Health care seeking behavior for common childhood illnesses in Birendranagar municipality, Surkhet, Nepal: 2018

Ganga Tiwari; Ajoy Kumar Thakur; Sushil Pokhrel; Ganesh Tiwari; Durga Prasad Pahari

doi:10.1371/journal.pone.0264676

Peer Review History

Original SubmissionJune 13, 2020
3 Sep 2020 Decision Letter - Edris Hasanpoor, Editor PONE-D-20-18110 Factors associated with health care seeking behavior on perceived illness of under five year children among caretakers in Birendranagar municipality, Surkhet, Nepal PLOS ONE Dear Dr. Ganga Tiwari 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 Oct 18 2020 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file. Please include the following items when submitting your revised manuscript: A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'. A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'. An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'. If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter. If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols We look forward to receiving your revised manuscript. Kind regards, Edris Hasanpoor Academic Editor PLOS ONE Additional Editor Comments: 1.Table 6, you should list the number of samples for each variable category. 2.Table 6, the definition of Ethnicity is not explained. 3.Table 6, is the secondary education includes higher secondary within the education level? 4.Why does Table 6 list the service industry separately? The service industry only accounts for 7%. 5.Table 6, i don't see the definition of socioeconomic status classification. 6.Does the distance between Table 6 and health care facilities refer to the geographical distance or the travel time as in Table 2? 7.Table 6, about the history of difficult breathing, the definition of difficulty? 8.What is the operational definition of knowledge for dangerous signals in Table 6? 9.From Table 2 we know that the reasons for choosing public and private medical institutions are different, and the regression analysis of seeking medical behaviors can be considered as a stratified analysis. 10.It is recommended that the coding method of the dependent variable be presented below Table 6 for explanation. 11. Is it confirmed that there are no multicollinearity issues. 12.The quality of logistic regression model and the result about Hosmer-Lemeshow Test?(less...) Generally, it is a useful paper since it addresses one of the major problems in developing countries, the relatively high death-rate of new-borns and small children. Unfortunately, however, there are some shortcomings which should be addressed before accepting this paper for publication. The authors refer to several studies in the Discussion chapter, sometimes to one or two, other times to other one or two, etc, but no general overview of these studies has been given. Probably the whole paper could be made shorter if a summary (maybe even in a table format) would be presented in the Introduction, and the major points would be stated. Later, then, they only have tp refer to this section. Methods are poorly described, especially regarding the interviews. No detailed information is given about the questions of the interviews. At least some typical examples and variations should be presented (maybe as an Appendix). The interview method is typically a crucial information since it can manipulate the interviewees and can lead to false interpretation. It isn’t clear, too, what method for coding had been used. It seems unusual to use 0.2 p-value for statistical analysis; at least some explanation should be given. Discussion is too long, generally because results are repeated several times in this section. Generally, Discussion is an overview of the results obtained is a short and compact format, to give the reader an impression about the meaning of the research. The many references to other studies make it even more complicated (see above). A technical note: No explanation is given on the first mention for abbreviation ARI (Page 4), that of FCHV (Page 5), IMCI (Page 6). etc. Although there is a list of abbreviations at the end of the manuscript, the reader does not find it while reading the text. Either the table should be placed onto the beginning of the paper, or abbreviations should be explained when first mentioned. Overall opinion: it is an important topic, but the manuscript requires general improvement (major revision) before accepting. 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 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. Whilst you may use any professional scientific editing service of your choice, PLOS has partnered with both American Journal Experts (AJE) and Editage to provide discounted services to PLOS authors. Both organizations have experience helping authors meet PLOS guidelines and can provide language editing, translation, manuscript formatting, and figure formatting to ensure your manuscript meets our submission guidelines. To take advantage of our partnership with AJE, visit the AJE website (http://learn.aje.com/plos/) for a 15% discount off AJE services. To take advantage of our partnership with Editage, visit the Editage website (www.editage.com) and enter referral code PLOSEDIT for a 15% discount off Editage services. If the PLOS editorial team finds any language issues in text that either AJE or Editage has edited, the service provider will re-edit the text for free. Upon resubmission, please provide the following: The name of the colleague or the details of the professional service that edited your manuscript A copy of your manuscript showing your changes by either highlighting them or using track changes (uploaded as a supporting information file) A clean copy of the edited manuscript (uploaded as the new manuscript file) 3. 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. 4. PLOS requires an ORCID iD for the corresponding author in Editorial Manager on papers submitted after December 6th, 2016. Please ensure that you have an ORCID iD and that it is validated in Editorial Manager. To do this, go to ‘Update my Information’ (in the upper left-hand corner of the main menu), and click on the Fetch/Validate link next to the ORCID field. This will take you to the ORCID site and allow you to create a new iD or authenticate a pre-existing iD in Editorial Manager. Please see the following video for instructions on linking an ORCID iD to your Editorial Manager account: https://www.youtube.com/watch?v=_xcclfuvtxQ 5. Please ensure that you refer to Figure 1 in your text as, if accepted, production will need this reference to link the reader to the figure. 6. We note you have included a table to which you do not refer in the text of your manuscript. Please ensure that you refer to Table 6 in your text; if accepted, production will need this reference to link the reader to the Table. [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: Partly Reviewer #2: Partly ******** 2. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: Yes Reviewer #2: No ****** 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: No Reviewer #2: No ****** 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: Generally, it is a useful paper since it addresses one of the major problems in developing countries, the relatively high death-rate of new-borns and small children. Unfortunately, however, there are some shortcomings which should be addressed before accepting this paper for publication. The authors refer to several studies in the Discussion chapter, sometimes to one or two, other times to other one or two, etc, but no general overview of these studies has been given. Probably the whole paper could be made shorter if a summary (maybe even in a table format) would be presented in the Introduction, and the major points would be stated. Later, then, they only have tp refer to this section. Methods are poorly described, especially regarding the interviews. No detailed information is given about the questions of the interviews. At least some typical examples and variations should be presented (maybe as an Appendix). The interview method is typically a crucial information since it can manipulate the interviewees and can lead to false interpretation. It isn’t clear, too, what method for coding had been used. It seems unusual to use 0.2 p-value for statistical analysis; at least some explanation should be given. Discussion is too long, generally because results are repeated several times in this section. Generally, Discussion is an overview of the results obtained is a short and compact format, to give the reader an impression about the meaning of the research. The many references to other studies make it even more complicated (see above). A technical note: No explanation is given on the first mention for abbreviation ARI (Page 4), that of FCHV (Page 5), IMCI (Page 6). etc. Although there is a list of abbreviations at the end of the manuscript, the reader does not find it while reading the text. Either the table should be placed onto the beginning of the paper, or abbreviations should be explained when first mentioned. Overall opinion: it is an important topic, but the manuscript requires general improvement (major revision) before accepting. Reviewer #2: 1.Table 6, you should list the number of samples for each variable category. 2.Table 6, the definition of Ethnicity is not explained. 3.Table 6, is the secondary education includes higher secondary within the education level? 4.Why does Table 6 list the service industry separately? The service industry only accounts for 7%. 5.Table 6, i don't see the definition of socioeconomic status classification. 6.Does the distance between Table 6 and health care facilities refer to the geographical distance or the travel time as in Table 2? 7.Table 6, about the history of difficult breathing, the definition of difficulty? 8.What is the operational definition of knowledge for dangerous signals in Table 6? 9.From Table 2 we know that the reasons for choosing public and private medical institutions are different, and the regression analysis of seeking medical behaviors can be considered as a stratified analysis. 10.It is recommended that the coding method of the dependent variable be presented below Table 6 for explanation. 11. Is it confirmed that there are no multicollinearity issues. 12.The quality of logistic regression model and the result about Hosmer-Lemeshow Test? ****** 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. https://doi.org/10.1371/journal.pone.0264676.r001
Revision 1
5 Oct 2020 Author Response Response to the reviewer and editor Date: October 5, 2020 To the Editor, PLOS ONE Journal Greetings! Hope you are fine and doing well. First of all, I would like to thank both the editor and reviewers for the extensive review of our manuscript and providing us opportunities to revise it. I have tried to incorporate all the feedback provided to us. For the revision of this manuscript, I took the support of my colleagues Dr. Sushil Pokhrel and Dr. Ganesh Tiwari. I checked language, spellings, and grammar using software/app for made for checking grammar. I have manually checked each sentence of this manuscript. I have mentioned below a table that explains my response in each comment of the reviewers and editor. Now, I am submitting the revised version of the manuscript as well as the original version with track changes. I am also submitting the supporting information such as tools of data collection in English as well as Nepali language and SPSS data set. Thank you very much for your time and consideration. Best regards! Ganga Tiwari SN. Comments by editor and reviewer Response Editor Comments 1 Table 6, you should list the number of samples for each variable category - Yes, I have listed the number of samples for each variable 2 Table 6, the definition of Ethnicity is not explained - I have provided an operational definition of ethnicity. 3 Table 6, is that secondary education includes higher secondary within the education level? - No the secondary education includes lower secondary education (6th standard to 10th standard) in our study. Higher secondary is considered a college education in our study. 4 Why does Table 6 list the service industry separately? The service industry only accounts for 7%. - I have checked the association of healthcare-seeking behavior with all the occupations categorizing into two group like home makers and non-homemakers/ business and non-business/agriculture and non-agriculture and service and non-service, I did not found any association among other categories but I found association with service and non -service category, so I have listed service and non-service category in table 6. 5 In table 6, I don't see the definition of socioeconomic status classification. - Now, I have mentioned the definition of socioeconomic class in the operational definition. 6 Does the distance between Table 6 and health care facilities refer to the geographical distance or the travel time as in Table 2? -Yes, the distance mentioned in table 6 refers to the geographical distance which is measured in travel time as in table 2. But in Bivariate and multivariate analysis I have not categorized distance into below 30 min and above 30 min, as the distance is a continuous variable I directly check the association of distance and healthcare-seeking behavior. It was measured in travel time to reach the nearest health facility in minutes. 7. Table 6, about the history of difficult breathing, the definition of difficulty? - Now, I have mentioned about the definition of difficulty in breathing in the operational definition. 8. What is the operational definition of knowledge for dangerous signals in Table 6? -Now, I have mentioned the definition of knowledge of danger signs in table 6 at the operational definition section. 9 From, Table 2 we know that the reasons for choosing public and private medical institutions are different, and the regression analysis of seeking medical behaviors can be considered as homemakers analysis. Yes, the regression analysis of seeking medical behavior can be considered as a stratified analysis. 10 It is recommended that the coding method of the dependent variable be presented below Table 6 for an explanation. - Now, I have mentioned in the data analysis section under methodology. 11 Is it confirmed that there are no multicollinearity issues? - Yes, I have calculated the Variance Inflation Factor (VIF) among the independent variables selected in the multivariate logistic analysis model. VIF value was less than 2 for every variable checked. So it is confirmed that there is no issue of multicollinearity. 12 The quality of the logistic regression model and the result of the Hosmer-Lemeshow Test? (less...) -Hosmer Lemeshow test, the goodness of fit of the model was assessed. The test statistic was 0.500 (>0.05) that showed that the model adequately fits the data. The authors refer to several studies in the Discussion chapter, sometimes to one or two, other times to other one or two, etc, but no general overview of these studies has been given. Probably the whole paper could be made shorter if a summary (maybe even in a table format) would be presented in the Introduction, and the major points would be stated. Later, then, they only have to refer to this section. - Now, I have tried to make the discussion section shorter by reducing the repeated contents of result and mentioned only major issues. Methods are poorly described, especially regarding the interviews. No detailed information is given about the questions of the interviews. At least some typical examples and variations should be presented (maybe as an Appendix). The interview method is typically a crucial information since it can manipulate the interviewees and can lead to false interpretation. It isn’t clear, too, what method for coding had been used. - Now, I have explained the interview technique in the methodology part. Regarding the coding of the dependent variable, I have now explained in the operational definition. A technical note: No explanation is given on the first mention for abbreviation ARI (Page 4), that of FCHV (Page 5), IMCI (Page 6) etc. Although there is a list of abbreviations at the end of the manuscript, the reader does not find it while reading the text. Either the table should be placed onto the beginning of the paper, or abbreviations should be explained when first mentioned. Overall opinion: It is an important topic, but the manuscript requires general improvement (major revision) before accepting. - Now I have explained abbreviations when used at first and then I have kept list of abbreviations at the last section of manuscript. Journal requirement Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming - Now I have revised my manuscript using PLOS ONE’s style requirement, and I have named file name accordingly. 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. - Yes, I have thoroughly copyedited my manuscript for language, spelling, and grammar through grammar checking websites/apps as well as with the help of my colleagues. It seems unusual to use 0.2 p-values for statistical analysis; at least some explanation should be given. Discussion is too long, generally because results are repeated several times in this section. Generally, Discussion is an overview of the results obtained is a short and compact format, to give the reader an impression about the meaning of the research. The many references to other studies make it even more complicated (see above). - It has been shown in a study that use of p-value < 0.05 is too stringent and often excludes important variables from the logistic regression model, so choosing a p-value ranging from 0.15 to 0.20 is highly recommended, various published studies have used p-value 0.2 for selecting the variables for multivariate logistic regression. Now I have explained this in the manuscript also. Now I have tried to make the discussion section shorter by reducing the repeated contents of result and mentioned only major issues Attachments Attachment Submitted filename: Response to Reviewer.docx https://doi.org/10.1371/journal.pone.0264676.r002
2 Feb 2021 Decision Letter - Shyam Sundar Budhathoki, Editor PONE-D-20-18110R1 Factors associated with health care seeking behavior on the perceived illness of under five year children among caretakers in Birendranagar municipality, Surkhet, Nepal PLOS ONE Dear Dr. Tiwari, Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process. ============================== Thank you for addressing all the comments on the previous version. The manuscript is is a good shape at the moment. We only have some minor comments to further improve the language and readability of the manuscript. Hope to receive the revised manuscript soon. ============================== Please submit your revised manuscript by Mar 19 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, Shyam Sundar Budhathoki, MBBS, MD, MPH Academic Editor PLOS ONE [Note: HTML markup is below. Please do not edit.] Reviewers' comments: Reviewer's Responses to Questions 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 #3: Title: needs to be modified, can be made short Abstract: Objective needs to be more specific. Conclusion needs language editing, can be made short. Last statement not a part of study objective. Keywords: can be written as per MeSH terms Introduction: needs language editing ; can be made short. Objectives: need to be more specific Methods: section needs to be rewritten. It is very lengthy, can be made short with only relevant details. Sample size and technique can be explained by a flowchart; will make it concise and reflect better understanding. “FCHVs” needs to be spelt out for the first time in text, it can later be used as an abbreviation. Was Kuppuswami scale modified Nepali version validated, before using in study. “Perceived Illness” used in study can be elaborated in operational definition section. Inclusion criteria mentions about only the treatment seeking period of last one month, which is a major limitation. Childhood/under-five manifestations may not always be present, a longer duration would be better like 3 months. Sentence construction not proper, grammatical errors need to be corrected. Pretesting of study tool mentioned, but whether the same sample was included in the sample size or not, is not mentioned. Results: require language editing. “Perceived Illness” needs to be explained in methodology. Similarly, “Perceived Severity” mentioned not explained in text. Too many[Table 1 to 5] tables. Can be combined with statistical analysis part of bivariable analysis. Multivariable analysis[Table 6] is fine. Discussion: is very elaborate; can be shortened in length and only relevant findings highlighted. Limitations: not mentioned References: Some old references may be removed. Recent studies within last 5 years can be cited. [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.0264676.r003
Revision 2
22 Mar 2021 Author Response Reviewer #3: Title: needs to be modified, can be made short -The title has been modified and made short Abstract: Objective needs to be more specific. Conclusion needs language editing, can be made short. Last statement not a part of study objective -Now, objectives are written more specifically, conclusion section has been edited. Keywords: can be written as per MeSH terms -Now, Key words are written as per MeSH terms Objectives: need to be more specific -Now, the objectives are written more specifically. Methods: section needs to be rewritten. It is very lengthy, can be made short with only relevant details. Sample size and technique can be explained by a flowchart; will make it concise and reflect better understanding. “FCHVs” needs to be spelt out for the first time in text, it can later be used as an abbreviation. Was Kuppuswami scale modified Nepali version validated, before using in study. “Perceived Illness” used in study can be elaborated in operational definition section. Inclusion criteria mentions about only the treatment seeking period of last one month, which is a major limitation. Childhood/under-five manifestations may not always be present, a longer duration would be better like 3 months -We have rewritten methodology section. We have tried to make it short. Sampling technique is now explained by a flowchart. FCHVs are now written in full word when it is first used. Kuppuswamy scale modified in context of Nepal was was used; this version was already validated in context of Nepal and used by various published studies. Perceived illness is now defined on the operational definition section. Illness period of only one month duration was taken to avoid recall bias among the caretakers. Results: require language editing. “Perceived Illness” needs to be explained in methodology. Similarly, “Perceived Severity” mentioned not explained in text. Too many[Table 1 to 5] tables. Can be combined with statistical analysis part of bivariable analysis. Multivariable analysis[Table 6] is fine -Perceived illness and severity has been defined in the operational definition section. Some tables have been removed, language editing has been done in result section. Discussion: is very elaborate; can be shortened in length and only relevant findings highlighted ---- -Discussion section has been made short. Limitations: not mentioned -Now, limitation has been mentioned. References: Some old references may be removed. Recent studies within last 5 years can be cited. -Some old references have been removed. Attachments Attachment Submitted filename: Response to reviewers.docx https://doi.org/10.1371/journal.pone.0264676.r004
9 Jun 2021 Decision Letter - Shyam Sundar Budhathoki, Editor PONE-D-20-18110R2 Health care seeking behavior for common childhood illnesses in Birendranagar municipality, Surkhet, Nepal PLOS ONE Dear Dr. Tiwari, 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 Jul 24 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. Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols. We look forward to receiving your revised manuscript. Kind regards, Shyam Sundar Budhathoki, MBBS, MD, MPH 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): [Note: HTML markup is below. Please do not edit.] Reviewers' comments: Reviewer's Responses to Questions Comments to the Author 1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation. Reviewer #4: (No Response) ******** 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 #4: Yes ****** 3. Has the statistical analysis been performed appropriately and rigorously? Reviewer #4: 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 #4: 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 #4: 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 #4: Health care seeking behavior for common childhood illnesses in Birendranagar municipality, Surkhet, Nepal Reviewer: Wingston Ng’ambi (Lecturer and Research Scientist), College of Medicine- Kamuzu University of Health Sciences (Formerly University of Malawi), Lilongwe, Malawi; & Institute of Global Health, University of Geneva, Geneva, Switzerland This is a nice paper touching on an important area. 1. The title should be changed to “Factors associated with healthcare seeking behavior for common illnesses amongst under-five children in Surkhet district, Nepal: 2018“ 2. The manuscript needs to be numbered in order to reference to line numbers. This makes review easier. Abstract Introduction of abstract 3. “There are few studies on health care seeking behavior among caretakers in Nepal, so the objective of this study was to itsassess the healthcare-seeking behavior of the caretakers in Birendranagar municipality of Surkhet district. So, this study aims to identify prevailing health care seeking behavior of caretakers on perceived illness of under five year children and to identify the association of socio demographic, economic, illness related and health system related factors with health care seeking behavior.” Should be changed to “There are few studies on healthcare seeking behavior among caretakers in Nepal. Therefore, we conducted this study to determine the level of healthcare seeking behavior of caretakers on perceived illness and to identify the factors associated with health care seeking behavior of the caretakers of under five-year children from Surkhet district in Nepal in 2018.” Methods section of abstract 4. Add level of P-value for statistical significance 5. How the logistic regression models were built (optional depending on word count) Results 6. Change “Regarding healthcare-seeking behavior of caretakers for their children’s illnesses, the most common source of care-seeking was visiting pharmacy directly at first (42.4 %), only one quarter (25.3 %) of the caretakers visited health facilities, among those who visited health facilities, only (37.2 %) of caretakers sought prompt health care.” to “Of these, 42.4% visited the pharmacy directly, 25.3% visited the health facilities and XXXX did nothing. Amongst those who visited a health facility, 37.2% of caretakers sought prompt health care.” Conclusion 7. Rather than just repeat the results consider using statements like (“There is a need to understand and address individual and socio-economic barriers to health seeking to increase access and use of health care and fast-track progress towards Universal Health Coverage amongst children from Surkhet district in Nepal.” This is what would be an appropriate conclusion that answers the question: How does this study relate to the SDGs and universal health coverage as well as Nepal National Health Strategy? Main body of the paper 8. Include a running title of the paper Introduction 9. Change the objectives as stipulated in the abstract Methods 10. p-value should be changed to P-value 11. The authors should make it clear how they arrived at the final model. Did they use log likelihood ratio methods or some other methods? They also need to be clear on what multivariate analysis that they are conducting. 12. Under a subsection “Appropriate health care seeking behavior” several studies include obtaining care from pharmacies as appropriate health care seeking behaviour (HSB), how come you are doing this differently? 13. Can you refer to “Ng'ambi W, Mangal T, Phillips A, Colbourn T, Mfutso-Bengo J, Revill P, Hallett TB. Factors associated with healthcare seeking behaviour for children in Malawi: 2016. Trop Med Int Health. 2020 Dec;25(12):1486-1495. doi: 10.1111/tmi.13499. Epub 2020 Oct 19. PMID: 32981174.” for some operational definition of HSB. Results 14. Format the tables for characteristics to look like this. Patient characteristics n (%) Total 255229 (100.0) Gender Male 122610 (48.0) Female 125275 (49.1) Missing 7344 (2.9) Location Rural 168258 (65.9) Urban 86971 (34.1) Age at Sample draw (in months) 0-1 145622 (57.1) 2-5 74707 (29.3) 6-11 21307 (8.4) 12-17 3337 (1.3) 18-24 1902 (0.8) Missing 8354 (3.3) Region Northern 22897 (9.0) Central 72,633 (28.5) Southern 159699 (62.6) Year Sample drawn 2013 16308 (6.4) 2014 25858 (10.1) 2015 41271 (16.2) 2016 41178 (16.1) 2017 42252 (16.6) 2018 43370 (17.0) 2019 36372 (14.3) 2020* 7741 (3.0) Missing 879 (0.3) 15. In all tables do not combine the mean or SD if the headings are number and percentage 16. All tables should not have lines crossing them 17. Include the illnesses (like fever, diarrheas) as appriori variables in the final multivariate model as these form key part of your analysis. Also include age and sex of the child as appriori variables. 18. We are not sure of the P-value for Table 5. Is it for crude or adjusted estimates? I would format the table to look like:- Characteristics (n=26386) Bivariate analysis Multivariate analysis OR (95%CI) P-value OR (95%CI) P-value Age group 15-19 1.00 1.00 20-24 1.10 (1.00-1.21) 0.06 1.26 (1.13-1.41) <0.001 25-29 1.07 (0.96-1.18) 0.22 1.42 (1.24-1.62) <0.001 30-34 1.06 (0.95-1.18) 0.33 1.48 (1.27-1.72) <0.001 35-39 1.07 (0.95-1.21) 0.27 1.61 (1.36-1.92) <0.001 40-44 0.91 (0.78-1.07) 0.25 1.47 (1.19-1.81) <0.001 45-49 1.02 (0.80-1.30) 0.88 1.77 (1.33-2.34) <0.001 Year 2004/5 1.00 1.00 2010 1.23 (1.14-1.32) <0.001 1.21 (1.12-1.31) <0.001 2015/16 2.19 (2.03-2.37) <0.001 2.12 (1.97-2.29) <0.001 Region North 1.00 Centre 1.03 (0.94-1.12) 0.55 South 0.96 (0.88-1.05) 0.40 Number of previous children ever born 1 1.00 1.00 2-3 0.79 (0.74-0.85) <0.001 0.70 (0.64-0.76) <0.001 4-5 0.74 (0.68-0.80) <0.001 0.62 (0.55-0.70) <0.001 6+ 0.69 (0.63-0.75) <0.001 0.59 (0.51-0.69) <0.001 Education level None 1.00 1.00 Primary 1.22 (1.13-1.32) <0.001 1.09 (1.00-1.18) 0.05 Secondary 1.69 (1.54-1.86) <0.000 1.24 (1.11-1.39) <0.001 Tertiary 4.36 (3.42-5.57) <0.001 2.35 (1.80-3.06) <0.001 Wealth index quintile Poorest 1.00 1.00 Poorer 1.07 (0.99-1.16) 0.10 1.07 (0.99-1.17) 0.09 Middle 1.09 (1.00-1.18) 0.05 1.10 (1.01-1.20) 0.024 Richer 1.17 (1.07-1.28) <0.001 1.15 (1.05-1.26) 0.002 Richest 1.47 (1.35-1.60) <0.001 1.23 (1.11-1.36) <0.001 Residence Urban 1.00 Rural 0.78 (0.72-0.84) <0.001 Sources of antenatal care knowledge Frequency of listening to radio Less than once a week 1.00 At least once a week 1.00 (0.95-1.05) 0.97 Frequency of watching television Less than once a week 1.00 1.00 At least once a week 1.44 (1.31-1.58) <0.001 1.13 (1.02-1.26) 0.025 Barriers to access antenatal care Permission to visit health services No problem 1.00 Big problem 1.10 (1.02-1.19) 0.01 Money to pay for health services No problem 1.00 Big problem 0.88 (0.83-0.92) <0.001 Distance to health facilities No problem 1.00 Big problem 0.93 (0.88-0.98) 0.005 Presence of companion No problem 1.00 Big problem 0.98 (0.92-1.04) 0.50 No drugs at health facility No problem 1.00 Big problem 1.28 (1.21-1.35) <0.001 No female provider No problem 1.00 Big problem 1.01 (0.95-1.09) 0.64 Marital status Never married 1.00 1.00 Married 1.20 (1.02-1.41) 0.026 1.65 (1.39-1.96) <0.001 Widowed 1.01 (0.78-1.34) 0.89 1.50 (1.13-1.99) 0.005 Divorced 1.08 (0.90-1.29) 0.40 1.50 (1.24-1.81) <0.001 Discussion 19. Start the discussion with a summary of the key results of your study and then move on to discuss them in light of other relevant literature. 20. The findings from this paper may be helpful to your discussion and conclusion. Consider citing it as well. Ng'ambi W, Mangal T, Phillips A, Colbourn T, Mfutso-Bengo J, Revill P, Hallett TB. Factors associated with healthcare seeking behaviour for children in Malawi: 2016. Trop Med Int Health. 2020 Dec;25(12):1486-1495. doi: 10.1111/tmi.13499. Epub 2020 Oct 19. PMID: 32981174. 21. Don’t repeat results in the discussion but rather compare your key results with those of other studies and explain any disparity or agreement. Conclusion 22. This section should provide policy insights as well as alignment of the study findings with the SDGs as well as universal health coverage. 23. Include the policy relevance of your study findings as well. ******** 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 #4: Yes:** Wingston Felix Ng’ambi [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.0264676.r005
Revision 3
31 Jul 2021 Author Response Response to the reviewer and editor Date: July 31, 2020 To the Editor, PLOS ONE Journal Greetings! Hope you are fine and doing well. First of all, I would like to thank both the editor and reviewers for the extensive review of our manuscript and providing us opportunities to revise it. For the revision of this manuscript, I took the support of my colleagues Dr. Sushil Pokhrel and Dr. Ganesh Tiwari. We have tried to incorporate all the feedback provided in the revised version of the manuscript. I have mentioned my response in comment of the reviewers and editor. Now, I am submitting the revised version of the manuscript as well as the original version with track changes. Thank you very much for your time and consideration. Best regards! Ganga Tiwari 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. Author’s response: I have reviewed the reference list. It is complete and do not include the retracted article, Reviewer's Responses to Questions 1. The title should be changed to “Factors associated with healthcare seeking behavior for common illnesses amongst under-five children in Surkhet district, Nepal: 2018“ Author’s response: I have changed the title accordingly. 2. The manuscript needs to be numbered in order to reference to line numbers. This makes review easier. Abstract Introduction of abstract 3. “There are few studies on health care seeking behavior among caretakers in Nepal, so the objective of this study was to itsassess the healthcare-seeking behavior of the caretakers in Birendranagar municipality of Surkhet district. So, this study aims to identify prevailing health care seeking behavior of caretakers on perceived illness of under five year children and to identify the association of socio demographic, economic, illness related and health system related factors with health care seeking behavior.” Should be changed to “There are few studies on healthcare seeking behavior among caretakers in Nepal. Therefore, we conducted this study to determine the level of healthcare seeking behavior of caretakers on perceived illness and to identify the factors associated with health care seeking behavior of the caretakers of under five-year children from Surkhet district in Nepal in 2018.” Author’s response: I have made slight change in the language of the objective and changed the objective, we did not determine the level, and we only determine the different health care seeking behaviors among the care takers. Methods section of abstract 4. Add level of P-value for statistical significance Author’s response: Previously, I had added level of p- value for statistical significance in abstract but previous reviewers of this journal suggested me to remove it from abstract so I have removed it. 5. How the logistic regression models were built (optional depending on word count) Author’s response: Abstract become lengthy, if we add this detail Results 6. Change “Regarding healthcare-seeking behavior of caretakers for their children’s illnesses, the most common source of care-seeking was visiting pharmacy directly at first (42.4 %), only one quarter (25.3 %) of the caretakers visited health facilities, among those who visited health facilities, only (37.2 %) of caretakers sought prompt health care.” to “Of these, 42.4% visited the pharmacy directly, 25.3% visited the health facilities and XXXX did nothing. Amongst those who visited a health facility, 37.2% of caretakers sought prompt health care.” Author’s response: Thank you for your feedback; I have changed the result section accordingly. Conclusion 7. Rather than just repeat the results consider using statements like (“There is a need to understand and address individual and socio-economic barriers to health seeking to increase access and use of health care and fast-track progress towards Universal Health Coverage amongst children from Surkhet district in Nepal.” This is what would be an appropriate conclusion that answers the question: How does this study relate to the SDGs and universal health coverage as well as Nepal National Health Strategy? Author’s response: Since, this study is confined to Birendranagar Municipality of Surkhet district, we have concluded according to our study results at the municipality level. Now, we have also included policy implication of our study. Main body of the paper 8. Include a running title of the paper Introduction 9. Change the objectives as stipulated in the abstract Methods 10. p-value should be changed to P-value 11. The authors should make it clear how they arrived at the final model. Did they use log likelihood ratio methods or some other methods? They also need to be clear on what multivariate analysis that they are conducting. Author’s response: We used SPSS for the data analysis. The twelve variables (ethnicity, educational status, occupation, socioeconomic status, distance to reach nearest health facility, place of delivery, perceived severity, history of difficulty breathing, knowledge on danger signs, number of symptoms, duration of illness, number of children) that exhibited significant association with health care seeking in bivariate analysis i.e. p value ≤ 0.2 were further analyzed in multivariate analysis using binomial logistic regression. Multivariate analysis was done for adjustment of possible confounders. Hosmer Lemeshow test, the goodness of fit of the model was assessed. The test statistic was 0.500 (>0.05) that showed that the model adequately fits the data. 12. Under a subsection “Appropriate health care seeking behavior” several studies include obtaining care from pharmacies as appropriate health care seeking behaviour (HSB), how come you are doing this differently? Author’s response: We also took references of several studies, obtaining medicines from pharmacies without prescription/doctor’s consultation is considered as in-appropriate health care seeking behavior. Obtaining medicines from pharmacies without any consultation comes under self- medication, because of this irrational use of medication; antibiotic/drug resistance is a big issue in Nepal, We had taken the reference of studies from Yemen, India and North- West Ethiopia. Full citations of these studies are mentioned below. Kalita D, Borah M, Kakati R, Borah H. Primary Caregivers Health Seeking Behaviour for Under-Five Children : A Study in a Rural Block of Assam, India. Ntl J Community Med. 2016;7(11):868–72. Webair HH, Bin-Gouth AS. Factors affecting health seeking behavior for common childhood illnesses in Yemen. Patient Prefer Adherence. 2013;7:1129–38. Molla Simieneh M, Mengistu Y, Gelagay AA, Gebeyehu MT. Mothers’ health care seeking behavior and associated factors for common childhood illnesses, Northwest Ethiopia: community based cross-sectional study. 13. Can you refer to “Ng'ambi W, Mangal T, Phillips A, Colbourn T, Mfutso-Bengo J, Revill P, Hallett TB. Factors associated with healthcare seeking behaviour for children in Malawi: 2016. Trop Med Int Health. 2020 Dec;25(12):1486-1495. doi: 10.1111/tmi.13499. Epub 2020 Oct 19. PMID: 32981174.” for some operational definition of HSB. Author’s response: As we had conducted this study on 2018, we had defined operational definitions ourselves before the conduction of study taking reference of relevant literature, now study have already conducted, we can’t modify our operational definitions. Operational definitions are always defined before the conduction of study, not after the completion of study, as operational definitions involves variables; these are set before data collection. Results 14. Format the tables for characteristics to look like this. Patient characteristics n (%) Total 255229 (100.0) Gender Male 122610 (48.0) Female 125275 (49.1) Missing 7344 (2.9) Location Rural 168258 (65.9) Urban 86971 (34.1) Age at Sample draw (in months) 0-1 145622 (57.1) 2-5 74707 (29.3) 6-11 21307 (8.4) 12-17 3337 (1.3) 18-24 1902 (0.8) Missing 8354 (3.3) Region Northern 22897 (9.0) Central 72,633 (28.5) Southern 159699 (62.6) Year Sample drawn 2013 16308 (6.4) 2014 25858 (10.1) 2015 41271 (16.2) 2016 41178 (16.1) 2017 42252 (16.6) 2018 43370 (17.0) 2019 36372 (14.3) 2020* 7741 (3.0) Missing 879 (0.3) 15. In all tables do not combine the mean or SD if the headings are number and percentage Author’s response: Thank you for your feedback, I have updated the tables accordingly. 16. All tables should not have lines crossing them Author’s response: Thank you for your feedback, I have updated the table accordingly. 17. Include the illnesses (like fever, diarrheas) as appriori variables in the final multivariate model as these form key part of your analysis. Also include age and sex of the child as appriori variables. 18. We are not sure of the P-value for Table 5. Is it for crude or adjusted estimates? I would format the table to look like:- Characteristics (n=26386) Bivariate analysis Multivariate analysis OR (95%CI) P-value OR (95%CI) P-value Age group 15-19 1.00 1.00 20-24 1.10 (1.00-1.21) 0.06 1.26 (1.13-1.41) <0.001 25-29 1.07 (0.96-1.18) 0.22 1.42 (1.24-1.62) <0.001 30-34 1.06 (0.95-1.18) 0.33 1.48 (1.27-1.72) <0.001 35-39 1.07 (0.95-1.21) 0.27 1.61 (1.36-1.92) <0.001 40-44 0.91 (0.78-1.07) 0.25 1.47 (1.19-1.81) <0.001 45-49 1.02 (0.80-1.30) 0.88 1.77 (1.33-2.34) <0.001 Year 2004/5 1.00 1.00 2010 1.23 (1.14-1.32) <0.001 1.21 (1.12-1.31) <0.001 2015/16 2.19 (2.03-2.37) <0.001 2.12 (1.97-2.29) <0.001 Region North 1.00 Centre 1.03 (0.94-1.12) 0.55 South 0.96 (0.88-1.05) 0.40 Number of previous children ever born 1 1.00 1.00 2-3 0.79 (0.74-0.85) <0.001 0.70 (0.64-0.76) <0.001 4-5 0.74 (0.68-0.80) <0.001 0.62 (0.55-0.70) <0.001 6+ 0.69 (0.63-0.75) <0.001 0.59 (0.51-0.69) <0.001 Education level None 1.00 1.00 Primary 1.22 (1.13-1.32) <0.001 1.09 (1.00-1.18) 0.05 Secondary 1.69 (1.54-1.86) <0.000 1.24 (1.11-1.39) <0.001 Tertiary 4.36 (3.42-5.57) <0.001 2.35 (1.80-3.06) <0.001 Wealth index quintile Poorest 1.00 1.00 Poorer 1.07 (0.99-1.16) 0.10 1.07 (0.99-1.17) 0.09 Middle 1.09 (1.00-1.18) 0.05 1.10 (1.01-1.20) 0.024 Richer 1.17 (1.07-1.28) <0.001 1.15 (1.05-1.26) 0.002 Richest 1.47 (1.35-1.60) <0.001 1.23 (1.11-1.36) <0.001 Residence Urban 1.00 Rural 0.78 (0.72-0.84) <0.001 Sources of antenatal care knowledge Frequency of listening to radio Less than once a week 1.00 At least once a week 1.00 (0.95-1.05) 0.97 Frequency of watching television Less than once a week 1.00 1.00 At least once a week 1.44 (1.31-1.58) <0.001 1.13 (1.02-1.26) 0.025 Barriers to access antenatal care Permission to visit health services No problem 1.00 Big problem 1.10 (1.02-1.19) 0.01 Money to pay for health services No problem 1.00 Big problem 0.88 (0.83-0.92) <0.001 Distance to health facilities No problem 1.00 Big problem 0.93 (0.88-0.98) 0.005 Presence of companion No problem 1.00 Big problem 0.98 (0.92-1.04) 0.50 No drugs at health facility No problem 1.00 Big problem 1.28 (1.21-1.35) <0.001 No female provider No problem 1.00 Big problem 1.01 (0.95-1.09) 0.64 Marital status Never married 1.00 1.00 Married 1.20 (1.02-1.41) 0.026 1.65 (1.39-1.96) <0.001 Widowed 1.01 (0.78-1.34) 0.89 1.50 (1.13-1.99) 0.005 Divorced 1.08 (0.90-1.29) 0.40 1.50 (1.24-1.81) <0.001 Author’s response: It is not crude, it is adjusted estimates. Discussion 19. Start the discussion with a summary of the key results of your study and then move on to discuss them in light of other relevant literature. 20. The findings from this paper may be helpful to your discussion and conclusion. Consider citing it as well. Ng'ambi W, Mangal T, Phillips A, Colbourn T, Mfutso-Bengo J, Revill P, Hallett TB. Factors associated with healthcare seeking behaviour for children in Malawi: 2016. Trop Med Int Health. 2020 Dec;25(12):1486-1495. doi: 10.1111/tmi.13499. Epub 2020 Oct 19. PMID: 32981174. 21. Don’t repeat results in the discussion but rather compare your key results with those of other studies and explain any disparity or agreement. Conclusion 22. This section should provide policy insights as well as alignment of the study findings with the SDGs as well as universal health coverage. 23. Include the policy relevance of your study findings as well. Author’s response: We have included policy relevance of our findings in the conclusion section. Attachments Attachment Submitted filename: Response to the reviewers.docx https://doi.org/10.1371/journal.pone.0264676.r006
16 Feb 2022 Decision Letter - Filiberto Toledano-Toledano, Editor Health care seeking behavior for common childhood illnesses in Birendranagar municipality, Surkhet, Nepal PONE-D-20-18110R3 Dear Dr. Tiwari, 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, Filiberto Toledano-Toledano, Ph.D. 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 #4: (No Response) ******** 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 #4: Yes ****** 3. Has the statistical analysis been performed appropriately and rigorously? Reviewer #4: 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 #4: 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 #4: 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 #4: 1. They need to round the AOR to two decimal places. 2. AOR should be put in full as it is appearing for the first time. 3. The study variables should be put in a box. The current presentation does not make them look sexy. 4. Illnesses interact and their co-existence affects the HSB, may you refer to the paper by Ng’ambi et al (https://onlinelibrary.wiley.com/doi/epdf/10.1111/tmi.13499) and this could be another nice reference for your work. 5. The tables need proper formatting (refer to https://onlinelibrary.wiley.com/doi/epdf/10.1111/tmi.13499) 6. The figures need to have the titles. 7. It is not clear how the variables were selected into the model. 8. One limitation of the paper is that they only looked at two illnesses. The authors should check (https://onlinelibrary.wiley.com/doi/epdf/10.1111/tmi.13499) where a multiplicity of illnesses have been looked at. ****** 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 #4: Yes:** Wingston Ng’ambi, Research Scientist- University of Geneva; Lecturer at Kamuzu University of Health Sciences https://doi.org/10.1371/journal.pone.0264676.r007
Formally Accepted
21 Mar 2022 Acceptance Letter - Filiberto Toledano-Toledano, Editor PONE-D-20-18110R3 Health care seeking behavior for common childhood illnesses in Birendranagar municipality, Surkhet, Nepal: 2018 Dear Dr. Tiwari: 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. Filiberto Toledano-Toledano Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0264676.r008

Open letter on the publication of peer review reports

PLOS recognizes the benefits of transparency in the peer review process. Therefore, we enable the publication of all of the content of peer review and author responses alongside final, published articles. Reviewers remain anonymous, unless they choose to reveal their names.

We encourage other journals to join us in this initiative. We hope that our action inspires the community, including researchers, research funders, and research institutions, to recognize the benefits of published peer review reports for all parts of the research system.

Learn more at ASAPbio .