PONE-D-20-18515

Prevalence and determinants of Anemia among young (15-24 years) women in Ethiopia; A multilevel analysis of the 2016 Ethiopian Demographic and Health Survey data

PLOS ONE

Dear Dr. Worku,

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.

Five experts in the field handled your manuscript. We are very thankful for their time and efforts. Although some interest was found in your study, several major comments arose that overshadowed this enthusiasm. These concerns include the overall impact on global policy changes, and perhaps the article should be directed toward national policy makers. Furthermore, there are details about the methods that need to be clarified; the data presentation needs work; and there are suggestions to increase the readability of this manuscript with the necessity to employ an expert to correct the English grammar and syntax.

Please submit your revised manuscript by Sep 19 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.

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We look forward to receiving your revised manuscript.

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Frank T. Spradley

Academic Editor

PLOS ONE

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https://bmcpregnancychildbirth.biomedcentral.com/articles/10.1186/s12884-020-03024-5

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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

Reviewer #2: Partly

Reviewer #3: Yes

Reviewer #4: Yes

Reviewer #5: Yes

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

Reviewer #1: Yes

Reviewer #2: I Don't Know

Reviewer #3: Yes

Reviewer #4: Yes

Reviewer #5: 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

Reviewer #2: No

Reviewer #3: Yes

Reviewer #4: Yes

Reviewer #5: 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

Reviewer #2: No

Reviewer #3: Yes

Reviewer #4: No

Reviewer #5: No

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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: This is a fine paper and will be useful to the field, however I have some comments:

1) The manuscript need English editing.

2) In table 3; it will be better if author add extra column for p value.

Reviewer #2: Prevalence and determinants of Anaemia among young (15-24 years) women in Ethiopia; A multilevel analysis of the 2016 Ethiopian Demographic and Health Survey data. This study is an overview demographic data from Ethiopia were association with anaemia and demographics are made.

I have two major concerns:

As these outcome are interesting and important for national policy makers, I am doubting if it is eligible for the international readers of PLOSONE this as outcomes might be region specific.

Secondly I do not understand why this study is needed, with regards to this age group, are young woman not part of the reproductive age group? What makes them different?

Abstract:

Background:

Line 28: Is this for all of Africa or only sub-sharan Africa? As I believe the needs are not as much possible in northern Africa. Please rephrase.

Line 30:I do not understand the difference between young woman and and woman in the reproductive age group. Is this not the same group? Why is there a difference?

Method:

Line 34 what kind of determinants?

Line 35 MOR/ ICC; please no abbreviations in the abstract without explanation.

Line 36 double (..) .

Line 36-38 this can be shortened not all needed in my perspective in the abstract. What is the definition of young woman’s? I can’t find that In the method.

Results/conclusion: strong and usefull conclusion.

Main manuscript:

Background: The terms young woman and adolescents are used all over the manuscript. However it is unclear what the exact definitions are.

Line 75-78 unclear sentences, which cut-off? Please define more specific.

Line79: Which population? Please define more specific.

Overall line 75-87 this alinea needs to be restructured, the data presenting on adolescents and young woman reproductive are not used in a structured way. Please rephrase and structure.

Line 89-92: This is a line-up most likely from a previous study. Please summarise the only needed information.

Line 93: This is a repetition of what is said in the first alinea. Please rephrase and restructure.

Line 95-96: the reason for his study is that most study look to the reproductive woman, it is unclear for me why this young woman are not part of that see previous comments. I addition: UDAID data 2000 shows that 16% of the woman between 15-19 years have been mothers. Moreover Adolescent childbearing trends and sub-national variations in Ethiopia: a pooled analysis of data from six surveys Yared Mekonnen et al. BMC Pregnancy and Childbirth volume 18, Article number: 276 (2018) shows similar data. Can the author explain why this study is needed next to a study on woman in the reproductive age ?

Line 99: Abbreviation not explained.

Methods:

Line 107-111 can this be displayed in a graph, that makes it easier for the reader to understand.

Line 113: add abbreviation (EDHS) as it used in the next sentence.

Line 113-126 can this be added in a graph/ figure with a flow diagram. That makes it easier for the reader to oversee what happened.

Outcome variable line 128: please define young woman.

Line 129-131 I do not understand this sentence and I am questioning if the sentence is needed. Moreover there is no difference between in mild-moderate-and severe anaemia in the study. So the author should remove this sentence.

Line 132: Reference 14; is this correct? And please add in writing which adjustment is done.

Line 133: Reference 13; correct? This is the WHO definition of anaemia please add the WHO as reference. Independent variable: line 136-140: please add definitions of the variable or add a reference. For example what is wealth status? What includes media exposure?? What includes modern contraceptives? Please rephrase.

Line 138 typo double (,,). Data management and analysis: 148-149 Descriptive (no needed information) please take out.

Line 152-154: this is a difficult statistical method, I cannot comment on it, as I am not familiar with the method.

Results:

Overall percentage can be given in one decimal.

Line 164: weighted sample not needed- please take out. The age range 15-24 can be taken out here, as this will be added to the method section.

The structure of line 165-173: could the author structural outcomes better. As a suggestion group in individual medical- social-economics and community. And use this structure as well in table 1.

Line 181-184: is this difference significant? Figure 1: what is the yellow line, please adjust figure.

Line 186-194: I can not comment on this, as my I do not have enough knowledge on statistics to do so.

Line 196-213/ Table 3: regions: why is all compared to Addis? Nutrition status: why all compared to malnutrition and not to none? Why with occupation display no below yes. Same for contraceptive and media exposure. Please display in a constituent manner. Distance to health facility: not a big problem? What does that mean? How is this defined??

Discussion:

I miss out in the discussion very clear statements why this outcome is 1) different than other woman previous investigated in Ethiopia? 2) is that surprising or not? What did others find in SSA for these age groups? Are you in line with that and if yes or no what are the difference? What are the clear limitations: limitations are stated very minimal. Conclusion: the conclusion is strong.

Line 217: Armenia-Timor: why a comparison tot his places?

Line 218: our country, what was the rate?

Line 219: Rate of comorbidity? This comment is based on which knowledge please explain

Line 236-249: this alinea has a lot of repetitive statements. Please rephrase and structure.

Line 247-249: Please add this to the section on rural areas in line 237-238

Line 254 ( see comment line 236-249)

Imitations: There is no data on age of first child, time between sampling and delivery. So major presumptions are made, but ideally this information would be available to say more about why are these women at risk. Or data on nutrition habits to underline the statements and suggestion. Moreover there is no data on malaria prevalence in this group. Or the availability of prophylaxis during pregnancy. All factors, which can be of major influence. The limitations need rephrasing and suggested limitations should be added.

Reviewer #3: This article covers an important global health concern. However, I believe the manuscript will benefit from a comprehensive language editing.

Please pay particular attention to the following and review the sentences:

Lines 25, 75, 95, 113, 129, 132,140, 150, 167. 170, 199, 229, 234, 238, 244, 253 and 257

Reviewer #4: Great work with potential impact on policy change.

However, the discussion needs to be written with clarity and better understanding. Most of the explanations given for the reported findings are difficult to comprehend.

There are also too many grammatical and spelling errors. The manuscript will benefit from review by a native English speaker.

Reviewer #5: Prevalence and determinants of Anemia among young (15-24 years) women in Ethiopia; A multilevel analysis of the 2016 Ethiopian Demographic and Health Survey data

The authors present findings from an analysis of data to determine the prevalence of anemia young women who participated in the 2016 Demographic Health Survey in Ethiopia. The key findings are the prevalence and identification of determinants of anemia among the study participants. The main strength of the study is the large sample size of women whose data were analyzed. However, the paper has several issues that the authors need to address before the paper can be suitable for publication in the journal.

The first issue is that the paper would need substantial English language editing; there are many editorial errors in the paper. The specific issues that require revision in the different components of the paper are provided below:

Abstract

1. The statement that there is a high prevalence of anemia in young persons (line 29) as a justification for the study is contradictory because If there is already high prevalence of anemia among young women why have the authors conducted another study among this same population? This should be clarified.

2. The statement ‘The overall prevalence of anemia among young women were 21.7% (line 40) should read ‘…was 21.7%’.

Background

1. There is need to clarify that the vulnerable population being referred to in line 69 are female adolescents and young women; this is necessary because male adolescents also suffer from anemia. This point should be clarified throughout the manuscript.

2. The statement ‘over half of young women worldwide are suffered...’ line 75 should read ‘… have suffered’

3. The statement ‘…and African as well...’ line 76 is not clear and should be revised.

4. If the statement ‘approximately one quarter of adolescents…’ line 78 is referring to female adolescents this should be clarified

5. There are many repetitive statements about the fact that sub-Sahara Africa has contributed to the high burden of anemia, this should be revised.

6. The authors have listed the socio-demographic factors (lines 89-92) that contribute to anemia in Ethiopia, but examples are not provided to illustrate this point. Some examples should be provided to illustrate this point.

7. The statement ‘Due to rapid growth…’ line 93 is a repetition because this point has been made earlier

8. The sentence ‘…and up to our knowledge’ line 96 should read ‘…to our knowledge’

9. The data for the study were extracted from the 2016 EDHS; is this the latest survey in the country? Have there been other surveys since the one in 2016? If there has been a more recent survey, the authors need to justify why they have used the 2016 survey as source of data for this study. This is should be clarified

Methods

1. An important information missing about the study area is the population of Ethiopia and more importantly the population of young persons in the country.

2. The reference to altitude and smoking (line 132) is not clear; how do these variables relate to the issue investigated. This should be clarified.

Results

1. The statement ‘of women were not had work’ line 170-171 is not clear and should be revised

2. The word ‘afar’ line 183 should read ‘Afar’

3. The use of the phrase ‘followers of Muslim and protestant religion’ line 203 are not clear. A better phrase may be people who practice Islam or Moslems and protestant Christians. This should be revised.

4. The statement ‘… with their counterparts’ line 207 should read ‘with their counterparts who do not’

5. The figure showing prevalence of anemia should have a number and reference should be made to it in the text

Discussion

1. I suggest that the authors provide the figure being referred to in the statement ‘but greater than the previous reported in our country’ line 218

2. The authors should give examples of the food types being referred to in line 228 and support this statement with appropriate reference

3. The statement i.e. barefooted line 241 should be revised to read walking barefooted

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Reviewer #1: No

Reviewer #2: No

Reviewer #3: No

Reviewer #4: Yes: KEHINDE OKUNADE

Reviewer #5: Yes: Ademola J. Ajuwon

[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.]

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Attachments

Attachment

Submitted filename: Comments on the paper on anemia in young persons in Ethiopia.docx

PONE-D-20-18515R1

Prevalence and determinants of Anemia among young (15-24 years) women in Ethiopia; A multilevel analysis of the 2016 Ethiopian Demographic and Health Survey data

PLOS ONE

Dear Dr. Worku,

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.

There are remaining comments from some reviewers that require your attention and must be addressed in your revised manuscript.

Please submit your revised manuscript by Nov 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,

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

Reviewer #2: (No Response)

Reviewer #3: All comments have been addressed

Reviewer #4: All comments have been addressed

Reviewer #5: 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

Reviewer #3: Yes

Reviewer #4: Yes

Reviewer #5: Yes

**********

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

Reviewer #1: Yes

Reviewer #2: I Don't Know

Reviewer #3: Yes

Reviewer #4: Yes

Reviewer #5: 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

Reviewer #3: Yes

Reviewer #4: Yes

Reviewer #5: 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: Yes

Reviewer #3: Yes

Reviewer #4: Yes

Reviewer #5: 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: This is a fine paper and will be useful to the field, and the results are interesting.

I don’t have any comment

Reviewer #2: Dear author,

Thanks for the major revisions to the manuscript. However I still have major concerns see them in detailed explained hereafter. But most important; I still mis out in your introduction and discussion. Why your study was essential to do? And what does it bring clearly new to this research field? Your methods and numbers are good but without that message very clear I am doubting for the eligibility for international readers. Please adjust that as you stated nicely in the explanations given to my comments.

• Reviewer 2 Comment 1 eligibility for international readers;

o Thanks for your clear response please add this information to the introduction

o Suggestion 1: change in the abstract line 27 particular in including

o Suggestion 2: line 99 add the age range of productive age (define)

o Suggestion 3: so explain why these two groups are different. Reproductive age and young woman and why your study is needed.

o Suggestion 4: line 100” determinates in Ethiopia” change to in Africa (or LMIC) including Ethiopia

• Reviewer 2 Comment 9: thanks for clarifying these definitions

o Suggestions: line 73 young woman and adolescents female. Change in including adolescent females

• Reviewer 2 Comment 15: see like the statement at comment 1. Clear clarification but please add this information to your introduction. To me it is still not clear why this study needed to be done. Please clarify clearly in the introduction and aim of the study.

• Reviewer 2 Comment 22: please state this calculation in the method section. Because you still used it and now it is taken out fully. That is incorrect. Please change.

• Reviewer 2 Comment 31:

o line 181-184: please add the CI to the groups you compare with as well and the p value. Now the sentence is not complete. Or take out all the CI and just give the P value. But the statement reads incorrect in the way it is stated now.

o Please add the CI to figure 3.

• Reviewer 2 Comment 32 : please add in section 181-184 to which area it was compared. Compared to addis… etc.

• Reviewer 2 Comment 34: This comparison to Timor is still out of place in my perspective. Please refrase. Either put this statement together with the comparison at line 225 or take out.

• Reviewer 2 Comment 35: thanks for this change. However to me it is still not clear why your study was important when you have these numbers already. Please rephrase and explain what your study showed more. Because in the way it reads now like you redid the study.

• Reviewer 2 Comment 40: line 275: add these variables which you stated in your explanation there aswell.

Reviewer #3: (No Response)

Reviewer #4: (No Response)

Reviewer #5: Prevalence and determinants of Anemia among young (15-24 years) women in Ethiopia; A multilevel analysis of the 2016 Ethiopian Demographic and Health Survey data

There is substantial improvement in the presentation of the revised manuscript. The authors have addressed all the issues and queries I raised in my previous review of the manuscript. However, in re-reading the manuscript, I detected some minor editorial errors which require the authors attention.

1. In line 80, the word ‘where’ should be replaced by the word ‘with’ to make the sentence clearer.

2. The statement on line 133 and 134 should be presented in past tense ‘for pregnant women…was considered as anemic…’

3. In line 165, the first letter of the university should start with a capital letter, to read ‘University of Gondar’; the authors should also clarify if this institution is in Ethiopia.

4. The statement on 226 needs revision; it should read ‘…greater than the 15.6% anemia found among young women in Rwanda’

5. The author should clarify which country is being referred to on line 227; is this Ethiopia or Rwanda? This should be revised.

6. The statement on line 262 should read ‘…which are common in lowland areas’

7. The word on line 330 should read ‘References’ not ‘reference’

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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: Osama Mohammed Al-Amer

Reviewer #2: No

Reviewer #3: No

Reviewer #4: Yes: KEHINDE OKUNADE

Reviewer #5: Yes: Professor Ademola J. Ajuwon

[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: New comments on revised paper on anemia among young women in Ethiopia, 210920.docx

Prevalence and determinants of Anemia among young (15-24 years) women in Ethiopia; A multilevel analysis of the 2016 Ethiopian Demographic and Health Survey data

PONE-D-20-18515R2

Dear Dr. Worku,

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