PONE-D-21-20589Geographic variation and factors associated with under-five mortality in Ethiopia. A spatial and multilevel analysis of Ethiopian Mini Demographic and Health Surveys 2019.PLOS ONE

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Comments to the Author

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Reviewer #1: Yes

Reviewer #2: Partly

Reviewer #3: Yes

Reviewer #4: Yes

Reviewer #5: Yes

Reviewer #6: Yes

Reviewer #7: Yes

Reviewer #8: Partly

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

Reviewer #1: Yes

Reviewer #2: I Don't Know

Reviewer #3: Yes

Reviewer #4: Yes

Reviewer #5: Yes

Reviewer #6: Yes

Reviewer #7: Yes

Reviewer #8: No

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Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

Reviewer #4: Yes

Reviewer #5: Yes

Reviewer #6: Yes

Reviewer #7: Yes

Reviewer #8: Yes

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Reviewer #1: Yes

Reviewer #2: No

Reviewer #3: Yes

Reviewer #4: No

Reviewer #5: No

Reviewer #6: No

Reviewer #7: Yes

Reviewer #8: 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: Overall authors have explained regional variation in under five mortality and the key predictors of U5M in Ethiopia. I have few comments to improve this paper further.

1. Authors have used random intercept model for binary multilevel logistic regression. Authors can also do some more testing of their model by including random slopes for their significant predictors in this model to check if the effect of their key predictors remains the same for each cluster or is it different. If they don't found any major difference by including the random slopes, then they can provide the current results as it is.

2. Authors have used different household condition indicators such as toilet clean fuel main roof etc than wealth index which captures the economic condition of the household better in the analysis. Is there any specific reason to adapt this strategy?

3. Authors should also provide the residuals plots for their final multilevel model in the appendix.

4. Authors have shown that there is a significant large cluster of population where U5MR is significantly higher than other areas in Figure 4. Authors can include a table with basic socio demographic profile of this high cluster region. This can be helpful to understand which population mostly suffers with high U5M in that region so that specific interventions and programmes can be targeted for those subgroups of population.

5. Authors should include a short paragraph in the discussion on the implications of their findings in context of the SDG goals.

6. Please see the flow of your texts in the discussion once more and edit the sentences wherever required for more clarity.

Reviewer #2: This publication is of high importance because it attempts to present sophisticated analyses of a legitimate population-based survey data to highlight key risk factors for under five mortality in Ethiopia. However, there are two problems with the manuscript: the first is that it is poorly written in English, which makes understanding of all processed hard; secondly, there are some explanations about the statistics used that (partly due to the poor English) are difficult to understand. Double check both the English and the statistical methods used (binary, bivariable?, multi-level logistic regression?).

Reviewer #3: This is an engaging, insightful paper and mostly methodologically sound paper (see bellow).

There is one important thing to resolve. The authors need to explain why the geospatial analysis was pertinent. Sure, it produced great maps, but the inferences that made it to the Discussion and Conclusion sections could have been made with simple aggregation instead of the employed GIS methods. If this is not the case, the authors need to explain why their approach was used and discuss that in the Discussion section.

The paper should undergo professional proofreading as some formulations were strange.

There were some minor mistakes and suggestions, which were marked and commented on in the attached PDF.

Reviewer #4: I have reviewed the manuscript and it brings a perspective of spatial and multilevel analysis to understanding the variations in under-five mortality in Ethiopia. The multilevel analysis introduces community level variables not examined before enabling the study to consider factors beyond individual ones. The study uses more recent data. The method of data analysis, that is, multivariate multilevel logistic regression is fine but its limitation is that it does not handle the aspect of censored data well. In performing the analysis, it is not clear in the manuscript if the data were weighted or not. The data source section (page 4, lines 91-108), this could have been summarized further and high light the information collected by the 2019 EMDHS relevant to study. On study variables (page 5, lines 112-122), the presentation of the variables could have been efficiently done in a table with definitions and categorization. More especially for community level variables. There are too many variables considered at individual level. Is it possible to reduce them to relevant ones only based on reviewed literature? For spatial analysis (page 5, lines 124-125), state what was actually done. Highlight the benefits and limitations of using multilevel analysis. In the results section (pages 8-9), is possible to use 1 decimal place for the percentages in the text. Also, check the table titles and ensure they are named appropriately. For multilevel analysis results, the intra-cluster correlation (ICC) is not shown in the table. A theoretical framework work should have been considered by the study. In the discussion section of the manuscript, emphasis should have been on discussing community level factors and the geographical variation in under-five mortality observed. The manuscript should have discussed if the under-five mortality rates in the 2019 EMDHS were reproduced for bench marking prior to deriving its own. The conclusion and recommendations of the manuscript should have been based on the multilevel analysis (community level variables) results in addition to the spatial variation findings on under-five mortality.

Reviewer #5: This paper is well motivated and carries out a series of multivariate and spatial analysis on Ethiopian data on under 5 child mortality. The survey data appears to be of excellent quality from a rigorous sampling design. The spatial analysis is a strong point and allows subregional rates to be detected that are higher or lower than the background. Spatial scan statistics provide a promising approach in this case and are good complements to the other approaches. The authors should properly cite the SaTScan software, along with the author M.Kulldforf (see the user manual). I would encourage citing Stata properly as well (note spelling and case).

In my experience, SaTScan runs need quite a bit of tinkering of the parameter file to get good hot spot representation (i.e., like that in the spatial EB approach) . I think the cluster detection can be improved by selecting a smaller window size or radius in order to detect smaller secondary clusters other than the primary two presented here. Otherwise, this is an informative paper on an important topic. Table 4 could use better formatting. Please consider using coefficient plots. Additional proofing of the manuscript is also recommended to improve clarity.

Reviewer #6: This is a thoughtful and interesting analysis of under five mortality in Ethiopia in the years preceding the current crisis and civil war. The analysis focusses on the major individual and area level variables that have been identified in the literature and the results are largely in line with previous findings. While my overall evaluation is positive there are a number of issues that need to be addressed before publication:

1. The style of writing is extremely telegraphic, to the point that at times the meaning is not strictly clear. For instance, your community level variables refer to place of delivery; toilet use; wealth and media exposure. I presume these are based on majority characteristics from your individual level analysis, but this should be made clearer. In particular, I see no reference to media exposure at the individual level, so what does this variable refer to?

2. A major contribution of this paper is the difference between the different areas of Ethiopia and the relation to community characteristics. It would be important, for non-Ethiopian readers, to provide a bit more background on the different regions, socially and historically. A comparison based on the community characteristics you describe would be particularly useful. You should also provide references for the spatial analysis you present (Moran’s I and the spatial interpolation).

3. Your choice of model (multilevel binomial) is appropriate but the presentation is a bit overloaded. Many of the variables appear to be non-significant in the multivariate model, even if they were significant at the bivariate level. This may be due to collinearity between the variables. Removing the non-significant variables would bring out better the major covariates related to U5M. It is also important to indicate that the coefficients are relative risks (eb). There is no need for both log-likelihood and deviance values (as you need, D = -2LL) but you should indicate the degrees of freedom and the variance of the random effects (clusters) as well as the number of individual cases (level 1) and clusters (level 2).

4. Your discussion focusses on the major factors reducing under 5 mortality, but you do not discuss differences between the models. For instance, use of solid fuel increases U5M in model 2 and reduces it in model 4; Amhara has higher mortality in model 3, lower mortality in model 4. In both cases, the coefficients are non significant (within the CI) but the reverse should still be mentioned (also see previous comment on removing non-significant comparisons).

5. Some of the comments in your discussion appear to be inconsistent. For instance, larger families have lower mortality, but so do higher birth orders. You mention mother’s age at first birth but not at current birth, which may be important in explaining this paradox. You rightly identify risk factors subject to intervention, such as short breast feeding or home delivery, but I fail to see how twin births fall into this category, except in the sense that greater attention should be given to mothers with multiple births.

In sum, this is a valuable contribution which I hope to see published, and my comments are intended to strengthen what is, at heart, a sound analysis based on a rich and valuable dataset.

Reviewer #7: The paper is sound and generallly well-written. The topic is very relevant and the analyses performed compatible and consistent with the research question. I have some minor remarks that I consider should be addressed before approving for publication:

Overall, please explain a bit further the difference between the mini DHS survey and the main DHS survey. Why do you think this new data is helpful to track the trends in U5M. The authors extensively explain the sampling design, but do not explain the difference between the mini and the main DHS survey, which would be helpful in interpreting the results. Is the mini DHS survey comparable to the main DHS survey? Can we use this to compare them in time?

In addition, it would be important to know whether any data quality assessment of deaths was performed before the regression analysis. Would any bias be added to the study due to misreporting of deaths in the survey or issues related to coverage areas? Did the authors correct the registry of deaths in any way or were deaths under 5 taken as it is from the survey? How do the authors feel about this data and do they trust the information?

In addition, some minor remarks/suggestions in the writing part that felt confusing:

lines 82- 84: the sentence is confusing. I would add here a period. and Say: "Though U5M has been declining, it is still high and is taking the lives of many children. Despite this fact, no research on U5M has been done with recent data available from the Ethiopian mini ... "

lines 85-87: similarly, the sentence is confusing. I would suggest: "...to show the current burden of U5M that is crucial for better planning different policies and interventions for U5M prevention. This allows for an efficient allocation of scarce resources according to spatial..."

lines 188: suggestion to make the sentence clearer: "Sociodemographic background" and not "background socio-demographic"

line 195: correct to : "are of poor economic status"

Reviewer #8: This paper aims to examine geographic variation and factors attributable to Under-Five Mortality (UFM) in Ethiopia. Recognizing as an important marker for health equity and access, UFM is considered the best proxy measure or indicator for socioeconomic development. In addition, child mortality rate is also a useful marker of overall development and a Millennium Development Goal (MDG) indicator and its importance has been further emphasized in an ambitious target under the Sustainable Development Goals. Generally, literature search reveals numerous or countless studies on factors determining UFM conducted in the Sub-Saharan African countries, however, spatial distributions and geographic variations are less investigated compared to the UFM factors.

The data sources used, statistical tests and analysis performed systematically support, but NOT to the full extent, in answering the research questions and its intended aims or objectives. Results and conclusion made in relation to research aims and objectives or intentions are supported by data and analysis, in general. However, there needs further refinement and improvement for author(s) to take into the consideration to make this paper more added-value to the knowledge and literature.

I foresee two major drawbacks of this study, which are described below:

1. The Primary Investigator should not limit the independent variables to individual and community level predictors. It is suggested to take into the consideration of inclusion of health interventions, such as malaria, sanitation and hygiene (WASH), reproductive health (RH), vaccinations, micronutrient supplementation and treatments. Most studies have revealed that there are significant association between these health interventions and reduction of UFM. For example, BCG, OPV, Measles, TT, etc. vaccinations have significantly contributed to drastic reduction in deaths of children in most developing countries. Furthermore, measure DHS captures or collects information on health interventions; and it's worthwhile to examine its association with UFM in Ethiopia.

2. Since the other known predictors of child morality are generally attributable to food security and accessibility in conflict areas thus, it is recommended to discuss how such conflicts or disruptions would influence or alter the geographic variations of UFM in Ethiopia? Other risk factors to take into considerations are: indoor air pollution (determined by type of cooking fuel used in household), nutrition, access to basic health services (ANC, PNC, FP, RH, etc.), poverty status by regions, fertility rates, among others.

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Reviewer #1: No

Reviewer #2: No

Reviewer #3: No

Reviewer #4: No

Reviewer #5: No

Reviewer #6: Yes: Jon Anson

Reviewer #7: No

Reviewer #8: No

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Submitted filename: PONE-D-21-20589_reviewer.pdf

Attachment

Submitted filename: PONE-D-21-20589_reviewer.pdf

PONE-D-21-20589R1Geographic variation and factors associated with under-five mortality in Ethiopia. A spatial and multilevel analysis of Ethiopian Mini Demographic and Health Surveys 2019.PLOS ONE

Dear Dr. Tadesse Tessema,

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 see the very detailed edits we are suggesting in the attached PDF, paying FULL ATTENTION to each and every comment (some of which have been made BEFORE, but have not been addressed). As per our note, make sure your next version is seen by a professional English writer. You will have one last chance to publish the manuscript if it is well written and technically sound. Please contact me if there is any doubts or consultations you may want to make.

Please submit your revised manuscript by August 8, 2022. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

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• An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript' (Please also send a clean Word file in case we may need to make last and final mini-edits). 

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,

Alfredo Luis Fort, M.D., Ph.D.

Guest Editor

PLOS ONE

Journal Requirements:

Additional Editor Comments (if provided):

Several reviewers have seen this document, and have provided lots of editorial and technical feedback. This is an article that has sufficient merit for publication, for global as well as Ethiopian interest. However, despite SEVERAL attempts and specific feedback from reviewers, the authors have failed to submit the manuscript to someone with good English writing skills, so it can be written in "standard English" as is clearly stated in criteria 5 for PLOS ONE publication.

Thus, the document continues to be written in poor English, extremely difficult to read, and still has several editing errors, imprecisions and confusing statements, making it impossible to the average reader to fully grasp the content and comfortably understand all the text, tables and graphs.

We will give you the authors one last chance to revise the manuscript, including giving you a detailed PDF full of comments and editing suggestions) and resubmit, to make a final decision for publication. Again, PLEASE LOOK FOR OR HIRE SOMEONE WITH PROFICIENT ENGLISH WRITING CAPACITY TO REVIEW AND REVISE YOUR MANUSCRIPT ENTIRELY. Resubmit your manuscript only after it has been rewritten ENTIRELY (put full attention to detail!), ensuring everything has been double-checked for technical as well as copy-editing quality. You can submit the typical PDF plus a Word document, in case we may want to make small edits from our end. Thank you.

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Reviewers' comments:

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

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

Attachments

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Submitted filename: PONE-D-21-20589_AF.pdf

PONE-D-21-20589R2Geographic variation and factors associated with under-five mortality in Ethiopia. A spatial and multilevel analysis of Ethiopian Mini Demographic and Health Surveys 2019.PLOS ONE

Dear Dr. Tessema,

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. Although the scientific concerns have now been addressed, your submission still requires extensive editing for English grammar and usage. Please note that PLOS ONE does not copyedit accepted manuscripts and that one of our criteria for publication is that articles must be presented in an intelligible fashion and written in clear, correct, and unambiguous English (https://journals.plos.org/plosone/s/criteria-for-publication#loc-5).  A file has been attached containing further edits that should be used as a guide to highlight the changes that need to be made. We suggest you have a fluent English-language speaker thoroughly copyedit your manuscript for language usage, spelling, and grammar. If you do not know anyone who can do this, you may wish to consider employing a professional scientific editing service. While you may approach any qualified individual or any professional scientific editing service of your choice, PLOS has partnered with American Journal Experts (AJE) to provide discounted services to PLOS authors. AJE has extensive 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. If the PLOS editorial team finds any language issues in text that AJE has edited, AJE will re-edit the text for free. To take advantage of this special partnership, use the following link: https://www.aje.com/go/plos/. Please note that PLOS does not financially benefit from this partnership; moreover, having the manuscript copyedited by AJE or any other editing services does not guarantee selection for peer review. Your manuscript has not yet been considered for its scientific merits, and we cannot do so unless the language is significantly improved.

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Attachments

Attachment

Submitted filename: PONE-D-21-20589_R2-AFort.pdf

Geographic variation and factors associated with under-five mortality in Ethiopia. A spatial and multilevel analysis of Ethiopian Mini Demographic and Health Surveys 2019.

PONE-D-21-20589R3

Dear Dr. Tadesse Tessema,

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,

Alfredo Luis Fort, M.D., Ph.D.

Guest Editor

PLOS ONE

Additional Editor Comments (optional):

Final manuscript in PDF sent my author was uploaded from my end. It is OK and should be ready for publication.

Reviewers' comments:

Attachments

Attachment

Submitted filename: final manuscript_ZTT.pdf