PONE-D-23-24168Geographical variation in hotspots of stunting among under-five children in Ethiopia using the 2019 Demographic and Health Survey: a geographically weighted regression and multilevel robust Poisson regression analysisPLOS ONE

Dear Dr. Seifu,

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.

The manuscript has been evaluated by two reviewers, and their comments are available below. The reviewers have raised a number of concerns. They feel the manuscript would benefit from expanding the introduction to comprehensively summarize the current state of literature, updating the methods to provide a rational and more detailed description regarding the GWR analysis and the Poisson regression analysis, and expanding the discussion to contextualize the study results. Could you please carefully revise the manuscript to address all comments raised?  I also note that one or more reviewers has recommended that you cite specific previously published works. As always, we recommend that you please review and evaluate the requested works to determine whether they are relevant and should be cited. It is not a requirement to cite these works. We appreciate your attention to this request.

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Reviewers' comments:

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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: 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?

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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: In this study, our aim was to investigate spatial disparities in the prevalence of stunted growth among children under the age of five in Ethiopia. Additionally, we explored how socioeconomic factors vary across space and influence stunted growth in the same context. While the topic under consideration is of significant importance, our study lacks a comprehensive contextualization within the existing body of research, particularly with respect to similar studies conducted using comparable methods in the same country. It is imperative to elucidate the unique contributions our study brings to the field of research. Consequently, substantial enhancements are required in the major sections of the paper to align it with the standards necessary for publication. Please refer to the detailed comments provided below for specific improvements.

Introduction

1. Providing Context and Rationale for the Study: Considering the existing body of research in Ethiopia on stunted growth, which often employs hotspot analysis as a common methodological approach, it is crucial to establish the unique contributions of our study. Furthermore, the absence of citations to these pertinent studies in our paper raises questions about the comprehensiveness of our literature review, including those published within this journal. To rectify this, I recommend revisiting the introduction section to incorporate references to these studies and elucidate the rationale for our study. Please refer to the specific studies mentioned for guidance and justification.

Haile, D., Azage, M., Mola, T. et al. Exploring spatial variations and factors associated with childhood stunting in Ethiopia: spatial and multilevel analysis. BMC Pediatr 16, 49 (2016). https://doi.org/10.1186/s12887-016-0587-9

Kuse, K.A., Debeko, D.D. Spatial distribution and determinants of stunting, wasting and underweight in children under-five in Ethiopia. BMC Public Health 23, 641 (2023). https://doi.org/10.1186/s12889-023-15488-z

Hagos S, Hailemariam D, WoldeHanna T, Lindtjørn B (2017) Spatial heterogeneity and risk factors for stunting among children under age five in Ethiopia: A Bayesian geo-statistical model. PLoS ONE 12(2): e0170785. https://doi.org/10.1371/journal.pone.0170785

Muche A, Melaku MS, Amsalu ET, Adane M (2021) Using geographically weighted regression analysis to cluster under-nutrition and its predictors among under-five children in Ethiopia: Evidence from demographic and health survey. PLoS ONE 16(5): e0248156. https://doi.org/10.1371/journal.pone.0248156

2. Justifying the Importance of Spatial Heterogeneity: In the introduction, it is imperative to provide a compelling argument for the significance of investigating spatial heterogeneity in predictors of stunted growth. To bolster this justification, it is essential to draw upon insights from prior studies that have employed this method to explore stunted growth or malnutrition. Demonstrating how these findings have contributed to the field and explaining how they lend weight to our study's objectives will enhance the rationale for our research. For reference and context, please consider examining the studies mentioned.

Amegbor, P.M., Zhang, Z., Dalgaard, R. et al. Multilevel and spatial analyses of childhood malnutrition in Uganda: examining individual and contextual factors. Sci Rep 10, 20019 (2020). https://doi.org/10.1038/s41598-020-76856-y

Muche A, Melaku MS, Amsalu ET, Adane M (2021) Using geographically weighted regression analysis to cluster under-nutrition and its predictors among under-five children in Ethiopia: Evidence from demographic and health survey. PLoS ONE 16(5): e0248156. https://doi.org/10.1371/journal.pone.0248156

Biswas, M. Identifying Geographical Heterogeneity in Associations between Under-Five Child Nutritional Status and Its Correlates Across Indian Districts. Spat Demogr 10, 143–187 (2022). https://doi.org/10.1007/s40980-022-00104-2

3. Page 4 line 79 to 81: please provide a reference

Data and Methods

4. Measures for Spatial Analysis: It is essential for the authors to clearly define how stunted growth was measured at the Enumeration Area (EA) level in both the Ordinary Least Squares (OLS) and Geographically Weighted Regression (GWR) models. Specify whether stunted growth was expressed as a rate per EAs, an absolute count, or using another metric to eliminate ambiguity.

5. Modified Poisson Regression: The description of the use of modified Poisson regression in the manuscript should be revised for clarity. The current explanation is not easily comprehensible. I recommend consulting the provided reference for guidance on how to present the use of modified Poisson regression effectively.

Amegbor, P. M. (2022). Early-life environmental exposures and anaemia among children under age five in Sub-Saharan Africa: An insight from the Demographic & Health Surveys. Science of the Total Environment, 832, 154957.

6. Data Management and Analysis: The section related to data management and analysis should be revised to provide more detailed information, especially concerning the process of merging survey data with GPS data. It would be valuable to explain how this integration was conducted. You may refer to the mentioned references for insight on how to structure this section effectively.

7. Use of GWR: The authors should address the choice of Geographically Weighted Regression (GWR) over alternatives such as Multiscale Geographically Weighted Regression (MGWR) in light of the known limitations of GWR. Additionally, clarify whether fixed or adaptive bandwidth was employed and provide a rationale for this choice. Specify which search option was used for selecting the optimal bandwidth. To justify the choice, consider referring to the provided references for further insights.

Fotheringham, A. S., Yang, W. & Kang, W. Multiscale geographically weighted regression (MGWR). Ann. Am. Assoc. Geogr. 107, 1247–1265 (2017).

Amegbor, P.M., Zhang, Z., Dalgaard, R. et al. Multilevel and spatial analyses of childhood malnutrition in Uganda: examining individual and contextual factors. Sci Rep 10, 20019 (2020). https://doi.org/10.1038/s41598-020-76856-y

Also, provide the information on whether fixed or adaptive bandwidth was used and why? And which search option was used for selecting the optimal bandwidth.

Results

8. Page 13, Lines 205-207: It is recommended to rewrite the sentence for clarity. Specify which models are being compared, as the current wording is confusing. While the Mixed Effect Poisson model is mentioned, it's unclear which other model or models are being referred to.

9. Table 3: Regarding Table 3, the choice of categorizing mother age below 20 should be explained, especially considering there was a significant association for mother age above 40 in the Mixed Effect Poisson model. Additionally, clarify that the table represents the proportion of mothers in poor households, as suggested.

Discussion

10. Grounding the Discussion: In the discussion section, it's important to contextualize the study's findings within the broader Sub-Saharan Africa (SSA) region, rather than referring to China. Given the prevalence of studies on stunted growth in SSA, consider comparing your findings with regional prevalence and explaining potential factors accounting for similarities, differences, or disparities. You may refer to the provided references for guidance on contextualizing your findings in the SSA context.

Amegbor, P.M., Sabel, C.E., Mortensen, L.H. et al. Early-life air pollution and green space exposures as determinants of stunting among children under age five in Sub-Saharan Africa. J Expo Sci Environ Epidemiol (2023). https://doi.org/10.1038/s41370-023-00572-8

Quamme, S. H., & Iversen, P. O. (2022). Prevalence of child stunting in Sub-Saharan Africa and its risk factors. Clinical Nutrition Open Science, 42, 49-61.

Tusting, L. S., Bradley, J., Bhatt, S., Gibson, H. S., Weiss, D. J., Shenton, F. C., & Lindsay, S. W. (2020). Environmental temperature and growth faltering in African children: a cross-sectional study. The Lancet Planetary Health, 4(3), e116-e123.

11. Regional Disparities: Provide explanations for the high prevalence of stunted growth in specific regions, such as Tigray, central, northeast, and southern Amhara, north, west, and south Afar, and east SNNPR. Analyze local or regional factors that could account for these disparities to make the discussion more contextualized and specific.

12. Interpreting GWR Results: Avoid using the term "hotspots" when discussing GWR results, as the method does not conceptually measure hotspots. Instead, focus on explaining the spatial variation in associations between predictors and stunted growth in a more methodologically accurate manner.

13. GWR Results: Analyze the GWR results in-depth, particularly the positive associations of all predictors with stunted growth, except for poverty and male household heads. If maternal education and other factors had a global effect, consider exploring alternatives like Spatially Varying Coefficient Models (e.g., SGWR or Semi-Parametric GWR) in the absence of MGWR.

14. Contextualize GWR Discussion: Given that poverty and male household heads show both positive and negative associations in different areas, delve into why such spatial variations in association exist. Explore the reasons behind the positive association in some places and negative association in others, emphasizing the spatial variation in association, which is a central motivation for the study.

Reviewer #2: Dear Author,

Please consider the following observations and revise accordingly:

1. The author should correct this manuscript: In Ethiopia Stunting has steadily decreased, from 58% 71 in 2000 (2) to 36.81% in 2019 (3).

2. In the Introduction section: there is no explanation of the geographical conditions of stunting hotspots in Ethiopia.

3. What are the limitations of using DHS secondary data? And how to overcome these limitations?

4. How to calculate the sample size of 5490 children under five? What are the author's considerations in calculating the sample size?

5. The author corrected the punctuation in this manuscript: Dependent variable: In this study, the dependent variable was stunting, which was classified as "Yes = 1" for a child with a length or height/age -2 Z score and "No = 0" for a child with a height/age > -2 Z score.

6. Ethical considerations: How did the authors obtain ethical considerations for the use of secondary data? For example, for permissions and approval of data use.

7. On discussion: On discussion: what recommendations are given by the author in stunting prevention based on the findings of this study?

8. How does it compare with the results of previous studies?

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Reviewer #1: Yes: Prince M. Amegbor

Reviewer #2: No

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PONE-D-23-24168R1Geographical variation in hotspots of stunting among under-five children in Ethiopia using the 2019 Demographic and Health Survey: a geographically weighted regression and multilevel robust Poisson regression analysisPLOS ONE

Dear Dr. Seifu,

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 Apr 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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• 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,

Johanna Pruller, Ph.D.

Associate Editor

PLOS ONE

Additional Editor Comments:

The manuscript has been evaluated by two reviewers, and one reviewer has major concerns.

Could you please carefully revise the manuscript to address all comments raised. In particular, could you please pay special attention to the second comment raised by the reviewer, and expand on how you conducted the MGWR test?

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: (No Response)

Reviewer #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: No

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

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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: While some of the initial concerns have been addressed, others remain unattended. Please find my detailed comments below.

Methods:

1. Sample Size: In accordance with Reviewer 2’s comments, the authors should provide information on how they arrived at the final sample size of 5,490 (Page 6, lines 126 to 127).

2. Comment 7 – Use of GWR: In response to my initial comment on the limitations of GWR and the advice for the authors to consider MGWR, the authors claim they used AUCc and R2 to determine the best-fitting model. To the best of my knowledge, the analytic platform used for spatial analysis, ARCGIS 10.7, doesn’t support MGWR testing or lacks MGWR functionality. Thus, how did the authors conduct the MGWR test? Additionally, the authors should provide the test diagnostics information for both the GWR and MGWR models in their response. Note that the developer of GWR strongly recommends the use of MGWR due to the known limitations of GWR; hence, I encourage the authors to read the Fotheringham et al. paper referenced in comment 7 in my previous assessment.

Discussion:

3. Page 21, lines 323 to 324: Please clarify this sentence: “The prevalence of stunting 324 is consistent with a 33 (8) and 55 (30) SSA countries and East African study (31).” It is incomprehensible in its current form.

4. Comment 12 – Use of Hotspot for GWR Result Interpretation: Despite my previous caution against using the term "hotspot" for GWR results, it still appears in the revised manuscript (e.g., Page 23, lines 366). Please refrain from using "hotspot" in reference to GWR results. Refer to the suggested reference for the correct interpretation of the GWR results.

5. Discussion of Poverty and Stunted Growth GWR Results: The authors need to clarify whether the intervention programs cited as offsetting the effect of poverty in some areas are specifically for those communities and provide a reference to that effect. If they are nationwide programs, then the authors should explain why they affect some communities positively and have no effect in other communities.

Reviewer #2: Dear author, thank you for revising the manuscript based on the reviewer's comments. The revisions you made in response to the feedback provided further strengthened the quality of the 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: Yes: Prince M. Amegbor

Reviewer #2: No

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

PONE-D-23-24168R2Geographical variation in hotspots of stunting among under-five children in Ethiopia using the 2019 Demographic and Health Survey: a geographically weighted regression and multilevel robust Poisson regression analysisPLOS ONE

Dear Dr. Seifu,

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 08 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.

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,

Dereje Oljira Donacho, PhD in Environmental Health

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 #3: (No Response)

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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 #3: Yes

**********

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

Reviewer #1: Yes

Reviewer #3: Yes

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

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Reviewer #1: Yes

Reviewer #3: Yes

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Reviewer #1: Yes

Reviewer #3: No

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6. Review Comments to the Author

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Reviewer #1: (No Response)

Reviewer #3: Comments to Authors

Thank you for addressing such interesting public health concern.

Abstract

Line 46…. rich household wealth index. I suggest to replace this phrase with “household wealth status”.

Method and materials

Line 141… community maternal illiteracy level… please use maternal literacy level instead of maternal illiteracy level.

Line 179: Did the authors check the assumption of spatial regression analysis?

Results

Table 1. The way by which authors compute household wealth index is not explained in methodology part. I suggest the authors explain how many variables were used to compute household wealth index? Did you check the assumption of PCA?...... need to be explained in the methodology section.

Table: 1 Source of drinking water

Improved, not improved… What is improved and not source of drinking water? I suggest these terms need to be operationalized.

Table :3

Proportion of mothers with poverty…. please replace this phrase with “proportion of mother with poor household wealth status”

Discussion

The discussion is shallow, and need to be discussed by adding more previous studies across the world.

Line 338…Tigray has been affected by armed conflict, leading to displacement, disrupted healthcare services, and food insecurity... As to me this cannot be a justification because the war in Tigray region was erupted in November 2020. The authors used 2019 EMDHS data which is before the war. Thus, the consequence of Tigray armed conflict cannot justify the discrepancy.

-Significantly associated variables in the geographically weighted regression were not well discussed. I suggest the authors compare this finding by adding more previous studies across the countries.

Conclusion

-Please clearly add the implication of the finding.

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Reviewer #1: Yes: Prince Amegbor

Reviewer #3: No

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Attachments

Attachment

Submitted filename: Comments to Authors.docx

Geographical variation in hotspots of stunting among under-five children in Ethiopia: a geographically weighted regression and multilevel robust Poisson regression analysis

PONE-D-23-24168R3

Dear Dr. Seifu,

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.

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Kind regards,

Dereje Oljira Donacho, PhD in Environmental Health

Academic Editor

PLOS ONE

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