PONE-D-23-04889Anxiety levels among school-going adolescents in peri-urban areas of Karachi, PakistanPLOS ONE

Dear Dr. Sharif,

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 06 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'.
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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,

Sheikh Mohd Saleem, MBBS, MD

Academic Editor

PLOS ONE

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Additional Editor Comments:

Dear Authors,

Thank you for submitting your manuscript titled "Anxiety levels among school-going adolescents in peri-urban areas of Karachi, Pakistan" to PLOS. I have carefully reviewed the manuscript and would like to provide feedback on the areas that require improvement.

Firstly, the abstract requires a clear rationale for the study and a brief summary of the key findings and strengths of the study. The introduction section should be rewritten to better emphasize the background of the study and the need for it.

In the objectives section, the authors should rephrase and condense the eight objectives into a single comprehensive objective that encapsulates the main aim of the study. The methods section needs to be revisited and made more specific. The term "self-generated" should be clarified, and the authors should provide information on how the questionnaire was developed and validated, including details about instrument calibration.

The authors should also revise the findings section to present the results in a more coherent and comprehensive manner. The statistical part needs attention. The conclusion and recommendations section needs to be rewritten to clearly summarize the main findings of the study and provide practical recommendations for policymakers and researchers.

Lastly, the authors need to edit the entire manuscript for language and grammar. The language used should be clear and concise, and the grammar should be accurate.

I suggest that the authors carefully review and revise the manuscript in light of these comments and suggestions. Once the revisions have been made, please resubmit the manuscript.

Thank you for your submission, and I look forward to receiving your revised manuscript.

Best regards,

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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: Partly

Reviewer #2: Partly

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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: No

**********

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: The study planned is of great importance, but not presented in an intelligent fashion.

1. Too many objectives mentioned , which can be addressed in two lines.

2. Unnecessary prolonged calculation of sample size. The calculated sample size with 50% expected rate (conservatively) produces a sample size of 385, with given confidence level and margin of error, and this sample size achieved even produces margin of error precisely is 0.042.

3. Analysis is done with logic but presented poorly and incorrectly. The severe anxiety should be the first column and mild/none the second, and each factor tested for association should also be presented in a manner that the risk factor should come in first row and other in second.

4. The significance levels seems to be incorrect. For example as an Adjusted Odds Ratio of 1.07 with interval of 0.661 - 1.731 is always insignificant, and it can never have a p-value <0.05.

The authors need to consult some professional statistician who can guide them on these aspects and need to revise the manuscript with better professional approach.

Reviewer #2: Anxiety levels among school-going adolescents in peri-urban areas of Karachi, Pakistan

Abstract

1. Please include rationale of the study and what this study adds to the exiting evidence.

2. Methods: “self-generated”???

3. Please revisit the methods section and make it more specific

4. Please rewrite the abstract

What this study adds: please rewrite the entire section to highlight the key findings and strengths of the study. Please revisit this text mentioned in the manuscript. “Pakistan is facing a serious challenge in ensuring the enrolment and retention of children and adolescents at schools [1]. There is a dire need to ensure such an education system in the country.”

Introduction: please rewrite and rationale for the study needs to be inbuilt within the background section

Objectives: The authors have mentioned 8 objectives in the manuscript. Please mention a comprehensive objective and rewrite.

Methods: the authors mention “systemic random sample” in sample size section (which is refereed as data size in the manuscript). Please revise to systematic.

Please clarify self-made form.

How was the questionnaire developed and validated?

Please mention about calibration of instruments as well.

Findings need to be rewritten and presented in a comprehensive manner.

Please rewrite conclusion and recommendations section.

The authors need to edit the entire manuscript for language and grammar.

**********

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: No

**********

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

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

Attachments

Attachment

Submitted filename: plos one review.docx

PONE-D-23-04889R1Anxiety levels among school-going adolescents in peri-urban areas of Karachi, PakistanPLOS ONE

Dear Dr. Sharif,

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 Aug 31 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,

Sheikh Mohd Saleem, MBBS, 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 #2: (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 #2: Yes

Reviewer #3: Yes

**********

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

Reviewer #2: 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 #2: 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 #2: 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 #2: Review:

Anxiety levels among school-going adolescents in peri-urban areas of Karachi, Pakistan

Overall comments:

1.Please re-write the conclusion in the abstract section.

2.Please edit the manuscript for language and grammar.

3.Please rewrite the ‘what this study adds’ section in the revised manuscript.

Introduction:

1.Please consider embedding rationale and objectives into the introduction section.

2.The objectives could be rewritten comprehensively.

Methods:

1.‘A systemic random sample’- please revise it to systematic and mention how systematic sampling was undertaken in the text.

2.‘we assumed the majority as 50% through a literature search,’: please check and cite references for the literature review undertaken

3.Under sample size calculation: The text mentions ‘Patient sample size’- who are the patients here?

4.Pilot study was undertaken among 15 students on what basis? At least 10-20% of the sample should have been considered.

Discussion:

1.Authors may consider adding implications of the study

Strengths:

1.‘By doing this kind of study, we can solve different mental issues in adolescents of a highly vulnerable state because Patients with mild cognitive Anxiety might be particularly vulnerable and lead to anxiety disorder’- how ??

Reviewer #3: The manuscript is a eloquent read. The authors have addressed all the previous comments which were asked by previous reviewers. i found grammatical and language mistakes and which needs to be corrected before publication.

**********

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 #2: No

Reviewer #3: No

**********

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

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

Attachments

Attachment

Submitted filename: plos one review.docx

PONE-D-23-04889R2Anxiety levels among school-going adolescents in peri-urban areas of Karachi, PakistanPLOS ONE

Dear Dr. Hina,

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 Sep 03 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,

Sheikh Mohd Saleem, MBBS, 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.

Additional Editor Comments (if provided):

ABSTRACT

Overall, the introduction and findings of the abstract provide a good overview of the study on anxiety among school-going adolescents in peri-urban areas of Karachi, Pakistan. However, there are some areas where improvements could be made:

1.Clarity in Objectives: The objective is stated but could be made clearer by specifically mentioning what the study aims to achieve, such as understanding the prevalence of anxiety, identifying risk factors, or assessing the impact of anxiety on adolescents' well-being.

2.Methodology: Provide more details about the sampling method and how the schools were selected. It would be helpful to mention the total number of schools approached and the criteria used for inclusion in the study.

3.Missing Information: The abstract lacks information on the response rate or participation rate of the students in the study. Including this data would give readers an idea of the representativeness of the sample.

4.Results: The findings mentioned in the abstract should be more specific. For example, provide the total number of participants who had moderate to severe anxiety symptoms, and clearly state the prevalence rates among males and females.

5.Statistical Significance: If possible, mention whether the associations between variables and anxiety levels were statistically significant to add more credibility to the findings.

6.Implications: The abstract could benefit from briefly discussing the potential implications of the study's findings. How could the results help in developing intervention programs or improving mental health services for adolescents in peri-urban areas?

7.Conclusion: The conclusion is clear in summarizing the key findings, but it could be strengthened by providing a brief recommendation for future research or practical implications for addressing adolescent anxiety.

Introduction

8.The introduction provides a clear overview of the importance of studying anxiety among adolescents and the lack of research in peri-urban areas of Karachi, Pakistan.

9.The introduction successfully highlights the global prevalence of anxiety disorders among adolescents, providing relevant statistics.

10.However, it would be helpful to include the specific sources for the cited statistics to enhance the credibility of the information.

11.There seems to be repetition of information regarding the GAD-7 scale and its psychometric qualities. Consider consolidating this information into a concise paragraph.

12.The mention of the recent studies conducted in the USA and Europe using the GAD-7 scale strengthens the case for using this tool for anxiety screening . However, it might be beneficial to provide a brief summary of their key findings.

13.The rationale for the study is well-explained, focusing on the lack of mental health screening for school-going adolescents in peri-urban areas of Karachi, Pakistan, and the specific challenges they face.

14.Consider including more specific information about the challenges faced by adolescents in peri-urban areas of Karachi, such as economic difficulties, lack of mental health resources, and the impact of the COVID-19 outbreak.

15.The objectives of the study are clearly stated, addressing the different factors that may contribute to anxiety levels among school-going adolescents .

16.It would be beneficial to include a brief overview of the methodology, such as the sample size, age group, data collection methods, and statistical analysis techniques to be used.

17.Ensure that the use of references is consistent throughout the introduction.

18.Overall, the introduction provides a solid foundation for the study, highlighting the significance of addressing anxiety among school-going adolescents in peri-urban areas. By addressing the points mentioned above, the introduction can be further improved for a more comprehensive and compelling overview of the research.

Methodology

19.The study site and sample selection process are well-explained, providing relevant information about the three selected slum areas and the rationale behind their selection.

20.The study's ethics approval and consent process are clearly described, ensuring that participants' identities remain confidential.

21.The justification for the sample size calculation is provided, considering a prevalence rate of 50% and a 20% no response rate. However, it would be helpful to include a brief explanation of the assumptions made in choosing these values.

22.The inclusion and exclusion criteria are clearly stated, defining the age range, socio-economic status, and consent requirements for participation.

23.The description of the data collection tools, including the demographic form and the GAD-7 scale, is well-presented, providing clarity on what information is being collected.

24.The validation process of the self-designed structured questionnaire through a pilot survey is a good approach to ensure the validity of the instrument.

25.The data collection process is well-outlined, mentioning the schools' selection, translation of the questionnaire, and the involvement of researchers in administering the survey.

26.The anthropometric measurements section provides details on how blood pressure measurements were taken and validated, which adds to the study's credibility.

27.The statistical analysis plan is comprehensive, covering data review, descriptive statistics, bivariate analysis, and multivariate logistics regression to identify significant predictors of anxiety levels.

28.It would be helpful to include a brief mention of the data analysis software used (SPSS version 24) and any statistical tests that will be employed.

29.Consider adding information about any measures taken to ensure data quality and minimize biases during data collection.

30.Ensure that all figures and tables mentioned in the text are included and appropriately labeled.

31.Overall, the methodology section is well-structured and provides sufficient details for understanding the study's design and data collection process. By addressing the points mentioned above, the methodology section can be further enhanced for a comprehensive and robust study.

Results

32.The introduction of the results section provides a clear summary of the participant recruitment process, with 700 participants approached and 544 participants included for final analysis.

33.Table 1 is mentioned, which shows socio-demographic analysis. However, it would be more informative if the key findings from Table 1 are briefly described in the text, highlighting the relevant demographic characteristics of the participants.

34.The use of odds ratios (OR) and confidence intervals (CI) to demonstrate the association between anxiety levels and various factors is appropriate. However, it is essential to interpret these results carefully, considering the wide confidence intervals and the potential for non-significant associations.

35.The results describe the association between anxiety levels and factors such as gender, food intake, presence of a smoker in the family, and parenting style. However, it would be more informative to present the actual values of OR and CI, not just stating whether they are significant or not.

36.Provide more clarity on the interpretation of the OR values. For example, an OR of 1.010 suggests a very minimal difference, so it is important to specify the practical significance of such results.

37.When mentioning percentages, ensure that the total sample size for each gender is specified for better context and interpretation.

38.It would be helpful to include additional statistical measures, such as p-values, to determine the significance of the observed associations.

39.The description of Table 4, showing anthropometric measurements, is brief and lacking in interpretation. Consider discussing any noteworthy findings or patterns in these measurements among adolescents.

40.Overall, the results section is informative, but additional details and interpretation of the findings would enhance its clarity and significance.

41.Consider organizing the results section with subheadings to make it more structured and reader-friendly, especially when referring to different tables.

Discussion

42.The discussion starts with a relevant and concise introduction that highlights the significance of mental health concerns among children and adolescents globally.

43.The first point discusses the higher prevalence of anxiety in females, which is supported by previous studies. However, it would be beneficial to elaborate on potential reasons for this gender difference in anxiety, such as hormonal factors, societal expectations, or coping mechanisms.

44.The discussion on parenting style and its influence on anxiety is well-presented, citing studies from different countries. To strengthen this point, consider discussing specific parenting practices associated with higher anxiety levels and potential interventions to promote healthier parenting styles.

45.When mentioning previous studies, ensure accurate referencing by providing complete citation details, including authors, year, and journal or publication.

46.The discussion on sedentary lifestyles, gaming, and transportation as factors influencing anxiety is informative. Consider discussing the underlying mechanisms behind these associations, such as increased screen time affecting sleep patterns or reduced physical activity affecting stress management.

47.To strengthen the discussion on adolescents from smoking families, provide further insights into the potential impact of secondhand smoke exposure on anxiety levels in adolescents. Discuss possible interventions to support families in reducing smoking and promoting a healthier environment for adolescents.

48.The impact of food intake on anxiety is well-explained, supported by relevant studies. To enhance this point, discuss the role of specific nutrients and dietary patterns in influencing mood and anxiety in adolescents.

49.The discussion on tuition and academic stress is valuable. Expand on potential reasons why tuition attendance may be associated with higher anxiety levels. Discuss strategies to promote academic support while minimizing stress among students.

50.The comparison of BMI and anxiety levels is relevant. However, provide a more nuanced analysis of the relationship, considering potential confounding factors, such as age, gender, and lifestyle habits. Discuss how BMI changes over time may influence anxiety outcomes.

51.Consider adding a final section summarizing the key findings and implications of the study. Discuss how the results contribute to the existing body of knowledge on adolescent anxiety and suggest potential interventions or areas for further research.

52.Overall, the discussion is well-structured, and the inclusion of supporting studies adds credibility to the presented findings. To enhance the section, provide more in-depth analysis and interpretation of the results, while also highlighting potential avenues for future research and practical implications for mental health interventions.

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Reviewers' comments:

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

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

Anxiety levels among school-going adolescents in peri-urban areas of Karachi, Pakistan

PONE-D-23-04889R3

Dear Dr. Sharif,

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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If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. 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.

Kind regards,

Sheikh Mohd Saleem, MBBS, MD

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Thanks for addressing the comments

Reviewers' comments: