PONE-D-22-24400Factors associated with elder abuse in rural Uganda: A hospital-based cross-sectional studyPLOS ONE

Dear Dr. Kaggwa,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

I agree with the reviewers on how necessary and important it is to carry out studies like this and I thank the authors for having this type of interest in the elderly population, previously always respected and today so frequently mistreated. I encourage authors to follow the suggestions made by reviewers in an effort to get their manuscript ready for publication.

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PLOS ONE

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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: Yes

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: Yes

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: Thank you for doing this study. The topic is important, along with your findings. Please see my comments:

Pg8 line 29: The population is actually community older adults who attend an hospital based outpatient clinic, therefore they are not hospital population per se.

Pg9 line 62: What is LMIC? Please define this term before using an abbreviation for it.

Pg10 lines 115-117: How were they recruited exactly? How was consent formally obtained?

Pg10 lines 119-120: What do you mean 'fast tracked them to recieve medical care'?

Pg10 line 130: What do you mean by the terms 'lame' and 'crippled'?

Pg11 line 145: What do you exactly mean by this, and what information did they give exactly

Pg11 lines 146-159: Did you look at higher levels of functionality, such as the ability to complete the instrumental acitivities of daily living, like managing ones own finances? If not, why not? This is particularly important when you are considering financial abuse.

Pg12 line 207: Please define what a VIF is.

Pg16 line 337: But this was not a hospital sample, it was from a sample derived from an outpatient clinic based in a hospital setting

Pg16 lines 344-351: I am not sure this adequately explains your findings - are there any reaons to explain your contradictory findings?

Pg18 lines 445-449: Additional limitations include the exclusion of people with more severe neurocognitive disorders, whom are at higher risk of abuse

Pg18 line 446: See my comment earlier about this being based in the Outpatient setting, not the hospital

Pg18 Lines 451-455: Please expand more on this section, including a summary of the findings, and future opportunities

Reviewer #2: This paper examines the prevalence of elder abuse in a hospital-based sample of adults from rural Uganda.

Given the social and medical significance of elder abuse, the general lack of awareness of the severity of this problem, and the paucity of literature on the subject from this region, the current study is meritorious from a public health perspective. I appreciate the authors’ work, as well as their thorough coverage of the ethical complexities involved in such research.

The following are aspects of the paper which would benefit from correction or clarification:

1. Abstract:

a. It is stated that about one in ten elderly individuals experiences abuse. This estimate is somewhat on the lower side; a recent systematic review of elderly people in rural areas suggests that the figure is closer to 33% (i.e., one in three) – cf. Zhang et al., 2022. This could be reflected in both the abstract and the text, as this study is based on a sample of elderly people from a rural area.

b. Has this study examined only abuse, neglect, or both abuse and neglect? The title and abstract refer to abuse but there is a mention of neglect in line 43.

2. Introduction:

a. The authors could incorporate recent systematic reviews of elder abuse, particularly from rural or non-Western countries, into this part of the text. See Zhang et al. (mentioned above), Wang et al. (2022) or Ho et al. (2017).

b. As this study is being conducted in rural Uganda, it would be informative to discuss those unique aspects of Ugandan culture that could either contribute to or protect against elder abuse. (For example, if respect for elders is a national cultural value, this could act as a protective factor; on the other hand, if there is a “culture of silence” about violence against women, as in many Asian and African cultures including this reviewer’s, this could be a risk factor for elderly women specifically.)

3. Methods:

a. Was the sample size of n = 363 sufficient to address the research questions? Were any subjects excluded based on criteria other than neurocognitive impairment (e.g., refusal of consent by the individual or by their family members?)

b. Terms such as “lame” and “crippled”, though vivid and descriptive, may be considered pejorative or “politically incorrect” by many modern readers. It is preferable if the authors use medical terms (e.g., orthopedically handicapped).

c. Did the instrument used to measure elder abuse require any modifications / adaptations based on local culture or idioms? If so, this could be mentioned. Did any of the study participants find it difficult to understand some of the concepts covered by this instrument?

d. Likewise, if the study instruments were translated into a local language for the purpose of this study, details of translation and validation should be provided in this section.

e. Were any practical difficulties faced by the researchers in the course of interviewing each subject for 40 minutes (e.g., hearing impairment, fatigue, emotional lability, catastrophic reactions)?

f. Apart from measures of functional capacity, did the authors collect any data on the mental health of the participants (e.g., symptoms of depression or anxiety)? This is important because there is a close relationship between elder abuse and mental health.

g. Were the MMSE scores also included in the data analysis? (There is some evidence that cognitive impairment, even if not in the severe range, could be a risk factor for elder abuse – see Lachs et al., 1997)

h. Was any information collected on family income / socioeconomic status? This could also be a potential risk factor.

4. Results:

a. See 3 g. above; if not done, this can be mentioned as a limitation / direction for future research.

b. Was information available on the different types / symptoms of physical illness in relation to elder abuse (e.g., were specific illnesses associated with visual or hearing impairment, incontinence, etc. associated with a higher risk of abuse)?

c. Were any meaningful differences in predictor variables for abuse / neglect identified when comparing elderly men and women (i.e., were there gender differences in risk factors)?

5. Discussion:

This section should be more than a repetition of the study results. For example, the authors could compare their finding of a prevalence of 89% with other studies from rural areas, which yield an estimate of 4 – 61%, and explore the possible reasons (methodological as well as actual) which could account for such a high estimate. The authors could also discuss recommendations for the prevention and management of elder abuse based on their study results (e.g., based on the predictor variables identified in the multivariate analyses) as well as the limitations / difficulties associated with managing this problem in a rural Ugandan setting.

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Reviewer #1: Yes: Frances Carr

Reviewer #2: Yes: Ravi Philip Rajkumar

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Attachments

Attachment

Submitted filename: PONE-D-22-24400_reviewer.pdf

Factors associated with elder abuse and neglect in rural Uganda: a cross-sectional study of community older adults attending an outpatient clinic

PONE-D-22-24400R1

Dear Dr. Kaggwa,

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.

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Kind regards,

Thalia Fernandez, 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 #1: All comments have been addressed

Reviewer #2: All comments have been addressed

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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: (No Response)

Reviewer #2: Yes

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

Reviewer #1: (No Response)

Reviewer #2: Yes

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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: (No Response)

Reviewer #2: Yes

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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: (No Response)

Reviewer #2: Yes

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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: (No Response)

Reviewer #2: The revisions made by the authors are satisfactory. I have no further major changes or corrections to suggest.

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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 #1: No

Reviewer #2: Yes: Ravi Philip Rajkumar

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