PONE-D-21-35901Alcohol, Tobacco and drug use among adults experiencing homelessness in Accra, Ghana: A cross-sectional study of risk levels and associated factorsPLOS ONE

Dear Dr. Osei Asibey,

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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We look forward to receiving your revised manuscript.

Kind regards,

Joel Msafiri Francis, MD, MS, PhD

Academic Editor

PLOS ONE

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2. In your Data Availability statement, you have not specified where the minimal data set underlying the results described in your manuscript can be found. PLOS defines a study's minimal data set as the underlying data used to reach the conclusions drawn in the manuscript and any additional data required to replicate the reported study findings in their entirety. All PLOS journals require that the minimal data set be made fully available. For more information about our data policy, please see http://journals.plos.org/plosone/s/data-availability.

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Additional Editor Comments (if provided):

It would be more helpful to use the STROBE guidelines and format the manuscript accordingly including the use of appropriate heading, for example, study population rather than study respondent etc. 

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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

**********

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

Reviewer #1: Yes

Reviewer #2: Yes

**********

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

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

Reviewer #1: Yes

Reviewer #2: Yes

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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

**********

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: Abstract

Line 42: Please rephrase the sentence “The likelihood of engaging in high-risk substance used higher for men than women 43 (AOR=4.09; 95%CI 2.06-8.12, p<.001)”

-Did authors mean “the likelihood of engaging in high-risk substance use was higher for men than women?

Methods

-There are terms introduced in the text starting from the abstract that may require inclusion of their standard definition in the method section: What do the authors mean by “sheltered and unsheltered homelessness”

Line 112: “Since there was no official data on homelessness in Ghana, the uncontrolled quota sampling technique [34, 35] was used to obtain a representation of sheltered and unsheltered homeless populations”

-Please add justification for using uncontrolled quota sampling, how uncontrolled was the sampling procedure?

Line 157: Substance use risk levels were assessed using the ASSIST version 3.0, a tool to identify levels of risky substance use and related health risks

-For those who used local language, is there a translated validated ASSIST tool as per the local language? please specify, it will be great to also report the validity and reliability of the translated tool

Line 183: Experiences of stigmatisation: Assessed using a 12-item Social Stigma Scale to measure the experience of general stigma

-Same here, please report on the internal consistency and validity of the tool used

Line 192: Violence and abuse: measured using items from the Ghana Living Standard Survey

193 (GLSS) Round 6

- Same here, please report on the internal consistency and validity of the tool used

-Please specify the level of statistical significance used

Line 188: Self-reported experience or diagnosis of a range of physical and mental health conditions in the past three months

-Weren’t the patients who reported mental health conditions diagnosed in the past three months excluded? This was one of the exclusion criteria reported in the study participant section “individuals with cognitive impairment, intellectual disability, and mental illness were excluded from participation following advice from social workers and shelter staff.” Please clarify how comes those with mental health diagnosis were included.

Results

Line 241: Self-reported physical and mental health problems were 72% and 87% respectively

-Please explain how comes participants with mental health problems were included despite it being an exclusion criterion

Table 2: Please specify, if possible, in bracket that the “Highest Specific Substance Index” has been reported as the overall risk to make it more clear

Line 270: “Moderate/high-risk substance users were also more likely have experienced general stigma than not (271 72% vs 51%, p<.001)”

-add “to” have experienced

Discussion/Limitation

Line 342: “Although generally high, differences in prevalence exist between the present study and previous research”

-While comparing the magnitude of risky substance use in literature, authors should take note of the differences in the substance use assessment tools used in other studies and how they can be comparable/correlated with ASSIST tool.

Authors should highlight the disadvantages/ limitations that result from using uncontrolled quota sampling, biases resulting from non-randomization among others and how these were dealt with in the study

With interview-based questionnaire, there is a risk of information bias, provision of socially desirable answers, especially since the use of some of the drugs is illegal in most African countries. These too are usually anticipated in studies relating to substance use hence should be reported if relevant.

Discussion/Conclusion

Please also comment on generalizability of the study findings

Reviewer #2: 6 May 2022

PONE-D-21-35901

Alcohol, Tobacco and drug use among adults experiencing homelessness in Accra, Ghana: A cross-sectional study of risk levels and associated factors

Benedict Osei Asibey

Dear Authors,

Some consideration for your manuscript.

Line 42: missing words… substance use were higher

Line 46: Missing word… with the experience

Line 86: Could some additional information iro of this larger cross sectional study be given and where this piece of work fits in or even provide a reference to a paper possibly published on the larger study.

Line 144: What would re-negotiate consent entail, please just expand on this and under what circumstance such a situation is likely to occur.

Line 146: Did the fieldworker pose the question to the participant and enter it on behalf of the participant or were the questions posed and the participant themselves entered the response on the tablet. Possibility of bias which should be detailed in the limitations if not there.

Line 149: The incentive with repellant is an interesting one presumably because of high prevalence of malaria. If this could be stated.

Line 151: Were referrals to centres facilitated by the field workers? Were the participants all given the option to do this or was it based on a score on the ASSIST?

Line 238: Perhaps added into the methods section under the relevant sub-heading, the authors should indicate what baseline was used to determine chronic homelessness versus “non-chronic” homelessness.

Line 244: Presumably data on whether participants who self-reported an ailment sought help for physical/mental health problems was not collected? If yes it would be interesting to know.

Line 146: were women more like than men to have encountered sexual violence in the past 6 months. Although I later on pick up, this was not possible to determine due to sample size.

Line 271: more likely to have experience… missing word

Lines 259-363 – Is there are reference for this, because there may be a divergent view iro of the value/effectiveness on measured outcomes of outpatient treatment vs inpatient – there is evidence of the value of outpatient/community based services to. Perhaps the authors should do a quick review to look into this and provide references. This would apply to line 364 to mid-paragraph.

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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.

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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

**********

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PONE-D-21-35901R1Alcohol, Tobacco and drug use among adults experiencing homelessness in Accra, Ghana: A cross-sectional study of risk levels and associated factorsPLOS ONE

Dear Dr. Osei Asibey,

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 Nov 16 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,

Joel Msafiri Francis, MD, MS, PhD

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.

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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: (No Response)

Reviewer #3: All comments have been addressed

**********

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

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

Reviewer #1: Yes

Reviewer #3: Yes

**********

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

Reviewer #1: Yes

Reviewer #3: 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 #3: 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 #3: 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: Line 131-133: Refer to “The initial plan was to sample 70% unsheltered and 30% sheltered homeless persons, and the final sample consisted of 68% unsheltered and 32% sheltered persons.”

Please move this statement that explains on the quota weightage just after mentioning quota sampling method.

Line 125-127: The authors report the sample size to be deemed sufficient to determine predictors. If possible, I would suggest reporting the power of the study at 5% significance level to support this.

Line 157: Substance use risk levels were assessed using the ASSIST version 3.0, a tool to identify levels of risky substance use and related health risks –

Line 173: This is a follow up from the previous comment: For those who used local language, is there a translated validated ASSIST tool as per the local language in Ghana? it will be great to also report the validity and reliability of the translated tool, same applies to the GLSS

NB: Some tools have been pre-translated into different languages for use by different localities, some of which will have studies reporting the validity of such translated tools. Hence, this question asks about the translated ASSIST tool, not the language used for the questionnaire – refer to the revision made by the authors on the Stigma tool

Line 298: Authors should be consistent with the statistical method used: is it univariate or bivariate? Please be consistent throughout

Line 320: Before reporting the AOR, authors may consider mentioning which variables were exclude in the multivariable model based on the p<0.25 cut-off as specified.

Line 340, table 4: Please clarify what the empty spaces in the table implies and if possible, indicate in the table legends. Indicate the long forms too in the legends for each table.

Line 340, table 4: Some factors that had p values >2.5 on bivariate analysis included in the multivariable model. For instance, the var Mental health problems and self-blame had p values of 0.36 on bivariate analysis, yet, they were included in the multivariable model. Please clarify.

NB: It is useful for the authors to mention the inclusion of factors that may be insignificant statistically but could be included in the model apriori, mental health problems is a good example here.

Line 381-384: “Although generally high, differences in prevalence exist between the present study and previous research”

-Mental health diagnosis varies as compared to other diseases, because of the presence of number of tools. While comparing the magnitude of risky substance use in literature, authors should take note of the differences in the substance use assessment tools used in other studies and how

they can be comparable/correlated with ASSIST tool (Please indicate where changes were made)

Line 453-454: The authors mentioned the representativeness of the quota sampling used for this study, please do also outline the limitation of using non-random sampling.

I would suggest a notable response to this, from previous comments: Please also comment on “generalizability of the study findings” ie. taking into account the sample size, are the authors able to make broad inferences about the findings from this study??

Reviewer #3: The current manuscript appears to be a revised version which has been resubmitted after fairly comprehensive revisions - this reviewer did not see the original version. As such, the paper seems fine. Any small issues are not worth another round of revisions.

**********

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: Yes: Belinda J Njiro

Reviewer #3: Yes: Alasdair M Barr

**********

[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.

PONE-D-21-35901R2Alcohol, Tobacco and drug use among adults experiencing homelessness in Accra, Ghana: A cross-sectional study of risk levels and associated factorsPLOS ONE

Dear Dr. Osei Asibey,

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 Jan 13 2023 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,

Joel Msafiri Francis, MD, MS, PhD

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):

Thanks for all the revisions. The paper reads well. Please kindly format the paper according to the journal format.

[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 #1: All comments have been addressed

Reviewer #3: All comments have been addressed

**********

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

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

Reviewer #1: Yes

Reviewer #3: Yes

**********

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

Reviewer #1: Yes

Reviewer #3: 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 #3: 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 #3: 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: (No Response)

Reviewer #3: (No Response)

**********

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: Yes: Belinda Jackson Njiro

Reviewer #3: Yes: Alasdair M Barr

**********

[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.

PONE-D-21-35901R3Alcohol, Tobacco and drug use among adults experiencing homelessness in Accra, Ghana: A cross-sectional study of risk levels and associated factorsPLOS ONE

Dear Dr. Osei Asibey,

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.

Thanks for the revisions and the paper reads well. I have one critical comment - it would be helpful to standardise the reporting of  p values - decide whether to use 2 or 3 decimal points throughout the document.

Please submit your revised manuscript by Feb 17 2023 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,

Joel Msafiri Francis, MD, MS, PhD

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):

Thanks for the revisions and the paper reads well. I have one critical comment - it would be helpful to standardise the reporting of  p values - decide whether to use 2 or 3 decimal points throughout the document.

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

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Alcohol, Tobacco and drug use among adults experiencing homelessness in Accra, Ghana: A cross-sectional study of risk levels and associated factors

PONE-D-21-35901R4

Dear Dr. Osei Asibey,

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Joel Msafiri Francis, MD, MS, PhD

Academic Editor

PLOS ONE

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