PONE-D-21-31212Prevalence of substance use and associated factors among secondary school adolescents in the Kilimanjaro region, northern TanzaniaPLOS ONE

Dear Dr. Mavura,

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.

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Yes

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

Reviewer #1: No

Reviewer #2: Yes

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3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: No

Reviewer #2: Yes

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4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

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5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: The authors of the manuscript; Prevalence of substance use and associated factors among secondary school adolescents in the Kilimanjaro region, northern Tanzania” sought to determine the prevalence of substance use and associated factors among secondary school adolescents in the Kilimanjaro region, Northern Tanzania. The authors report that the prevalence of substance use among school-going adolescents was higher than in previous studies conducted in Tanzania, with alcohol and cigarette us, being the most common substances used. They also noted sociodemographic and behavioral factors associated with substance use in this population. Overall, this manuscript is well written. However, there are some comments below for the authors to consider that would help improve the manuscript’s overall readability.

General comments: Please read entire manuscript thoroughly for typos and missing articles, incomplete sentences. I mentioned some below; but please cross-check the entire manuscript.

Abstract:

1. There is a typo in first sentence in the methods; missing “of”

2. Typo in second sentence in the methods; missing “were summarized”

3. “We used logistic regression to obtain odds ratios and 95% confidence intervals (CI) for risk factors associated with differences in PA”. What is PA?

4. “Multivariable logistic regression models was used to obtain odds ratios and 95% confidence intervals (CI)”. CI has been previously defined…

Background:

1. Typo in this sentence (missing aged): “Substance use has increased in recent years and is a growing public health problem and a worldwide threat, significantly affecting young people 10-24 years”

2. “For example, in developed countries, the estimated risk of developing drug dependence on cannabis uses alone…”; change uses to use

3. After looking it up, bhang seems to be marijuana? Can the authors clarify, many people in the international audience may not be familiar with the word..

Methods:

1. Please define KCMUCO

2. Please rewrite the following sentence; unclear as currently written: “A total of 3224 for the current study was analyzed data for adolescents after excluding three (0.1%) individuals aged less than ten and greater than 19 years.”

3. “Trained students of Doctor of Medicine to collect data.” Sentence is not complete.

4. “Lifetime substances use was defined as using any substance at least once in their lifetime”. Remove “s” from behind “substances”

5. Were the same substances examined for lifetime use, also examined for current use? I ask because I see amphetamines examined in current use, but not mentioned in lifetime use under the subsection “outcome and explanatory variables”. Can the authors clarify?

6. Did the authors consider source of the other substances examined besides alcohol as covariates? How did the authors select the independent variables to include in their study?

7. The authors can use one: crude or unadjusted

Results: I suggest that the authors redo or recheck the analysis they have presented in the results section; as well as the table arrangement and ordering.

1. I am not sure why the authors presented Table 3 before table 2 in their manuscript. Tables are supposed to be ordered…Table 1, Table 2….The authors should rearrange the way the results were presented or change the Table numbering so it’s sequential.

2. Can the %s come after the corresponding sentences/statements as the previous sentences? “…few adolescents (15.3%) reported having always seen alcohol advertisements and (4.5%) had ever rode in a car with a drunk driver.”

3. There are two table 2’s in this manuscript. Authors should correct this error. Also, are the percentages presented in the table for Substance use by participant characteristics, for the lifetime and current use row percentages or column percentages? Where are these numbers from? They are not adding up to 100. Can the authors clarify what they have done? Also, it would help if the authors put the n’s for the lifetime and current use in the table.

4. There are two table 3’s? Manuscript jumps from Table 4, in the results to Table 6, no mention of Table 5. Authors should arrange their results accordingly.

5. Last table: the authors mentioned in the methods that they presented crude/unadjusted and adjusted Cis…I do not see it presented in the tables. Can the authors clarify…

Discussion:

1. “The lifetime prevalence of substance use among adolescents in this study is high than the 2006 and 2017 Tanzanian Global School-based Student Health Surveys (GSHS)”. There is a typo in this sentence, change “high” to “higher”

2. When the authors are comparing prevalence to other studies in the discussion, they should remind the readers what prevalence they are comparing by providing the numbers they obtained in their study for comparison.

3. Can the authors provide more insight as to why they did not find a significant association between adolescent age and substance use in their current study?

3. Why is this sentence written this way with a period after the first sentence?: "These findings are consistent with the study done in Bangladesh. Which reported that the likelihood of substance use increases with a lack of peer support as it exhibits greater anti-social behaviors that can manifest to substance use"

Reviewer #2: TITLE

Prevalence of substance use and associated factors among secondary school adolescents in Kilimanjaro region, Northern Tanzania.

OVERALL COMMENTS

The study is an important contribution to the knowledge of the prevalence of substance use in Tanzania, specifically the Kilimanjaro region. Findings, especially factors related to substance use could influence policymakers in where to channel resources in dealing with the burden of substance abuse in the region. However, I recommend that the authors address these concerns below:

1. The study should mention some policies or efforts made to curb substance use amongst adolescents in Tanzania. It is worth mentioning if there is no policy at all. This could highlight the shortfalls in policies.

2. The study needs a conclusion to emphasize the results and clearly outline recommendations. It can also make suggestions for future studies.

3. The authors should consider using the assistance of a professional editor to correct grammatical and typing errors.

SPECIFIC COMMENTS

Abstract

1. The abstract has major grammatical errors that need to be addressed. I suggest authors use the assistance of a professional editor.

2. The statement in line 7, ‘...and whose parent/guardians rarely understood their problems’, is unclear and needs revision.

3. The sentence “The study used secondary data from a cross-sectional study adolescents aged 10- 19 years from public secondary schools in the Kilimanjaro Region, northern Tanzania” should be revised as “The study used secondary data from a cross-sectional survey of adolescents aged 10- 19 years from public secondary schools in the Kilimanjaro Region, northern Tanzania”

4. “Substance use was measured using the Global School Health Survey (GSHS) questionnaire.” – You should be as specific as possible.

5. What does “PA” stand for?

6. Similar factors [were] associated with lifetime substance users.

7. You indicated in the conclusion that “The prevalence of substance use among school-going adolescents in this study is higher than the previous studies in Tanzania …”. This conclusion is not directly derived from the study and should be deleted. Please note that your conclusion should exclusively be based on your results.

Background

In the last paragraph, the authors mention other studies focusing on only a few substances used by adolescents. Studies by Mnyika et al. in 2011, evaluated various substances used by adolescents in the region. I suggest authors rather focus on factors influencing substance use, as this was missing in other studies.

Methods

1. The last statement of the study design and population, ‘…According to the countries profile, adolescent accounts for 23% of Tanzania’s population, 13% and 10% for 10-14, 15-19 age groups,’ is unclear and need to be rephrased.

2. In the sampling data collection methods and tools, authors should consider rephrasing the first sentence of the second paragraph. Consider ‘Data was collected by medical students’, since the study has already been done.

3. Line 8 of the second paragraph of the sampling data, collection methods and tools should be revised. ‘the point ‘Trained medical students collected the data’ had been mentioned in line 1.

4. Authors should mention sources of stealing of substances as a limitation of the study and give future recommendations for other studies.

5. Table 2, statistics on number of sexual partners needs realignment.

Discussion

1. Authors need to provide the 2006 and 2015 GSHS statistics that were compared to the study.

2. The study, done in Ghana that found no association between peer support and substance use, needs to be cited.

3. Authors were able to compare each of the significant factors that were associated with adolescent substance use in the area to existing literature. However, they failed to compare the prevalence of other recreational substances like khat and methamphetamines to that of existing literature. They only compared alcohol, cigarettes, and marijuana, but no discussion on the other recreational substances.

Strengths and Limitations

The study in 2011 by Mnyika et al., titled ‘Prevalence of and predictors of substance use among adolescents in rural villages of Moshi district, Tanzania’, assessed substance use amongst adolescents. Moshi District was included in this study. I suggest you revise this statement that says this study is the first to be done in the region. Consider saying it is the first that includes associated factors to substance use.

Conclusion

The authors concluded that ‘The study’s prevalence of substance use is higher than the previous 2006 and 2015 Tanzania Global School-based Student Health Surveys’. This inference does not relate to the study results. The findings of the study did not result in this conclusion. I suggest the authors make concluding statements based on the findings of this study.

References

Reference No. 1 has the name of main author missing from lists of authors.

Minor Comments

1. In the Methods (p.6), you used “outcome”, “explanatory”, and “dependent” variable interchangeably. However, these terms are qualitatively different. In your case, it involves “substance use”, so I will suggest that you should use “dependent” variable throughout the paper.

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Reviewer #1: No

Reviewer #2: No

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PONE-D-21-31212R1Prevalence of substance use and associated factors among secondary school adolescents in Kilimanjaro region, northern TanzaniaPLOS ONE

Dear Dr. Mavura,

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 Aug 25 2022 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: https://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,

Vanessa Carels

Staff 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.

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

Reviewer #2: (No Response)

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2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Yes

********** 

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

Reviewer #1: Yes

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 #1: Yes

Reviewer #2: Yes

********** 

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

********** 

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: I thank the authors for addressing my concerns. The manuscript is much improved and should be received favorably by the target audience.

Reviewer #2: Thanks for being responsive to my reviews and suggestions. However, my remaining point is that the discussion should focus on studies conducted in Africa and other low- and middle-income countries. As such, the authors should consider revising the paragraph 3 of the discussion section that makes reference to studies conducted in the United States.

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Reviewer #1: No

Reviewer #2: Yes: Hadii Mamudu

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PONE-D-21-31212R2Prevalence of substance use and associated factors among secondary school adolescents in Kilimanjaro region, northern TanzaniaPLOS ONE

Dear Dr. Mavura,

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 Sep 23 2022 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: https://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,

Hadii Mamudu, Ph.D

Guest 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:

Dear Dr. Mavura,

Thank you for revising your manuscript up to this point! However, you have not been responsive to the suggestion of the reviewer, i.e., "My remaining point is that the discussion should focus on studies conducted in Africa and other

low- and middle-income countries. ... the authors should consider revising paragraph 3 of the discussion section that makes reference to studies conducted in the United States." Nevertheless, you still make reference to studies in the United States where there has been enormous studies on substance use among youth and it will be under-reporting to refer to the United States in the Discussion. Indeed, I agree with the reviewer that the focus should be on studies conducted in African countries, not elsewhere.

While it is true that "there are limited studies about the association between adolescent age and substance use in SSA", extensive studies have been conducted on the use of substances such as tobacco using the GYTS data etc. The substances considered in this study are alcohol, cigarette smoking, marijuana, khat, and recreational drugs (cocaine, heroin); therefore, the discussion should relate to studies in SSA on any of these substances. GYTS studies on the association between age and initiation of tobacco use/cigarette smoking exist. As such, I will encourage the authors to review the literature and use the results to address the issue raised by the reviewer (including paragraphs 2 and 3). The GSHS does not capture the landscape of substance use among adolescents in SSA, so you should look outside that for such studies.

Thank you,

Prof. Hadii M. Mamudu

Guest Editor

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Reviewers' comments:

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While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

Attachments

Attachment

Submitted filename: PONE-D-21-31212R2.pdf

Prevalence of substance use and associated factors among secondary school adolescents in Kilimanjaro region, northern Tanzania

PONE-D-21-31212R3

Dear Ms. Mavura,

Congratulation! 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.

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Kind regards,

Hadii Mamudu, Ph.D

Guest Editor

PLOS ONE