…” Line 182: No need to start new paragraph here Line 188: “A principal component…” Line 191: delete comma Line 218: delete “have” Line 219: insert space after 27 Line 252: do not capitalize “meat” Line 263: replace “to” with “for” Line 268: “…were included in the multivariable analysis. Educational…” Line 270: “...considered to be determinants for…” Line 276: “…status was found…” Line 277: “vitamin A-rich food…” Start sentence with capital letter: “Mothers…” Line 290: Please check for meaning > “Lactating women have a higher vitamin A requirement compared to women who are not pregnant as vitamin A in the mother’s diet is directly transferred into breast milk. As such, the FAO/WHO…” Line 300: “…, and physiological state” Line 301: No need to start a new paragraph here. Line 304: “This difference may reflect differing economic status, as the study participants…” Line 312: “…consequences of inadequate dietary vitamin A intake” Line 313: “..4 times more likely chance of consuming adequate…” Line 315: “…foods to a large family…” Line 318: “This may be because mothers…” Line 322: “WHO guidelines” Line 325: No need to start a new paragraph here Line 332: “Because the study was institution based, it may overestimate consumption and may… Throughout the entire manuscript, please make sure there is a space between the last letter and the brackets containing the references. For example, line 75 has no space, but line 76 does have a space. All brackets containing references should be preceded by a single space. Please submit your revised manuscript by Sep 27 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, Robin D Clugston, Ph.D. Academic Editor PLOS ONE [Note: HTML markup is below. Please do not edit.] [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. https://doi.org/10.1371/journal.pone.0239308.r009
Revision 5
1 Sep 2020 Author Response Response to Reviewers Dear respected editor, Sincerest thanks for your response and comments on our manuscript. We have modified the quality of English in this paper in response to the given comments. We would be glad to respond to any further questions and comments that you may have. We look forward to hear your response. Thank you! Attachments Attachment Submitted filename: Response to Reviewers.docx https://doi.org/10.1371/journal.pone.0239308.r010
4 Sep 2020 Decision Letter - Robin D Clugston, Editor Adequate vitamin A rich food consumption and associated factors among lactating mothers visiting child immunization and post-natal clinic at health institutions in Gondar Town, Northwest Ethiopia PONE-D-19-28467R5 Dear Dr. Aserese, 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. An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org. If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org. Kind regards, Robin D Clugston, Ph.D. Academic Editor PLOS ONE Additional Editor Comments (optional): Reviewers' comments: https://doi.org/10.1371/journal.pone.0239308.r011
Formally Accepted
11 Sep 2020 Acceptance Letter - Robin D Clugston, Editor PONE-D-19-28467R5 Adequate vitamin A rich food consumption and associated factors among lactating mothers visiting child immunization and post-natal clinic at health institutions in Gondar Town, Northwest Ethiopia Dear Dr. Aserese: I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department. If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org. If we can help with anything else, please email us at plosone@plos.org. Thank you for submitting your work to PLOS ONE and supporting open access. Kind regards, PLOS ONE Editorial Office Staff on behalf of Dr. Robin D Clugston Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0239308.r012

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