Under nutrition and associated factors among adolescent girls attending school in the rural and urban districts of Debark, Northwest Ethiopia: A community-based comparative cross-sectional study

Tewodros Getaneh Alemu; Addis Bilal Muhye; Amare Demsie Ayele

doi:10.1371/journal.pone.0254166

Peer Review History

Original SubmissionFebruary 26, 2021
7 Apr 2021 Decision Letter - Madhavi Bhargava, Editor PONE-D-21-06490 Undernutrition and Associated Factors among Adolescent Girls Attending School in the rural and urban districts of Debark town, Northwest Ethiopia: A community-based comparative cross-sectional study. PLOS ONE Dear Dr. Alemu, Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process. Please submit your revised manuscript by May 22 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. 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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 If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references.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 If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.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): [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: No Reviewer #2: Yes ****** 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: Comments on manuscript entitled” Undernutrition and Associated Factors among Adolescent Girls Attending School in the rural and urban districts of Debark town, Northwest Ethiopia: A community-based comparative cross-sectional study”. PONE-D-21-06490 The authors assessed the association between the prevalence of undernutrition and different socio-demographic factors among school going adolescent girls of Debark district, Northwest Ethiopia. I have the following few comments… 1. In the title, the authors mentioned as Adolescent Girls Attending School in the rural and urban districts of Debark town. It is not clear, whether Debark is town or district and whether Debark has rural and urban districts. 2. In abstract, total number of adolescent girls was mentioned as 792 in methodology and 757 in results. Need to clarify the same. Correct the error in spelling of stunting. 3. Page 10, line 3. Delete you in “low resistance to infection due you to low immunity” 4. Authors reported in methodology as—Lottery method was used to select 20% of the 51 schools. Thus, accordingly we need 10 schools; however, a total 13 schools were covered. Similarly, authors have not selected the schools proportionately. Authors need to explain whether they selected the number of schools purposively or there is any rationale behind it. 5. Authors selected 396 adolescent girls each from rural and urban areas. Here also authors have not followed the PPS method for selection of adolescent girls. 6. Discussion part is exhaustive. Need to condense the same Reviewer #2: The topic is interesting and the findings are unique, it is a study that shows originality of the subject. In the abstract: the data collection should not be written as indepth interview since the study design is not qualitative, it is a quantitative study. It is mentioned in the conclusion (in the abstract) that food insecurity associated with stunting and thinness, however this variable is not mentioned in the results (in the abstract). In the introduction: The reason for conducting the study in adolescent nutrition is justified, however it should be better to add justification for investigating the disparities between urban and rural adolescent girls. Why we need to examine the disparities, what previous research tell about this? Is disparity between urban and rural become a big problem in Ethiopia? In the method: The operational definition section provides detail explanation about each variable. The difference between moderately exposed and very often exposed is not clear, the cut off value for very often needs to be added. Assessment of MDD requires respondents to report consumption of 10 food items, it needs explanation on what basis or consideration to choose/generate this list of foods? The explanation of upper, middle, and lower class based on the quantiles in method section is not consistent with that described in narration of table 3 and 5 in the result section. In the result: There is an error of typing drinking (dirking) water in table 2. Narration for table 3 mentions that adolescent girls who were in the lower and middle class experience stunting more than the upper class, referring the wealth index in the table (1st, 2nd, and 3rd quantile). This needs to be rechecked since in the method section, it is mentioned that 1st quantile as upper class, 2nd quantile as middle, and 3rd quantile as the lowest. It seems there is inconsistency for labelling the wealth class. The same problem with the narration of table 5. In table 6, wealth index uses different name of categories (i.e. lower, middle, late), I recommend to use same name of categories across tables. In discussion: please provide practical implications based on the findings, for instance implication for policy or programs. I recommend to indicate contribution of this work to the scientific community. ****** 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: No [NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.] While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step. Attachments Attachment Submitted filename: COMMENTS-PLOS ONE.docx https://doi.org/10.1371/journal.pone.0254166.r001
Revision 1
28 May 2021 Author Response Authors’ response to concerns of Editor and Reviewers Dear Editor and Reviewers, we the authors of this article would be very happy to convey our deepest gratitude for your immense contribution - rigorous editorial and review concerns for which we will go one by one to make our manuscript suitable for publication in PLOS ONE journal. Therefore, we are going to respond the Editor, Reviewer #1 and Reviewer #2 concerns respectively as presented hereunder: 1. Editor concerns and Authors’ responses: Editor concern: “1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming.” Authors’ response: Dear Editor, in all parts of the revised manuscript, we have used PLOS ONE’s requirements for publication of manuscripts. All the changes have been presented in a manuscript with track changes and without track changes. Editor concern: “2. Please provide additional details regarding participant consent. In the ethics statement in the Methods and online submission information, please ensure that you have specified what type you obtained (for instance, written or verbal, and if verbal, how it was documented and witnessed). If your study included minors, state whether you obtained consent from parents or guardians. If the need for consent was waived by the ethics committee, please include this information. Once you have amended this/these statement(s) in the Methods section of the manuscript, please add the same text to the “Ethics Statement” field of the submission form (via “Edit Submission”).” Authors’ response: Dear Editor, in the revised manuscript, we have included the details of participant consent in the ‘Methods and Materials’ section. Previously, the ethical statement was written as a separate section; but now it is being moved to the methods part. Therefore, all the ethical statement queries and changes have been presented in a manuscript with track changes and without track changes. Editor concern: “3. Please state in your methods section whether you obtained consent from parents or guardians of the minors included in the study or whether the research ethics committee or IRB approved the lack of parent or guardian consent.” Authors’ response: Dear Editor, in the revised manuscript, we have included the details of consent from parents or guardians of the minors included in the study in the ‘Methods and Materials’ section. Previously, the ethical statement of consent from guardians or parents of minors was written as we took assent from them; but now it is being moved to the methods part and written explicitly as per your recommendation. Therefore, all the ethical statement queries and changes about assent from guardians or parents of minors have been presented in a manuscript with track changes and without track changes. Editor concern: “4. Please include additional information regarding the survey or questionnaire used in the study and ensure that you have provided sufficient details that others could replicate the analyses. For instance, if you developed a questionnaire as part of this study and it is not under a copyright more restrictive than CC-BY, please include a copy, in both the original language and English, as Supporting Information. Moreover, please include more details on how the questionnaire was pre-tested, and whether it was validated.” Authors’ response: Dear Editor, in the revised manuscript, we have included the information regarding the survey or questionnaire used in the study. We have stated the tool availability both in Amharic and English, its pretest and validation process before the actual data collection. Therefore, all the changes have been presented in a manuscript with track changes and without track changes. Editor concern: “5. We suggest you thoroughly copyedit your manuscript for language usage, spelling, and grammar. If you do not know anyone who can help you do this, you may wish to consider employing a professional scientific editing service.” Authors’ response: Dear Editor, in the revised manuscript, we included an updated English language usage, spelling and grammar. We have given the manuscript for language edition and all the changes have been included in the manuscript with track changes and without track changes attached as supporting files. Editor concern: “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 move it to the Methods section and delete it from any other section. Please ensure that your ethics statement is included in your manuscript, as the ethics statement entered into the online submission form will not be published alongside your manuscript.” Authors’ response: Dear Editor, in the revised manuscript, the ethical statement it is being moved to the methods part only, and we have presented it in a manuscript with track changes and clean version. Editor concern: “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: Dear Editor, in the revised manuscript, there is no any change that we made in the list of references. 2. Reviewer #1 concerns and Authors’ responses: Reviewer concern: “1. In the title, the authors mentioned as Adolescent Girls Attending School in the rural and urban districts of Debark town. It is not clear, whether Debark is town or district and whether Debark has rural and urban districts.” Authors’ response: Dear Reviewer, when we say, in the rural and urban districts of Debark, we mean that Debark is a districts with rural and urban areas in its administration. Reviewer concern: “2. In abstract, total number of adolescent girls was mentioned as 792 in methodology and 757 in results. Need to clarify the same. Correct the error in spelling of stunting.” Authors’ response: Dear Reviewer, in the abstract section of our manuscript, we mentioned 792 adolescent girls in the methodology part and while 757 in the results part. We would assume that these numbers are correctly stated in the abstract that 792 adolescent girls were the minimum sample size that was calculated while we design the research work. Whereas, on the field work, we actually collected the data from 757 adolescent girls that were included in the data analyses processes which would give us a response rate of 95.6%. That means 35 of our study participants were non-respondents. The word ‘stunding’ in the original abstract is being corrected as ‘stunting’ in the revised version of the manuscript with track changes and without track changes. Reviewer concern: “3. Page 10, line 3. Delete you in “low resistance to infection due you to low immunity” Authors’ response: Dear Reviewer, the word ‘you’ in the original manuscript is being deleted in the revised version of the manuscript with track changes and without track changes. Reviewer concern: “4. Authors reported in methodology as—Lottery method was used to select 20% of the 51 schools. Thus, accordingly we need 10 schools; however, a total 13 schools were covered. Similarly, authors have not selected the schools proportionately. Authors need to explain whether they selected the number of schools purposively or there is any rationale behind it.” Authors’ response: Dear Reviewer, as you clearly mentioned, if we took 20% of 51 schools, they would have been 10 schools to cover all the sampling issue. However, the number of schools from rural districts (we took 9 from 44 schools) gave us enough number of adolescent girls as per the proportional allocation; whereas taking proportionately calculated schools from the urban districts (we would have taken 1 from 7 schools), the number of adolescent girls there not enough to cover the required sample size from urban districts. Referring to the World Health Organization Guideline for Sampling Design for Community-based studies recommends that the proportion of study population should not be below 20%. It also recommends that there is a possibility to increase more than this proportion. Therefore, we took 4 schools in the urban districts to meet the minimum sample size required for our study. Finally, the 4 urban schools were selected by lottery method among the available 7 schools there. Reviewer concern: “5. Authors selected 396 adolescent girls each from rural and urban areas. Here also authors have not followed the PPS method for selection of adolescent girls.” Authors’ response: Dear Reviewer, we have calculated the sample size of our study using a double population proportion formula where we used two different prevalence [Prevalence 1 (P1) for rural and Prevalence 2 (P2) for urban. This sample was calculated for a single group thereby we multiplied by two to get a sample of two settings. Moreover, we have used a 1:1 ratio of samples from rural and urban districts assuming that the we could get enough number of cases from the rural districts which was assumed have exposed for undernutrition. Finally, based on our ratio of samples, the overall sample size was divided equally for rural and urban districts. Reviewer concern: “6. Discussion part is exhaustive. Need to condense the same” Authors’ response: Dear Reviewer, the discussion part of our original manuscript is being condensed in the revised version of the manuscript with track changes and without track changes. 3. Reviewer #2 concerns and Authors’ responses: Reviewer concern: “In the abstract: the data collection should not be written as in-depth interview since the study design is not qualitative, it is a quantitative study. It is mentioned in the conclusion (in the abstract) that food insecurity associated with stunting and thinness, however this variable is not mentioned in the results (in the abstract).” Authors’ response: Dear Reviewer, in the abstract section of our original manuscript, the phrase ‘in-depth interview’ is being replaced by ‘face-to-face interview’; and the variable ‘food insecurity’ is being included in the ‘results’ section of the abstract. Both are available in the revised version of the manuscript with track changes and without track changes Reviewer concern: “In the introduction: The reason for conducting the study in adolescent nutrition is justified, however it should be better to add justification for investigating the disparities between urban and rural adolescent girls. Why we need to examine the disparities, what previous research tell about this? Is disparity between urban and rural become a big problem in Ethiopia?” Authors’ response: Dear Reviewer, we have planned and conducted a comparative cross-sectional (urban and rural disparity) study assuming that there are higher exposure variables for undernutrition among rural adolescents. Previous evidences didn’t show us the clear variation in undernutrition among urban and rural settings. Moreover, nearly 80% of Ethiopian population have been living in the countryside areas in which the there is high fertility rates and low socioeconomic status. Therefore, in the revised version of the manuscript, we have included the points you raised in a manuscript with track changes and without track changes. Reviewer concern: “In the method: The operational definition section provides detail explanation about each variable. The difference between moderately exposed and very often exposed is not clear, the cut off value for very often needs to be added.” Authors’ response: Dear Reviewer, the cut off value for ‘moderately exposed’ was ‘the highest value of all the three indicators is 2, i.e., at least once a week to any one or all of the indicators; whereas the cut of value for ‘very often exposed’ was ‘the highest value of all of the three indicators is 3, i.e., very often exposed to any one or all of the indicators. Therefore, in the revised version of the manuscript, we have included these cuts of values as in a manuscript with track changes and without track changes. Reviewer concern: “Assessment of MDD requires respondents to report consumption of 10 food items, it needs explanation on what basis or consideration to choose/generate this list of foods?” Authors’ response: Dear Reviewer, the Dietary Diversity Questionnaire (DDQ) were prepared based on the items presented in the Food and Agricultural Organization (FAO) Guideline 2016. Therefore, the list of food items was taken from this guideline and data were collected using this standard questionnaire. Reviewer concern: “The explanation of upper, middle, and lower class based on the quantiles in method section is not consistent with that described in narration of table 3 and 5 in the result section.” Authors’ response: Dear Reviewer, in the revised version of the manuscript, we have used a consistent categorization of wealth status as upper, middle and lower classes; and the changes were presented in a manuscript with track changes and without track changes. Reviewer concern: “In the result: There is an error of typing drinking (dirking) water in table 2. Narration for table 3 mentions that adolescent girls who were in the lower- and middle-class experience stunting more than the upper class, referring the wealth index in the table (1st, 2nd, and 3rd quantile). This needs to be rechecked since in the method section, it is mentioned that 1st quantile as upper class, 2nd quantile as middle, and 3rd quantile as the lowest. It seems there is inconsistency for labelling the wealth class. The same problem with the narration of table 5. In table 6, wealth index uses different name of categories (i.e., lower, middle, late), I recommend to use same name of categories across tables.” Authors’ response: Dear Reviewer, in the revised version of the manuscript, we have changed the word ‘dirking’ as ‘drinking’ and in all section of the results part of the manuscript, we have used a consistent categorization of wealth status as upper, middle and lower classes; and the changes were presented in a manuscript with track changes and without track changes. Reviewer concern: “In discussion: please provide practical implications based on the findings, for instance implication for policy or programs. I recommend to indicate contribution of this work to the scientific community.” Authors’ response: Dear Reviewer, in the revised version of the manuscript, we have included the implication of our work for policy, program and scientific community. The changes were presented in a manuscript with track changes and without track changes. Attachments Attachment Submitted filename: Response to Reviewers.docx https://doi.org/10.1371/journal.pone.0254166.r002
22 Jun 2021 Decision Letter - Madhavi Bhargava, Editor Undernutrition and Associated Factors among Adolescent Girls Attending School in the rural and urban districts of Debark town, Northwest Ethiopia: A community-based comparative cross-sectional study. PONE-D-21-06490R1 Dear Dr. Alemu, 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, Madhavi Bhargava Academic Editor PLOS ONE Additional Editor Comments (optional): Reviewers' comments: Reviewer's Responses to Questions Comments to the Author 1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation. Reviewer #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: 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 #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 the reviewer's concerns have been addressed, and reviewer has no more additional comments to the authors ****** 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:** Rahayu Indriasari, PhD https://doi.org/10.1371/journal.pone.0254166.r003
Formally Accepted
6 Aug 2021 Acceptance Letter - Madhavi Bhargava, Editor PONE-D-21-06490R1 Under nutrition and Associated Factors among Adolescent Girls Attending School in the rural and urban districts of Debark, Northwest Ethiopia: A community-based comparative cross-sectional study. Dear Dr. Alemu: 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. Madhavi Bhargava Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0254166.r004

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