Prevalence of childhood stunting and determinants in low and lower-middle income African countries: Evidence from standard demographic and health survey

Tadesse Tarik Tamir; Soliyana Adisu Gezhegn; Dejen Tegegne Dagnew; Abebe Tilahun Mekonenne; Genetu Tadese Aweke; Ayenew Molla Lakew

doi:10.1371/journal.pone.0302212

Peer Review History

Original SubmissionFebruary 1, 2024
17 Mar 2024 Decision Letter - Satyajit Kundu, Editor PONE-D-24-04373Prevalence of Childhood Stunting and Determinants in Low and Lower-Middle Income African Countries: Evidence from Standard Demographic and Health SurveyPLOS ONE Dear Dr. Tamir, 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 01 2024 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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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 Additional Editor Comments: The authors are requested to revise the manuscript carefully based on the reviewer's comments to avoid the further delay. [Note: HTML markup is below. Please do not edit.] 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 Reviewer #3: Yes ******** 2. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: Yes Reviewer #2: Yes Reviewer #3: No ****** 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 Reviewer #3: 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: Yes Reviewer #2: Yes Reviewer #3: 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: This study aimed to assess the prevalence of childhood stunting and its determinants in low-and lower-middle-income African countries. Studying stunting in developing countries is very important and I encourage authors to continue their good work. I have a few suggestions, however, to help improve the manuscript. 1. In the introduction, I will suggest the authors add some policies, strategies and interventions done in Africa to meet the SDG 2.2 by 2030 for stunting and undernutrition. 2. In the variables section, i will suggest the authors clearly state how stunting was operationally defined in the DHS dataset and the responses and not just give how coding was done. 3. The authors should please provide references for what informed the explanatory variables. 4. In the discussion section, I will suggest the authors give reasons with references for the high prevalence of stunting in low-and lower-middle-income African countries and not just compare with the WHO findings. Reviewer #2: The authors have done a comprehensive analysis of available standard demographic datasets to investigate the prevalence of childhood stunting throughout Africa and and its determinants in African countries. I think the findings will be really helpful to adopt continent-wide policy making by governments and international agencies. I hope this article will add value to the public health related literatures on low and middle income African countries. Reviewer #3: I would like to thank the editor for giving me opportunity to review this article. Here are few points I am concerned about. Methodology 1. The wording of second line in section data source, setting and sampling seems need correction. 2. Mentioning how researchers came with those potential predictors in section variables? Referencing again basically. I believe they are 7-11. 3. The description provided for the expression of the generic model presented in section The Regression Model need amendments? Basically, correcting subscripts. 4. In the regression model what assumptions were made? I see three random terms there. What distribution they have? Is r_jk independent of u_ik? 5. Since sample size is large will considering a 0.01 level make sense? So, 99% CI needs to be calculated instead of 95% CI. 6. Did authors do data cleaning? If so, what was their procedure? Results 7. With table 2 researchers selected model IV. Is there a need for mentioning results from other models in table 3? 8. After considering 0.01 level, I believe there will more variables that will be insignificant. In that case will keeping only the significant variables in the model make sense? 9. If authors do not agree with 0.01 level, will keeping only significant variable in the model make sense? 10. “At the individual level, the odds of stunting were 1.76 times higher among children aged 24-59 months (AOR = 1.76 at 95% CI: 1.70, 1.83) compared to children aged less than 24 months.” In my opinion, this is not correct. The correct interpretation would be “At the individual level, the odds of stunting were 1.76 times as high among children aged 24-59 months (AOR = 1.76 at 95% CI: 1.70, 1.83) compared to children aged less than 24 months.” If authors agree, please change rest of the interpretations in this way. ****** 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 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. https://doi.org/10.1371/journal.pone.0302212.r001
Revision 1
20 Mar 2024 Author Response Response to Comments Manuscript ID: PONE-D-24-04373 Title: Prevalence of Childhood Stunting and Determinants in Low and Lower-Middle Income African Countries: Evidence from Standard Demographic and Health Survey Journal: PLOS ONE Subject: Submission of revised manuscript I hope this letter finds you well. We appreciate the diligent efforts of the editorial team in facilitating the review process for our manuscript. Additionally, we extend our gratitude to the reviewers for their valuable time and thoughtful feedback, which significantly contributed to enhancing the quality of our work. The constructive comments provided by the reviewers have been instrumental in refining our study. We are pleased to note that the reviewers share our assessment of the scientific significance of our findings. In response to their suggestions, we have meticulously addressed each point raised. Please find our comprehensive responses to the comments below. Furthermore, we have attached the revised manuscript file separately for your convenience. We believe that the revisions strengthen the manuscript and align it more closely with the journal’s scope and standards. Thank you for considering our work for publication. We look forward to your feedback and hope that our revised submission meets the high standards set by PLOS ONE. Best regards, Tadesse Tarik Tamir, corresponding author (on behalf of all authors) University of Gondar, Gondar, Ethiopia Response to editors and reviewers’ and comments Reviewer #1: This study aimed to assess the prevalence of childhood stunting and its determinants in low-and lower-middle-income African countries. Studying stunting in developing countries is very important and I encourage authors to continue their good work. I have a few suggestions, however, to help improve the manuscript. Response: Dear reviewer, we sincerely appreciate your enthusiasm for our manuscript’s subject and hypotheses. Additionally, we value your detailed perspectives and insightful comments. 1. In the introduction, I will suggest the authors add some policies, strategies and interventions done in Africa to meet the SDG 2.2 by 2030 for stunting and undernutrition. Response: Dear reviewer, thank you for your insightful suggestion. We incorporated policies, strategies, and interventions done in Africa for meeting SDG 2.2 by 2030. Kindly refer to the introduction section in our revised manuscript. 2. In the variables section, i will suggest the authors clearly state how stunting was operationally defined in the DHS dataset and the responses and not just give how coding was done. Response: Dear reviewer, Thank you for your invaluable insights regarding the operational definition of the outcome variable. In response to your suggestion, we have clearly stated how the dependent variable was operationally defined. Kindly refer to the relevant section in our revised manuscript. 3. The authors should please provide references for what informed the explanatory variables. Response: Dear reviewer, I sincerely appreciate your valuable insights regarding variable selection in our study. In response to your suggestion, we have included references that informed our decision-making process regarding explanatory variables. Please find these details in the variable section of our revised manuscript. 4. In the discussion section, I will suggest the authors give reasons with references for the high prevalence of stunting in low-and lower-middle-income African countries and not just compare with the WHO findings. Response: Dear reviewer, I extend my gratitude for your insightful suggestion. In light of this, we have elucidated the reasons behind the high prevalence of stunting in low- and lower-middle-income African countries. Kindly find the point in our revised manuscript. Reviewer #2: The authors have done a comprehensive analysis of available standard demographic datasets to investigate the prevalence of childhood stunting throughout Africa and and its determinants in African countries. I think the findings will be really helpful to adopt continent-wide policy making by governments and international agencies. I hope this article will add value to the public health related literatures on low and middle income African countries. Response: Dear reviewer, we sincerely appreciate your enthusiasm for our manuscript’s subject and hypotheses. Additionally, we value your detailed perspectives and insightful comments. Reviewer #3: I would like to thank the editor for giving me opportunity to review this article. Here are few points I am concerned about. Response: Dear reviewer, we sincerely appreciate your enthusiasm for our manuscript’s subject and hypotheses. Additionally, we value your detailed perspectives and insightful comments. Methodology 1. The wording of second line in section data source, setting and sampling seems need correction. Response: Dear reviewer, I sincerely appreciate your valuable insights. In response to your feedback, we have diligently made the necessary corrections. I kindly invite you to refer to the relevant section in our revised manuscript for further details. 2. Mentioning how researchers came with those potential predictors in section variables? Referencing again basically. I believe they are 7-11. Response: Dear reviewer, I sincerely appreciate your valuable insights regarding variable selection in our study. In response to your suggestion, we have included how we selected potential predictors and provided references that informed our decision-making process regarding explanatory variables. Please find these details in the variable section of our revised manuscript. 3. The description provided for the expression of the generic model presented in section The Regression Model need amendments? Basically, correcting subscripts. Response: Dear reviewer, Thank you for your insightful feedback regarding the model formulation. We have carefully considered your point and made the necessary amendments to the model. Please refer to our revised manuscript for the specific details. 4. In the regression model what assumptions were made? I see three random terms there. What distribution they have? Is r_jk independent of u_ik? Response: Dear reviewer, Thank you for your valuable scientific inquiry. In our nested model with three levels, we operate under the following assumptions: Variations at different levels are intricately linked to the levels above them. At the foundation, Level 1, individual observations or measurements—variations in stunting among children—serve as the fundamental building blocks for our entire model. As we ascend to Level 2 (communities), we encounter community-level variations influenced by correlations between individuals within the same community. These community-level dynamics, in turn, reverberate upward to impact the highest level (Level 3), which represents countries. Importantly, our model explicitly accounts for the hierarchical structure inherent in the data: individuals nest within communities, and communities nest within countries. 5. Since sample size is large will considering a 0.01 level make sense? So, 99% CI needs to be calculated instead of 95% CI. Response: Dear reviewer, Thank you for your thoughtful question. While the sample size in our study is indeed large, it’s essential to consider the practical context. However, when compared to the total population of low and lower-middle income African countries, our sample may not be adequate to confidently report a 99% confidence interval (CI). In the literature, similar studies have consistently reported findings using a 95% CI, which is widely accepted as the standard. Therefore, we recommend adhering to the 95% CI for consistency and comparability. 6. Did authors do data cleaning? If so, what was their procedure? Response: Dear reviewer, Thank you for your insightful feedback on our manuscript. We sincerely appreciate your thorough review and valuable suggestions. We have incorporated a detailed explanation of our data cleaning procedures into the revised methodology section of the manuscript. This update ensures transparency and allows readers to understand the steps taken to prepare the dataset for analysis. We believe that these enhancements significantly strengthen the scientific rigor of our study. Kindly refer to the data cleaning and management section of our revised manuscript. Results 7. With table 2 researchers selected model IV. Is there a need for mentioning results from other models in table 3? Response: Dear reviewer, Thank you for your thoughtful question. Including results from other models in Table 3 is valuable for contextual relevance, transparency, and guidance for readers. By presenting a comprehensive view of different modeling choices, we enhance the robustness of our findings and facilitate meaningful discussions. This approach aligns with standard reporting practices in the scientific literature. (Refer: https://doi.org/10.1371/journal.pone.0295289, https://bmcmedresmethodol.biomedcentral.com/articles/10.1186/s12874-019-0876-8) 8. After considering 0.01 level, I believe there will more variables that will be insignificant. In that case will keeping only the significant variables in the model make sense? Response: Dear reviewer, Thank you for your insightful question. When considering a stricter significance level (0.01), it’s essential to evaluate the practical context. While some variables may become insignificant, we recommend assessing their theoretical relevance. If a non-significant variable has practical importance or contributes to interpretability, it may still be valuable to retain it. The principle of parsimony suggests balancing statistical rigor with meaningful predictors. Additionally, retaining significant variables at the standard 0.05 level is reasonable. 9. If authors do not agree with 0.01 level, will keeping only significant variable in the model make sense? Response: Thank you for your inquiry. While retaining significant variables is standard practice, we must balance statistical rigor with practical relevance. If a non-significant variable contributes to understanding or aligns with existing literature, it may be valuable to retain it. Authors’ agreement on the significance level is crucial, considering that some fields tolerate a 0.05 level due to practical constraints. Transparent reasoning remains essential. 10. “At the individual level, the odds of stunting were 1.76 times higher among children aged 24-59 months (AOR = 1.76 at 95% CI: 1.70, 1.83) compared to children aged less than 24 months.” In my opinion, this is not correct. The correct interpretation would be “At the individual level, the odds of stunting were 1.76 times as high among children aged 24-59 months (AOR = 1.76 at 95% CI: 1.70, 1.83) compared to children aged less than 24 months.” If authors agree, please change rest of the interpretations in this way. Response: Dear reviewer, Thank you for your scientifically sound and valuable corrections regarding the interpretation of our results. We have diligently addressed the points you raised and made the necessary revisions in our manuscript. Kindly refer to the same section in our revised version. We sincerely thank the anonymous reviewers and the editor for their constructive comments and suggestions! Attachments Attachment Submitted filename: Rebutal letter.docx https://doi.org/10.1371/journal.pone.0302212.r002
1 Apr 2024 Decision Letter - Satyajit Kundu, Editor Prevalence of Childhood Stunting and Determinants in Low and Lower-Middle Income African Countries: Evidence from Standard Demographic and Health Survey PONE-D-24-04373R1 Dear Dr. Tadesse Tarik Tamir, 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. An invoice will be generated when your article is formally accepted. Please note, if your institution has a publishing partnership with PLOS and your article meets the relevant criteria, all or part of your publication costs will be covered. Please make sure your user information is up-to-date by logging into Editorial Manager at Editorial Manager® and clicking the ‘Update My Information' link at the top of the page. If you have any questions relating to publication charges, please contact our Author Billing department directly at authorbilling@plos.org. 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, Satyajit Kundu Academic Editor PLOS ONE Reviewers' comments: Reviewer #1: 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 ****** 3. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: 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 ****** 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 ****** 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: Thank you to the authors for addressing all my comments and the changes made to the manuscript. I have no additional comments. ****** 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 ******** https://doi.org/10.1371/journal.pone.0302212.r003

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