Epidemiology of unintentional childhood injuries in urban and rural areas of Nepal- A comparative study

Pratiksha Pathak; Sunil Kumar Joshi

doi:10.1371/journal.pone.0287487

Peer Review History

Original SubmissionJanuary 22, 2023
21 Feb 2023 Decision Letter - Hariom Kumar Solanki, Editor PONE-D-23-01914Epidemiology of unintentional childhood injuries in urban and rural areas of Nepal - A comparative studyPLOS ONE Dear Dr. Pathak, 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. ============================== ACADEMIC EDITOR: Please respnd to queries by the reviewers especially the updated references, mismatch in the number of families and the number of children included in the study. Also include definition used for including unintentional childhood injuries in the methods section. In the result section please include the numbers and denominators alongwith the percent / proportion for all the rlevant tables. These changes are must for consideration of the manuscript for acceptance. It will be better if a flow chart for sampling and data collection steps is included in the manuscript in addition to addressing the other reviewer comments. Please submit your revised manuscript by Apr 07 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. 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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, Hariom Kumar Solanki, M.D. Academic Editor PLOS ONE Journal requirements: When submitting your revision, we need you to address these additional requirements. 1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf 2. 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. Upon re-submitting your revised manuscript, please upload your study’s minimal underlying data set as either Supporting Information files or to a stable, public repository and include the relevant URLs, DOIs, or accession numbers within your revised cover letter. For a list of acceptable repositories, please see http://journals.plos.org/plosone/s/data-availability#loc-recommended-repositories. Any potentially identifying patient information must be fully anonymized. Important: If there are ethical or legal restrictions to sharing your data publicly, please explain these restrictions in detail. Please see our guidelines for more information on what we consider unacceptable restrictions to publicly sharing data: http://journals.plos.org/plosone/s/data-availability#loc-unacceptable-data-access-restrictions. Note that it is not acceptable for the authors to be the sole named individuals responsible for ensuring data access. We will update your Data Availability statement to reflect the information you provide in your cover letter. Additional Editor Comments: Dear Dr Pathak There have been significant issues raised by the reviewers regarding methodology and/ or presentation of this manuscript. Please revise the manuscript before further consideration. 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: No Reviewer #2: Yes ****** 4. Is the manuscript presented in an intelligible fashion and written in standard English? PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here. Reviewer #1: No Reviewer #2: Yes ******** 5. Review Comments to the Author Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters) Reviewer #1: I enjoyed reading your manuscript and this study could be the stepping stone for framing policies to prevent unintentional childhood injuries in Nepal. having said that, I would like to point out some points that need to be addressed. 1. The abstract needs to be refined. The conclusion in the abstract is a repetition of the results. 2. Line 25 - Use recent data from WHO regarding childhood injuries. 3. Make use of references that are recent, preferably those published during the previous 10 years. 4. Line 62 - approval from the parents for any type of study is termed as "assent" and not "consent" 5. Please elaborate how the sample size of 712 was obtained 6. How the interview was conducted and was interviewed could be included in the "Methods" section. 7. Line 73 - PPS should be Probability Proportional to size 8. Please clarify how your total number of participants was 667 when your sample size was calculated to be 712. 9. For the tables, it will be proper if you provide the actual numbers besides the percentages. 10. Table 1 - Please check the socioeconomic status of the participants. The rural population seems to fare better as compared to their counterpart. 11. Have you considered fatal injuries as part of "modes of injury" for unintentional childhood injuries? 12. Line 121 - 58.4% is more than half, that is why you cannot use the term "nearly half". 13. Line 182-188 - RTIs and Burns can be addressed separately. Your study concurs with the other study you mentioned when it comes to "burn" injuries, but you mentioned that they are contrary. 14. Line 184 - You can elaborate more on this. "household chores" as you mentioned here seems to be a fire hazard. 15. Line 218 - the present study being a community based cross-sectional study utilizing convenience sampling, i would suggest that you remove the word "true" from "true snapshot". 16. Recommendations and strengths of the study can be mentioned Reviewer #2: Attached in the reviewer comments text file. Also mentioning here Please mention the definition of unintentional injuries used in the methods section. Since the study population included children aged 1-16 years, who were the respondents. Was it always mothers.? What proportion of respondents was non-mothers.? Line 27: Can we update the citation to any recent report from WHO. I am sure there was a recent update from GBD study and also from the WHO centre for injury prevention Line 36: Shows the number of children that had sought for an injury. Do we have any information on treatment seeking behaviours for childhood injury from Nepal. Line 37 to 53 are more of content for the discussion. Can we have details on injury prevention programmes that are envisaged at WHO, or regional level or at the country level. How evidences like those collected from your study can contribute to such a programme.? Some economic aspects of childhood injury like school days lost, parents wages lost, etc would add a societal dimension to this public health issue. Overall background needs to be improved a lot Line 61: Are you sure you took consent from children aged 1-16 years.? Or was it from their parents.? Can you provide a flowchart for the sampling technique.? Why was a convenient sampling method opted instead of a systematic random sampling. By doing so the study appears to have been weakened a bit The definition used for including unintentional childhood injuries is missing in the main methodology. Kindly mention and cite the reference that was used for this definition In the results you say there were 667 children from 658 mothers and 659 fathers. In the methods you said that only one child was chosen from a household. In that case the number of children should match the number of mothers/fathers isn't it.? Kindly provide the broad numbers instead of just mentioning the proportions. Please mention (n - XXX) in the table heading Please provide Confidence interval to the prevalence estimate. I am surprised to see 2/3rd of children suffering from falls. Guess the definition used was very broad. Did the child have any disability after all these falls.? It's hard for me to understand the absolute number and disaggregated numbers when only the proportion is used. What does the proportion infer to.? Which denominator was used isn't clear to me in few places especially in the multiple modes of injury table.? Can we break Table 3 and show by each injury type (as a column). Rural vs Urban in the column head is not adding value. Suggest creating a haddon's matrix with whatever information was collected to see what all factors were collected in your study. You may distinguish significant ones from the insignificant ones using a * or any symbol. That would add a lot of value for a policy maker Also let's refrain from point prevalence and shift to period prevalence as this study "COUNTS" injury events across 12 months prior to the date of interview. ******** 6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files. If you choose “no”, your identity will remain anonymous but your review may still be made public. Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy. Reviewer #1: No Reviewer #2: Yes: Giridara Gopal Parameswaran ******** [NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.] While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step. https://doi.org/10.1371/journal.pone.0287487.r001
Revision 1
7 Apr 2023 Author Response Response to reviewers’ comments Reviewer #1: I enjoyed reading your manuscript and this study could be the stepping stone for framing policies to prevent unintentional childhood injuries in Nepal. having said that, I would like to point out some points that need to be addressed. 1. The abstract needs to be refined. The conclusion in the abstract is a repetition of the results. Thank you for the comments. I have accepted the comment and corrected accordingly. 2. Line 25 - Use recent data from WHO regarding childhood injuries. Thank you for the comments. I have accepted the comment and corrected accordingly. 3. Make use of references that are recent, preferably those published during the previous 10 years. Thank you for the comments. I have accepted the comment and corrected accordingly. 4. Line 62 - approval from the parents for any type of study is termed as "assent" and not "consent" Thank you for the comments. I have accepted the comment and corrected accordingly. 5. Please elaborate how the sample size of 712 was obtained Sample size was calculated as follows: Sample size calculation was done as follows; Sample size (n) =(z^2.p.q)/d^2 Where, z= at 95% confidence level (standard value = 1.96) p= prevalence of unintentional injury in Asian children= 5.5% 13 = 0.055 q= 1-p = 1- 0.055 = 0.0945 d= margin of error of 5% Sample Size (n) = (1.96×1.96×0.055×0.0945)/(0.05×0.05) = 80 Considering 10% non – response rate, Sample size (n) = 80/0.9 = 89 Considering the design effect, Sample size (n) = 89 X 4 = 356 Since, the study was conducted both in rural and urban area, Final sample size = 356×2 = 712 Thus, the final sample size was 712 considering the prevalence of unintentional injury among Asian children as 5.5%. 13 6. How the interview was conducted and was interviewed could be included in the "Methods" section. Thank you for the comments. I have accepted the comment and corrected accordingly. 7. Line 73 - PPS should be Probability Proportional to size Thank you for the comments. I have accepted the comment and corrected accordingly. 8. Please clarify how your total number of participants was 667 when your sample size was calculated to be 712. The overall response rate was 93.7% (rural: 96.0% and urban: 91.3%). Thus, the total number of participants in this study were 667 out of which 342 were from rural area and 325 from urban area. 9. For the tables, it will be proper if you provide the actual numbers besides the percentages. Thank you for the comments. I have accepted the comment and corrected accordingly. 10. Table 1 - Please check the socioeconomic status of the participants. The rural population seems to fare better as compared to their counterpart. Thank you for the comments. I have accepted the comment and corrected accordingly. 11. Have you considered fatal injuries as part of "modes of injury" for unintentional childhood injuries? No, only nonfatal injuries were included. 12. Line 121 - 58.4% is more than half, that is why you cannot use the term "nearly half". Thank you for the comments. I have accepted the comment and corrected accordingly. 13. Line 182-188 - RTIs and Burns can be addressed separately. Your study concurs with the other study you mentioned when it comes to "burn" injuries, but you mentioned that they are contrary. Thank you for the comments. I have accepted the comment and corrected accordingly. 14. Line 184 - You can elaborate more on this. "household chores" as you mentioned here seems to be a fire hazard. Household chores like: cooking, preparing cattle feeds, using fire for heating, etc. 15. Line 218 - the present study being a community based cross-sectional study utilizing convenience sampling, i would suggest that you remove the word "true" from "true snapshot". Thank you for the comments. I have accepted the comment and corrected accordingly. 16. Recommendations and strengths of the study can be mentioned Strengths This is a community-based study that might somewhat show the true burden of injuries as all the cases might not seek treatment in health facilities. Also, a comparison between rural and urban area has been done as the epidemiology of injuries is different in both places. Recommendations Further studies are required on larger scale in order to establish the evidence base necessary for effective injury prevention program. Also, establishment of both facility-based and community-based injury registry would provide further contribution for evidence generation. Similarly, childhood injury prevention programs could be introduced at school by trained teachers and also at community level by FCHVs. Furthermore, the health systems should be strengthened to address child injuries which includes the provision of high-quality care to the injured children as well as rehabilitation and support services. Reviewer #2: Attached in the reviewer comments text file. Also mentioning here 1. Please mention the definition of unintentional injuries used in the methods section. The unintentional injuries are those where the intent to use the force may not necessarily intend to cause the damage. This issue can be quite complex as the intent to use force may not necessarily mean that there was an intent to cause harm or damage. Unintentional injuries are classified as per their occurrence: poisoning, burns, and scalds, drowning, falls and transport-related. 10 Thank you for the comments. I have accepted the comment and corrected accordingly. 2. Since the study population included children aged 1-16 years, who were the respondents. Was it always mothers.? What proportion of respondents was non-mothers.? About two-third of the respondents were mothers (64.9%) followed by fathers (32.7%) and few of them were grandparents (2.4%). 3. Line 27: Can we update the citation to any recent report from WHO. I am sure there was a recent update from GBD study and also from the WHO centre for injury prevention Thank you for the comments. I have accepted the comment and corrected accordingly. 4. Line 36: Shows the number of children that had sought for an injury. Do we have any information on treatment seeking behaviours for childhood injury from Nepal. A study conducted in Makwanpur district of Nepal found that the use of local contacts especially FCHVs for first aid and referral purposes after an injury event were mostly preferred among the respondents. Also, delay in seeking medical care and thinking that ‘injury will heal with time’ were their common misconceptions. As the community health volunteers are not equipped with adequate medical supplies, people were bound to consult faith healers or apply home remedies such as soap water or dung water for poisoning, use of Aloe Vera for burns and application of tourniquet for snakebites. 4. Line 37 to 53 are more of content for the discussion. Can we have details on injury prevention programmes that are envisaged at WHO, or regional level or at the country level. How evidences like those collected from your study can contribute to such a programme.? Some economic aspects of childhood injury like school days lost, parents wages lost, etc would add a societal dimension to this public health issue. Overall background needs to be improved a lot. Thank you for the comments. I have accepted the comment and corrected accordingly. 5. Line 61: Are you sure you took consent from children aged 1-16 years.? Or was it from their parents.? Assent was taken from their parents or primary care givers 6. Can you provide a flowchart for the sampling technique.? Why was a convenient sampling method opted instead of a systematic random sampling. By doing so the study appears to have been weakened a bit Yes, convenience sampling has weakened the study but due to the lack of sampling frame this option had to be chosen. As the study was conducted after the earthquake of 2015 in Nepal, many of the families had changed their settlement area thus it was difficult to locate them and bring into the sampling frame. 7. The definition used for including unintentional childhood injuries is missing in the main methodology. Kindly mention and cite the reference that was used for this definition Thank you for the comments. I have accepted the comment and corrected accordingly. 8. In the results you say there were 667 children from 658 mothers and 659 fathers. In the methods you said that only one child was chosen from a household. In that case the number of children should match the number of mothers/fathers isn't it.? The details of 658 mothers (335 and 323 in rural and urban area respectively) and 659 fathers (337 and 322 in rural and urban area respectively) were included. Total 9 mothers and 8 fathers were either separated or expired thus they were excluded from the study. 9. Kindly provide the broad numbers instead of just mentioning the proportions. Please mention (n - XXX) in the table heading Thank you for the comments. I have accepted the comment and corrected accordingly. 10. Please provide Confidence interval to the prevalence estimate. Out of the total 667 children, 21.7% [95% CI: 18.6 – 24.9] had sustained unintentional injuries in the past 12 months. In rural area, the prevalence was 26% [95% CI: 21.3 – 30.7] whereas in urban area it was 17.2% [95% CI: 13.1– 21.4]. 11. I am surprised to see 2/3rd of children suffering from falls. Guess the definition used was very broad. Did the child have any disability after all these falls.? Yes, this has been included in the impact of the injuries. Among the children who were injured, 22 hospitalized for treatment, 11 were left with some form of disability and 10 of them were not able to return back to school. 12. It's hard for me to understand the absolute number and disaggregated numbers when only the proportion is used. What does the proportion infer to.? Which denominator was used isn't clear to me in few places especially in the multiple modes of injury table.? Thank you for the comments. I have accepted the comment and corrected accordingly. 13. Can we break Table 3 and show by each injury type (as a column). Rural vs Urban in the column head is not adding value. Suggest creating a haddon's matrix with whatever information was collected to see what all factors were collected in your study. You may distinguish significant ones from the insignificant ones using a * or any symbol. That would add a lot of value for a policy maker Thank you for the comments. Actually the main motive of the table is to show the scenario of the injury events as a whole rather than breaking down into each injury type as that was not the main objective of the study. Please do correct me if I am unclear regarding this. 14. Also let's refrain from point prevalence and shift to period prevalence as this study "COUNTS" injury events across 12 months prior to the date of interview. Thank you for the comments. I have accepted the comment and corrected accordingly. Attachments Attachment Submitted filename: Rebuttal letter.docx https://doi.org/10.1371/journal.pone.0287487.r002
11 Apr 2023 Decision Letter - Hariom Kumar Solanki, Editor PONE-D-23-01914R1Epidemiology of unintentional childhood injuries in urban and rural areas of Nepal - A comparative studyPLOS ONE Dear Dr. Pathak, 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 May 26 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, Hariom Kumar Solanki, M.D. Academic Editor PLOS ONE Additional Editor Comments: Dear Author, It seems that the main article file attached as revised manuscript is the same as the original submission file. Please do the following 1. Make revsions to the manuscript as advised by the reviewers (or provide justification/ reason to not incorporting reviewer comments) and highlight the text where revisions have been made so that they could be easily identified by the reviewers / editors as additions / deletions from the original manuscript 2. In response to the reviewer comments, detailed changes made may not be required to be mentioned if you simply identify the place where the relevant change has been made. (For example Introduction section, line ... , so on ) Thanks and regards [Note: HTML markup is below. Please do not edit.] While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step. https://doi.org/10.1371/journal.pone.0287487.r003
Revision 2
13 Apr 2023 Author Response Response to reviewers’ comments Reviewer #1: I enjoyed reading your manuscript and this study could be the stepping stone for framing policies to prevent unintentional childhood injuries in Nepal. having said that, I would like to point out some points that need to be addressed. 1. The abstract needs to be refined. The conclusion in the abstract is a repetition of the results. Thank you for the comments. I have accepted the comment and corrected accordingly. 2. Line 25 - Use recent data from WHO regarding childhood injuries. Thank you for the comments. I have accepted the comment and corrected accordingly. 3. Make use of references that are recent, preferably those published during the previous 10 years. Thank you for the comments. I have accepted the comment and corrected accordingly. 4. Line 62 - approval from the parents for any type of study is termed as "assent" and not "consent" Thank you for the comments. I have accepted the comment and corrected accordingly. 5. Please elaborate how the sample size of 712 was obtained Sample size was calculated as follows: Sample size calculation was done as follows; Sample size (n) =(z^2.p.q)/d^2 Where, z= at 95% confidence level (standard value = 1.96) p= prevalence of unintentional injury in Asian children= 5.5% 13 = 0.055 q= 1-p = 1- 0.055 = 0.0945 d= margin of error of 5% Sample Size (n) = (1.96×1.96×0.055×0.0945)/(0.05×0.05) = 80 Considering 10% non – response rate, Sample size (n) = 80/0.9 = 89 Considering the design effect, Sample size (n) = 89 X 4 = 356 Since, the study was conducted both in rural and urban area, Final sample size = 356×2 = 712 Thus, the final sample size was 712 considering the prevalence of unintentional injury among Asian children as 5.5%. 13 6. How the interview was conducted and was interviewed could be included in the "Methods" section. Thank you for the comments. I have accepted the comment and corrected accordingly. 7. Line 73 - PPS should be Probability Proportional to size Thank you for the comments. I have accepted the comment and corrected accordingly. 8. Please clarify how your total number of participants was 667 when your sample size was calculated to be 712. The overall response rate was 93.7% (rural: 96.0% and urban: 91.3%). Thus, the total number of participants in this study were 667 out of which 342 were from rural area and 325 from urban area. 9. For the tables, it will be proper if you provide the actual numbers besides the percentages. Thank you for the comments. I have accepted the comment and corrected accordingly. 10. Table 1 - Please check the socioeconomic status of the participants. The rural population seems to fare better as compared to their counterpart. Thank you for the comments. I have accepted the comment and corrected accordingly. 11. Have you considered fatal injuries as part of "modes of injury" for unintentional childhood injuries? No, only nonfatal injuries were included. 12. Line 121 - 58.4% is more than half, that is why you cannot use the term "nearly half". Thank you for the comments. I have accepted the comment and corrected accordingly. 13. Line 182-188 - RTIs and Burns can be addressed separately. Your study concurs with the other study you mentioned when it comes to "burn" injuries, but you mentioned that they are contrary. Thank you for the comments. I have accepted the comment and corrected accordingly. 14. Line 184 - You can elaborate more on this. "household chores" as you mentioned here seems to be a fire hazard. Household chores like: cooking, preparing cattle feeds, using fire for heating, etc. 15. Line 218 - the present study being a community based cross-sectional study utilizing convenience sampling, i would suggest that you remove the word "true" from "true snapshot". Thank you for the comments. I have accepted the comment and corrected accordingly. 16. Recommendations and strengths of the study can be mentioned Thank you for the comments. Strengths and recommendations have been added in the manuscript. Reviewer #2: Attached in the reviewer comments text file. Also mentioning here 1. Please mention the definition of unintentional injuries used in the methods section. The unintentional injuries are those where the intent to use the force may not necessarily intend to cause the damage. This issue can be quite complex as the intent to use force may not necessarily mean that there was an intent to cause harm or damage. Unintentional injuries are classified as per their occurrence: poisoning, burns, and scalds, drowning, falls and transport-related. 10 Thank you for the comments. I have accepted the comment and corrected accordingly. 2. Since the study population included children aged 1-16 years, who were the respondents. Was it always mothers.? What proportion of respondents was non-mothers.? About two-third of the respondents were mothers (64.9%) followed by fathers (32.7%) and few of them were grandparents (2.4%). 3. Line 27: Can we update the citation to any recent report from WHO. I am sure there was a recent update from GBD study and also from the WHO centre for injury prevention Thank you for the comments. I have accepted the comment and corrected accordingly. 4. Line 36: Shows the number of children that had sought for an injury. Do we have any information on treatment seeking behaviours for childhood injury from Nepal. A study conducted in Makwanpur district of Nepal found that the use of local contacts especially FCHVs for first aid and referral purposes after an injury event were mostly preferred among the respondents. Also, delay in seeking medical care and thinking that ‘injury will heal with time’ were their common misconceptions. As the community health volunteers are not equipped with adequate medical supplies, people were bound to consult faith healers or apply home remedies such as soap water or dung water for poisoning, use of Aloe Vera for burns and application of tourniquet for snakebites. 4. Line 37 to 53 are more of content for the discussion. Can we have details on injury prevention programmes that are envisaged at WHO, or regional level or at the country level. How evidences like those collected from your study can contribute to such a programme.? Some economic aspects of childhood injury like school days lost, parents wages lost, etc would add a societal dimension to this public health issue. Overall background needs to be improved a lot. Thank you for the comments. I have accepted the comment and corrected accordingly. 5. Line 61: Are you sure you took consent from children aged 1-16 years.? Or was it from their parents.? Assent was taken from their parents or primary care givers 6. Can you provide a flowchart for the sampling technique.? Why was a convenient sampling method opted instead of a systematic random sampling. By doing so the study appears to have been weakened a bit Yes, convenience sampling has weakened the study but due to the lack of sampling frame this option had to be chosen. As the study was conducted after the earthquake of 2015 in Nepal, many of the families had changed their settlement area thus it was difficult to locate them and bring into the sampling frame. 7. The definition used for including unintentional childhood injuries is missing in the main methodology. Kindly mention and cite the reference that was used for this definition Thank you for the comments. I have accepted the comment and corrected accordingly. 8. In the results you say there were 667 children from 658 mothers and 659 fathers. In the methods you said that only one child was chosen from a household. In that case the number of children should match the number of mothers/fathers isn't it.? The details of 658 mothers (335 and 323 in rural and urban area respectively) and 659 fathers (337 and 322 in rural and urban area respectively) were included. Total 9 mothers and 8 fathers were either separated or expired thus they were excluded from the study. 9. Kindly provide the broad numbers instead of just mentioning the proportions. Please mention (n - XXX) in the table heading Thank you for the comments. I have accepted the comment and corrected accordingly. 10. Please provide Confidence interval to the prevalence estimate. Out of the total 667 children, 21.7% [95% CI: 18.6 – 24.9] had sustained unintentional injuries in the past 12 months. In rural area, the prevalence was 26% [95% CI: 21.3 – 30.7] whereas in urban area it was 17.2% [95% CI: 13.1– 21.4]. 11. I am surprised to see 2/3rd of children suffering from falls. Guess the definition used was very broad. Did the child have any disability after all these falls.? Yes, this has been included in the impact of the injuries. Among the children who were injured, 22 hospitalized for treatment, 11 were left with some form of disability and 10 of them were not able to return back to school. 12. It's hard for me to understand the absolute number and disaggregated numbers when only the proportion is used. What does the proportion infer to.? Which denominator was used isn't clear to me in few places especially in the multiple modes of injury table.? Thank you for the comments. I have accepted the comment and corrected accordingly. 13. Can we break Table 3 and show by each injury type (as a column). Rural vs Urban in the column head is not adding value. Suggest creating a haddon's matrix with whatever information was collected to see what all factors were collected in your study. You may distinguish significant ones from the insignificant ones using a * or any symbol. That would add a lot of value for a policy maker Thank you for the comments. Actually, the main motive of the table is to show the scenario of the injury events as a whole rather than breaking down into each injury type as that was not the main objective of the study. Please do correct me if I am unclear regarding this. 14. Also let's refrain from point prevalence and shift to period prevalence as this study "COUNTS" injury events across 12 months prior to the date of interview. Thank you for the comments. I have accepted the comment and corrected accordingly. https://doi.org/10.1371/journal.pone.0287487.r004
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Formally Accepted
13 Jun 2023 Acceptance Letter - Hariom Kumar Solanki, Editor PONE-D-23-01914R2 Epidemiology of unintentional childhood injuries in urban and rural areas of Nepal- A comparative study Dear Dr. Pathak: I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department. If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org. If we can help with anything else, please email us at plosone@plos.org. Thank you for submitting your work to PLOS ONE and supporting open access. Kind regards, PLOS ONE Editorial Office Staff on behalf of Dr. Hariom Kumar Solanki Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0287487.r006

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