Pooled prevalence and associated factors of chronic undernutrition among under-five children in East Africa: A multilevel analysis

Getayeneh Antehunegn Tesema; Yigizie Yeshaw; Misganaw Gebrie Worku; Zemenu Tadesse Tessema; Achamyeleh Birhanu Teshale

doi:10.1371/journal.pone.0248637

Peer Review History

Original SubmissionJuly 26, 2020
18 Jan 2021 Decision Letter - Jane Anne Scott, Editor PONE-D-20-18977 Pooled prevalence and associated factors of chronic undernutrition among under-five children in East Africa: A multilevel analysis PLOS ONE Dear Dr. Tesema, 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. I have reviewed the paper as the second reviewer and have identified a number of issues to be addressed in your revision. In addition, I have copy edited the paper to improve the English language and writing style. These changes are made to a copy of the paper which is attached to this letter. Please submit your revised manuscript by Feb 12 2021 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, Jane Anne Scott, PhD, MPH Grad Dip Dietetics, BSc Academic Editor PLOS ONE Journal Requirements: When submitting your revision, we need you to address these additional requirements. 1. 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 https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf 2. We note that you have stated that you will provide repository information for your data at acceptance. Should your manuscript be accepted for publication, we will hold it until you provide the relevant accession numbers or DOIs necessary to access your data. If you wish to make changes to your Data Availability statement, please describe these changes in your cover letter and we will update your Data Availability statement to reflect the information you provide. 3. Your ethics statement should only appear in the Methods section of your manuscript. If your ethics statement is written in any section besides the Methods, please delete it from any other section. 4. We noticed you have some minor occurrence of overlapping text with the following previous publication(s), which needs to be addressed: https://link.springer.com/article/10.1007/s10668-010-9278-0?code=17828610-9ce7-412d-b01f-238f1863e02f&error=cookies_not_supported https://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-020-09965-y https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0157814 In your revision ensure you cite all your sources (including your own works), and quote or rephrase any duplicated text outside the methods section. Further consideration is dependent on these concerns being addressed. [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 Reviewer #2: Yes ******** 2. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: Yes Reviewer #2: 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 Reviewer #2: 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: Yes Reviewer #2: 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: The study is relevant and timeous considering that stunting remains persistent in most African countries. The authors determined the pooled prevalence of chronic undernutrition and associated factors. Data from 12 East African DHS was used (i.e. secondary analysis). The overall pooled prevalence for stunting and by country are reported. Regression analysis was used to study the associated factors, and the manuscript report several factors similar to other studies, such as residence, maternal age, maternal education, wealth status, birth size, sex of the child, ANC visit, place of delivery, family size, type of birth, birth order, country, and child age. The strength and the limitations of the study are well discussed and the conclusion summarizes the findings and the recommendation. The manuscript has adhered to the standard format. Abstract Under the results; the third sentence should read "Children whose mothers" not mother. Key words The authors can consider to add stunting, pooled prevalence, associated factors, under-five children, East-Africa, DHS . Remove "mixed effect analysis". Background first paragraph sentence 7 - A child is considered stunted... The authors should remove "as" second paragraph this sentence is missing something and should be rephrased "Malnutrition is the leading cause of under-five morbidity and mortality". Is it under-five 'children'? Results This sentence "The median age of children was 31 (IQR±13.5) months" should either report median (IQR) or mean±SD. It cant be IQR and SD. Reviewer #2: In general, this is a well conducted study although the writing is awkward in places with some grammatical errors. A lack of line numbering made it difficult to highlight these issues so I have edited the paper and I attach a copy of this paper with changes marked. Further suggestions for improvements are listed below. Abstract 1. The results section of the abstract contains a single, very long sentence which contains all of the factors significantly associated with undernutrition. I suggest breaking this into two sentences which first identifies those factors associated with an increased risk of stunting and then a second sentence which identifies those factors which were associated with a decreased risk of stunting. Background 2. Is the statistic of 1 in 4 infants in East African countries being stunted actually for infants (i.e. children under 12 months of age) or for children under-five years, which is the target group for this study? Methods 3. The explanatory variable ‘exclusive breastfeeding’ needs to be more clearly defined. Is this a continuous variable which indicates the duration of EBF or is it a binary variable which indicates whether a child was EBF to 6 months of age? The results in table 4 suggest it is the latter. Results 4. Under the data management section you say that the pooled prevalence of stunting with the 95% Confidence Interval (CI) was reported using a forest plot. However, while you report the pooled prevalence in the results section you have not included the forest plot. 5. When reporting the findings from the multivariable mixed-effect logistic regression analysis you describe each variable individually and you move between variables that are associated with an increased risk of stunting and those with a decreased risk of stunting. I think it would be clearer if you were to first present those variables associated with a higher risk of stunting and then in a new paragraph identify those that are associated with a lower risk of stunting. 6. The sentence that compares the odds of stunting for each country compared to Kenya is very long and repeats results that are easily discernible from the table. I suggest simplifying this finding and only provide the results for the countries with the lowest and highest odds ratios e.g. “Compared with Kenya which had the lowest prevalence of stunting, all of the other countries had a significantly higher odds of stunting ranging from an odds of 1.30 (1.19, 1.42) for Uganda to 4.76 (4.40, 5.14) for Burundi.” 7. PNC is described in the methods section as an explanatory variable. While it is reported in table 1 there is no further reference to PNC. This variable isn’t included in Table 3 or reported in the results or discussion in terms of its association with stunting. You should either remove all reference to PNC or redo the analysis with this variable in the model. Or does table 3 only contain those variables which had a p-value above 0.2 in the bivariable analysis? This is not clear if this is the case. Discussion 8. For clarity, I suggest discussing all of the factors associated with an increased risk of stunting and THEN discussing those factors associated with a decreased risk. You move between factors associated with increased and decreased risk and then back to increased risk. References 9. A number of the references are very dated e.g. 1, 11, 16, 32, 41, 52, 57, 61, 65. Are they seminal papers or can they be replaced with more recent references? 10. Reference 7 The last ‘author’ appears to be a group/organisation but it is unclear which group. When entering the details of a group put a comma after the last word of the name to denote that this is a group. E.g. WHO Child Health Epidemiology Reference Group, Otherwise ENDNOTE treats the last word as the family name and initialises all of the other words e.g. Group,WCHERG 11. Reference 33 Some details appear to be missing. Is this a book or a chapter of a book? 12. Reference 35 Please do not abbreviate the institution which has published the report. Where was this report published? 13. Reference 59 Reference details are incomplete. ****** 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: No Reviewer #2: Yes:** Jane A Scott [NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.] While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step. Attachments Attachment Submitted filename: PONE-D-20-18977_reviewer.docx https://doi.org/10.1371/journal.pone.0248637.r001
Revision 1
10 Feb 2021 Author Response PLOS ONE Point by point response for editors/reviewers comments Manuscript title: Pooled prevalence and associated factors of chronic undernutrition among under-five children in East Africa: A multilevel analysis Manuscript ID: PONE-D-20-18977 Dear editor/reviewer. Dear all, We would like to thank you for these constructive, building, and improvable comments on this manuscript that would improve the substance and content of the manuscript. We considered each comment and reviewers on the manuscript thoroughly. Our point-by-point responses for each comment and question are described in detail on the following pages. Response to reviewers comments Reviewer#1 1. Abstract Under the results; the third sentence should read "Children whose mothers" not mother. Authors’ response: Thank you for the comments. We accept and modified it. (See Abstract section, line 41, page 2) 2. Key words The authors can consider to add stunting, pooled prevalence, associated factors, under-five children, East-Africa, DHS . Remove "mixed effect analysis". Authors’ response: Thank you for the concerns. We removed it in the revised manuscript. (See Abstract section, line 57, line 3) 3. Background first paragraph sentence 7 - A child is considered stunted... The authors should remove "as" second paragraph this sentence is missing something and should be rephrased "Malnutrition is the leading cause of under-five morbidity and mortality". Is it under-five 'children'? Authors’ response: Thank you for the comments. We accepted and modified it. (See Background section, page 4) 4. Results This sentence "The median age of children was 31 (IQR±13.5) months" should either report median (IQR) or mean±SD. It cant be IQR and SD. Authors’ response: Thank you for the comments. We reported the median as a measure of central tendency and Inter-quartile Rage (IQR) as a measure of dispersion since the variable was not normally distributed (skewed) with Shapiro Wilks test p-value<0.05. Reviewer #2 1. In general, this is a well conducted study although the writing is awkward in places with some grammatical errors. A lack of line numbering made it difficult to highlight these issues so I have edited the paper and I attach a copy of this paper with changes marked. Further suggestions for improvements are listed below. Authors’ response: Thank you reviewer for the detailed comments and changes you made for the betterment of the paper. Sorry for the missing line number, and now, we insert the line number and address the comments you raised. (See the revised manuscript) 2. Abstract The results section of the abstract contains a single, very long sentence which contains all of the factors significantly associated with undernutrition. I suggest breaking this into two sentences which first identifies those factors associated with an increased risk of stunting and then a second sentence which identifies those factors which were associated with a decreased risk of stunting. Authors’ response: Thank you for the comments. We accept the comments and write accordingly. (See Abstract section, line 39 -52, page 2-3) 3. Background Is the statistic of 1 in 4 infants in East African countries being stunted actually for infants (i.e. children under 12 months of age) or for children under-five years, which is the target group for this study? Authors’ response: Thank you for the comments. We rewrote it as our target population is under-five children. (See the revised manuscript) 4. Methods The explanatory variable ‘exclusive breastfeeding’ needs to be more clearly defined. Is this a continuous variable which indicates the duration of EBF or is it a binary variable which indicates whether a child was EBF to 6 months of age? The results in table 4 suggest it is the latter. Authors’ response: Thank you for the comments. We consider the duration of EBF as a binary outcome by categorizing those children who breastfeed for a minimum of 6 months exclusively as yes and for those children who feed less than months as no. (See the revised manuscript) 5. Results 5. Under the data management section you say that the pooled prevalence of stunting with the 95% Confidence Interval (CI) was reported using a forest plot. However, while you report the pooled prevalence in the results section you have not included the forest plot. Authors’ response: Thank you for the comments. We planned to present using a forest plot but we prefer to present it in a bar graph as this study was not a metanalysis. As you know while we have done, in the forest plot several columns were presented like weight but this may not be important to present it. So, we presented the pooled prevalence in the bar graph. (See Figure 1) 6. When reporting the findings from the multivariable mixed-effect logistic regression analysis you describe each variable individually and you move between variables that are associated with an increased risk of stunting and those with a decreased risk of stunting. I think it would be clearer if you were to first present those variables associated with a higher risk of stunting and then in a new paragraph identify those that are associated with a lower risk of stunting Authors’ response: Thank you for the comments. We accept the comments and report the findings from factors that increase the odds of stunting to factors that decrease the odds of stunting. (See the Result section, line 195 – 228, page 9-11) 7. The sentence that compares the odds of stunting for each country compared to Kenya is very long and repeats results that are easily discernible from the table. I suggest simplifying this finding and only provide the results for the countries with the lowest and highest odds ratios e.g. “Compared with Kenya which had the lowest prevalence of stunting, all of the other countries had a significantly higher odds of stunting ranging from an odds of 1.30 (1.19, 1.42) for Uganda to 4.76 (4.40, 5.14) for Burundi.” Authors’ response: Thank you for the comments. We revised it. (See Result section, line 202-203, page 10) 8. PNC is described in the methods section as an explanatory variable. While it is reported in table 1 there is no further reference to PNC. This variable isn’t included in Table 3 or reported in the results or discussion in terms of its association with stunting. You should either remove all reference to PNC or redo the analysis with this variable in the model. Or does table 3 only contain those variables which had a p-value above 0.2 in the bivariable analysis? This is not clear if this is the case. Authors’ response: Thank you for the concern. We consider PNC in the method and result section. But, in the multivariable multilevel analysis, we did not use PNC as it has a p-value>0.2 in the bivariable analysis. As we stated in the method section we consider variables with a p-value in the bivariable multilevel analysis were included in the multivariable multilevel analysis, that is why we did not include PNC in the final model. 9. Discussion For clarity, I suggest discussing all of the factors associated with an increased risk of stunting and THEN discussing those factors associated with a decreased risk. You move between factors associated with increased and decreased risk and then back to increased risk. Authors’ response: Thank you for the suggestions. We accept it and rewrote it. (See discussion section) 10. References A number of the references are very dated e.g. 1, 11, 16, 32, 41, 52, 57, 61, 65. Are they seminal papers or can they be replaced with more recent references? Reference 7 The last ‘author’ appears to be a group/organisation but it is unclear which group. When entering the details of a group put a comma after the last word of the name to denote that this is a group. E.g. WHO Child Health Epidemiology Reference Group, Otherwise ENDNOTE treats the last word as the family name and initialises all of the other words e.g. Group,WCHERG Reference 33 Some details appear to be missing. Is this a book or a chapter of a book? Reference 35 Please do not abbreviate the institution which has published the report. Where was this report published? Reference 59 Reference details are incomplete. Authors’ response: Thank you for the comments. We modified all the suggested references. (See the revised manuscript) Attachments Attachment Submitted filename: Point by point response.docx https://doi.org/10.1371/journal.pone.0248637.r002
23 Feb 2021 Decision Letter - Jane Anne Scott, Editor PONE-D-20-18977R1 Pooled prevalence and associated factors of chronic undernutrition among under-five children in East Africa: A multilevel analysis PLOS ONE Dear Dr. Tesema, Thank you for resubmitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but still 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 minor issues that I have identified at the end of this letter. Please also note that your image file "Figure 1.tif" could not be opened and processed. It appears that the image file is corrupt or invalid. Please check and make sure that this problem is corrected when you resubmit your final version of the paper. Please submit your revised manuscript by Apr 09 2021 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, Jane Anne Scott, PhD, MPH Grad Dip Dietetics, BSc Academic Editor PLOS ONE Journal Requirements: Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice. Additional Editor Comments (if provided): Minor issues to be addressed 1. Line 49 Being small size at birth should be included with the factors that were associated with increased odds of stunting, not those associated with a decreased odds as the AOR is greater than 1 (AOR=1.35, 95% CI: 1.29, 1.40). 2. Line 55 How are ‘multiple births’ a modifiable factor unless a woman is having fertility treatment? The conclusions in your abstract should be consistent with the conclusions in your main paper on page 15. 3. Line 60 you have misquoted reference 3. It is the first 1000 days ‘post conception’ NOT ‘after birth’. 4. Line 304-305 The way in which you have worded this sentence makes it sound as though ‘health facility delivery and ANC visit’ are associated with an increased risk of chronic malnutrition and NOT that they are protective of chronic malnutrition. I suggest rewording this sentence ‘In our study, health facility delivery and ANC visit were protective of child chronic malnutrition.’ 5. Table 3 please include a footnote explaining the meaning of the asterisks. Also I recommend that you included a footnote to explain that the table includes only those variables for which the bi-variable analysis had a p <0.20, otherwise readers may wonder why some of the variables listed in Table 1 are not included in Table 2, (as I was). Minor grammatical errors 6. line 34 should read ‘Variables’ (plural) 7. line 37 should read ‘were reported for significant factors’ 8. Line 45 2nd -4th birth order 9. line 72 the word half is a collective noun and is treated as a singular. Therefore this should read ‘More than half …… is due ….’ 10. line 84 the word ‘to’ is not needed, should read ‘… children include residence…..’ 11. Line 89 should read ‘ has declined from..’ 12. Line 139 I suggest replacing the word ‘divided’ with ‘categorised’. 13. Line 149 should read ‘presented in a bar graph’. 14. Line 195 Given that the next paragraph describes the multivariable mixed-effect logistic regression analysis, shouldn’t this subheading read ‘The mixed effect results’? 15. Lines 260 to 262 should read ‘Besides, educated women are more likely to exclusively breastfeed for….” 16. Line 266 suggest rewording this sentence ‘Children who live in poor households typically have poor access to adequate food, safe water, and sanitation.’ [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.0248637.r003
Revision 2
26 Feb 2021 Author Response Point by point response for editors/reviewers comments PLOS ONE Journal Manuscript title: Pooled prevalence and associated factors of chronic undernutrition among under-five children in East Africa: A multilevel analysis Manuscript ID: PONE-D-20-18977R1 Dear editor/reviewer. Dear all, We would like to thank you for these constructive, building, and improvable comments on this manuscript that would improve the substance and content of the manuscript. We considered each comment and clarification questions of editors and reviewers on the manuscript thoroughly. Our point-by-point responses for each comment and question are described in detail on the following pages. Response to Editors 1. Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice. Authors’ response: Thank you for the comments. We have checked the references and it is correctly presented. Response to reviewers Minor issues to be addressed 1. Line 49 Being small size at birth should be included with the factors that were associated with increased odds of stunting, not those associated with a decreased odd as the AOR is greater than 1 (AOR=1.35, 95% CI: 1.29, 1.40). Authors’ response: Thank you for the comments. We included with the factors that were associated with increased odds of stunting. (See Abstract section line 48, page 2) 2. 2. Line 55 How are ‘multiple births’ a modifiable factor unless a woman is having fertility treatment? The conclusions in your abstract should be consistent with the conclusions in your main paper on page 15 Authors’ response: Thank you for the comments. We rewrote it. (See Abstract section, line 53-57, page 3) 3. Line 60 you have misquoted reference 3. It is the first 1000 days ‘post conception’ NOT ‘after birth’ Authors’ response: Thank you for the comments. We rewrote it. (see Background section, line 61, page 4) 4. Line 304-305 The way in which you have worded this sentence makes it sound as though ‘health facility delivery and ANC visit’ are associated with an increased risk of chronic malnutrition and NOT that they are protective of chronic malnutrition. I suggest rewording this sentence ‘In our study, health facility delivery and ANC visit were protective of child chronic malnutrition.’ Authors’ response: Thank you for the suggestions. We accept it and revised the sentence. (See Discussion section, line 302-303, page 14) 5. Table 3 please include a footnote explaining the meaning of the asterisks. Also I recommend that you included a footnote to explain that the table includes only those variables for which the bi-variable analysis had a p <0.20, otherwise readers may wonder why some of the variables listed in Table 1 are not included in Table 2, (as I was). Authors’ response: Thank you for the comments. We included the points you raised. (See Table 3) Grammatical errors 6. line 34 should read ‘Variables’ (plural) 7. line 37 should read ‘were reported for significant factors’ 8. Line 45 2nd -4th birth order 9. line 72 the word half is a collective noun and is treated as a singular. Therefore this should read ‘More than half …… is due ….’ 10. line 84 the word ‘to’ is not needed, should read ‘… children include residence…..’ 11. Line 89 should read ‘ has declined from..’ 12. Line 139 I suggest replacing the word ‘divided’ with ‘categorised’. 13. Line 149 should read ‘presented in a bar graph’. 14. Line 195 Given that the next paragraph describes the multivariable mixed-effect logistic regression analysis, shouldn’t this subheading read ‘The mixed effect results’? 15. Lines 260 to 262 should read ‘Besides, educated women are more likely to exclusively breastfeed for….” 16. Line 266 suggest rewording this sentence ‘Children who live in poor households typically have poor access to adequate food, safe water, and sanitation.’ Authors’ response: We thank you a lot for your extensive effort to improve our work. We accept all the abovementioned comments and revised the manuscript. (See the revised manuscript) Attachments Attachment Submitted filename: Point by point response.docx https://doi.org/10.1371/journal.pone.0248637.r004
3 Mar 2021 Decision Letter - Jane Anne Scott, Editor Pooled prevalence and associated factors of chronic undernutrition among under-five children in East Africa: A multilevel analysis PONE-D-20-18977R2 Dear Dr. Tesema, 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, Jane Anne Scott, PhD, MPH Grad Dip Dietetics, BSc Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0248637.r005
Formally Accepted
17 Mar 2021 Acceptance Letter - Jane Anne Scott, Editor PONE-D-20-18977R2 Pooled prevalence and associated factors of chronic undernutrition among under-five children in East Africa: A multilevel analysis Dear Dr. Tesema: 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. Jane Anne Scott Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0248637.r006

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