PONE-D-22-29049

Predictors of diarrhea among children under 24 months in Nepal: A multilevel analysis of Multiple Indicator Cluster Survey 2019

PLOS ONE

Dear Dr. Thapa,

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. The reviewers have raised a number of points which we believe would improve the manuscript and may allow a revised version to be published in PLOS one.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 Feb 02 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.

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We look forward to receiving your revised manuscript.

Kind regards,

Ammal Mokhtar Metwally, Ph.D (MD)

Academic Editor

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: Dear authors,

I reviewed your paper entitled "Predictors of diarrhea among children under 24 months in Nepal: A multilevel analysis

of Multiple Indicator Cluster Survey 2019". Your analysis have several policy implications in the child health in Nepal. Here I drafted my comments in three section: Summary ( My takeaways, no need to address) , Major comments and Minor comments.

Summary

The authors analyzed Nepal's Multiple Indicator Cluster Survey (MICS) 2019 to analyze the factors associated with incidence of diarrhea among children below 24 months. They found that the prevalence of diarrhea among children aged 0-24 months was 11.9%. The predictors for the incidence of diarrhea were province of residence, age group, incidence of ARI, access to prenatal care, household's wealth status, open defecation, and access to improved sanitation facilities.

Major comments

Introduction:

The rationale for the study is not strong enough. Especially, what is the gap in previous literature about the factors associated with childhood diarrhea among children aged 0-24 months? Or in another words, is this topic previously studied or not? If yes, what is the gap you are trying to fulfill? I recommend you to provide literature review related to your study and provide gaps in the literature, and show the contribution made by your study. You can address this issue in your fourth paragraph of introduction section.

Conceptual framework

• The authors said that they categorized the factors into three categories as presented in Figure 1. Is the conceptual framework based on previous study or any standard framework? If yes, please provide the reference.

• In terms of vaccination status, I recommend to be specific about vaccines that prevent diarrhea. For example, Rota virus vaccine, Rota virus is the most common cause of diarrhea in low- and middle-income countries. I recommend to analyze your data using such vaccines, whether you see any change in p-value? If you observe any difference, you can include it in your model, otherwise, you can describe it in method section stating that we also analyzed our data using the vaccination status of vaccines that prevent diarrhea.

• Is there any reason to include wasting only? Why you did not include stunting and underweight? Please describe about it while describing your study variables.

• Please provide reference while categorizing caste ethnic group into two groups: relatively advantaged and relatively disadvantaged.

Statistical Methods

• You said that those variables that have p-value less than 0.2 were included in multivariate analysis. Could you provide any reference that recommend this concept? or is this arbitrary cut-off?

• I think your final model is model 2, but it is not clear in data analysis section, please make it clear in words.

Discussion

• In line number 238: You provided association of GDP and diarrhea to explain the possible linkage of Province and incidence of diarrhea. Please support your argument with reference that shows the association between GDP and incidence of diarrhea.

Conclusion and Recommendations

• What are the policy implications of your study? You only talked about it in conclusion section, I think you need a separate subsection for policy implications of your findings. What are the 2-3 key points that policymakers can take from your study?

Minor Comments

• In table 4, please use reference instead of "1" as a reference category.

• Title of table 2: Characteristics of children under 24 months in seven provinces of Nepal. It does make sense to use "seven provinces of Nepal". You can simple use sample characteristics or sample characteristics of children under 24 months.

Reviewer #2: manuscript is well written by utilizing the data from the open access data of MICS conducted in Nepal. I suggest authors to more minutely discuss the "participation and sample size " section as it looks inadequate and incomplete. Please specify "what was the basis for identifying numbers of urban and rural strata? you have mentioned "Within each stratum, primary

81 sampling units (PSUs) were selected systematically with probability proportional to size." how did you decide to take 81 PSUs? how did you calculated the sample size? please elaborate.

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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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Reviewer #1: No

Reviewer #2: Yes: Dr Kishor Adhikari

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PONE-D-22-29049R1Predictors of diarrhea among children under 24 months in Nepal: A multilevel analysis of Multiple Indicator Cluster Survey 2019PLOS ONE

Dear Dr. Thapa,

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 Jun 04 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,

Ammal Mokhtar Metwally, Ph.D (MD)

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: 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: Yes

Reviewer #2: Yes

**********

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

Reviewer #1: Yes

Reviewer #2: Yes

**********

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

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

Reviewer #1: Yes

Reviewer #2: Yes

**********

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

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

Reviewer #1: Yes

Reviewer #2: Yes

**********

6. Review Comments to the Author

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

Reviewer #1: Dear Authors,

Thank you for addressing my comments. Here are my additional comments. I hope this paper will be better after addressing these comments.

Comments:

1. The sentence mentioned below is very strong as if there are no studies that explored diarrheal risk in under two children. Please revise your sentence because there are some studies that have explored heterogeneity in diarrheal risk across age groups while studying diarrhea in under five children.

"Although previous studies reported that the diarrheal risk is higher in under two years children, no studies have been conducted in this specific population"

It could be: To the extent of our knowledge, we did not find national-level studies that explicitly explored diarrheal risk in under two years children in Nepal.

2. As suggested in first review, I think you have not provided the reference for determining the p-value of <0.2?

"First, bivariate analysis was conducted where the Rao-Scott chi131 square test was applied to determine the p-value between diarrhea and independent variables, and variables significant at p<0.2 in bivariate analysis were considered candidate variables for the multilevel analysis"

3. Please correct "Province one" as "Koshi Province" in table and other places. as this province is recently named.

4. Is this policy implications based on the findings of your study? "It is important to note that these interventions need to be culturally appropriate, and involve community participation to ensure their sustainability." If not, provide reference and try to link with your study's findings.

5. Conceptual framework title: I think it should be like this: Conceptual framework for diarrheal risk among under two children

Thank you.

Best,

Reviewer

Reviewer #2: All the concerns are addressed and modified as per the suggestion. I am happy with the this version of manuscript.

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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: Dr. Kishor Adhikari

**********

[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.

Predictors of diarrhea among children under 24 months in Nepal: A multilevel analysis of Multiple Indicator Cluster Survey 2019

PONE-D-22-29049R2

Dear Dr. Thapa,

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,

Ammal Mokhtar Metwally, Ph.D (MD)

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

**********

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

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

Reviewer #1: Yes

Reviewer #2: Yes

**********

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

Reviewer #1: Yes

Reviewer #2: Yes

**********

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

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

Reviewer #1: Yes

Reviewer #2: Yes

**********

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

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

Reviewer #1: Yes

Reviewer #2: Yes

**********

6. Review Comments to the Author

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

Reviewer #1: Dear Authors,

Thank you for addressing all of my comments. Hope my comments were helpful to improve the manuscript.

Best,

Reviewer

Reviewer #2: (No Response)

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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: Dr. Kishor Adhikari

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