PONE-D-24-27355Social determinants and risk factors associated with non-communicable diseases among urban population in Nepal: A comparative study of poor, middle and rich wealth categories of urban population using STEPS surveyPLOS ONE

Dear Dr. Kakchapati,

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 carefully address all the concerns expressed by reviewers and editor's feedback.Terai is fine to keep though Reviewer suggested Tarai as both are being used. 

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Rajendra Prasad Parajuli, PhD

Academic Editor

PLOS ONE

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Additional Editor Comments:

Editors' Feedback:

Version: 1                                                  Date: Aug 25, 2024

MS: PONE-D-24-27355

Title: Social determinants and risk factors linked to non-communicable diseases among urban populations in Nepal: A comparative analysis across poor, middle, and affluent wealth groups using the STEPS survey .

General Feedback:

In this study, the authors examined the prevalence and contributing factors of non-communicable diseases (NCDs) within various wealth groups in Nepal.

This research introduces new data regarding the prevalence and relationship between NCDs and contextual factors, highlighting a crucial area of exploration. Nevertheless, the authors should address concerns regarding potential chance findings due to the extensive number of associations analyzed. To mitigate this, authors may consider applying a Bonferroni correction.

Despite these issues, the study offers valuable data and insights. I therefore suggest resubmitting the paper with revisions to address these points.

Typographical Errors

Abstract:

• Urban population Hilly region → Urban population from the Hilly region

Introduction:

• Typographical errors:

o Socio-economic factors are associated with behavioral risk factors ..Remove "for" and mortality from NCDs.

• The phrases "Rapid urbanization, connection with vulnerable populations, and elevated NCDs risk" are unclear and challenging for readers. Please clarify what the authors intend to convey, particularly why the detection rate is increasing.

• The statement "Urban residents face material constraints, limiting access to nutritious food, quality healthcare, and the ability to maintain healthy lifestyles" requires further elaboration. How do these constraints manifest?

• The authors should expand their literature review to encompass the latest epidemiological knowledge, particularly in relation to the social determinants of NCDs, both in Nepal and internationally. This will help identify gaps in knowledge and strengthen the rationale for the study, as reviewers have also suggested.

Methodology:

• In the Site selection section, numerous data points lack citations.

• Clarify the term "weighted" in the context of multivariate logistic regression models.

• Include the NHRC Ethical Approval Number.

Results:

• Given the extensive number of associations examined, there is a high likelihood of chance findings. Therefore, applying Bonferroni correction would be advisable.

Discussion:

• The interpretation that "This finding underscores the potential vulnerability of all urban segments to NCDs and emphasizes the need for targeted interventions and policies across diverse urban populations " does not align with the results and previous statements. Please revise.

• The statement "This discrepancy may be attributed to hormonal differences, as well as lifestyle and behavioral factors more prevalent in males, such as higher rates of tobacco and alcohol consumption " should be directly linked to the study data on alcohol and smoking, rather than relying on citations.

• Consider the application of Bonferroni correction, as only a few associations will likely remain significant, which should be the focus of the discussion.

Despite these concerns, the comprehensive analysis provides valuable new insights. I recommend resubmission with revisions to address these points including that of 3 expert reviewers.

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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

Reviewer #3: Partly

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

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: No

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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

Reviewer #3: 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

Reviewer #3: 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: Minor revisions to grammar suggested- occasional use of incorrect articles and verbs (a/and/the - was/were/is/are/had/have), extra spaces, incorrect plural versions of words, inconsistencies in capitalization and number formatting (i.e. 1,000 vs 1000), and comma-separated lists (line 202-203). Ensure that "sex" and "gender" are used consistently rather than interchangeably. Line numbering is lost after page 20.

Figure 1 is labeled as Figure 2. Table 1 could be made easier to understand with some formatting revisions. Ensure consistency in the use of the "STEP" acronym- in line 31, the approach is written as "STEP wise", while later in the paper, it becomes clear that a stepwise approach was used (see lines 115 & 123). Check the R Studio version reported in line 184. The definition of the salt consumption variable is not clear (unclear what "for first time" is referring to).

The discussion section could benefit from expanded explanations of contradictory findings. In some areas of the methods and results section, it is not fully clear whether the authors have controlled for age in the logistic regression models (for example, within the hypertension outcome between students and homemakers). Clarification of the models and adjustments to models for each of the two main outcomes would increase understanding of results.

Ensure correct links in reference list- i.e. reference #1 links to a Google Search, rather than the article.

Overall assessment: Minor Revisions

Reviewer #2: Dear Editor and Valued authors

The manuscript “PONE-D-24-27355” entitled “Social determinants and risk factors associated with non-communicable diseases among urban population in Nepal: A comparative study of poor, middle and rich wealth categories of urban population using STEP survey” in itself is well written and represents a comprehensive study in relation to the risk factors for non-communicable diseases (NCDs). While scanning the manuscript thoroughly, it is understood that authors have clearly mentioned the methodological design with multistage stratified technique. One of the crucial parts of this paper is noticed that it has incorporated almost all socio-demographical parameters which might contribute as risk factors for NCDs. However, some suggestions are provided below which would enable further strength of the manuscript and imply its importance in public health domain. This paper can be considered provided the below mentioned aspects are satisfactorily addressed. In a nutshell, a minor revision is required.

Suggestions/Comments:

1. This manuscript is silent regarding the hypothesis of the study which is deemed pertinent in such kind of public health related analytical study. It would be fine to mention the hypothesis briefly in the last paragraph of the “Introduction” section. Please consider it in the revised MS.

2. As mentioned in Table 1, what does the term “average day” indicate? Please specify.

3. The variable “24 hours salt consumption” seems to be poorly defined (Table 1). Please redefine it.

4. The term “Terai” used in the MS should be mentioned as “Tarai” as it is a typical Nepali naming and should look like an original one.

5. In Methods section or elsewhere, a country map of Nepal indicating the proportion of study participants representing the provincial location and ecological belt would be worth incorporating. If possible, the dominant associated risk factors for NCDs be mentioned with specific notation (i.e., with different color code or same color with decreasing intensity) in the specific ecological and political zone of the country. This would provide readers an overall picture of the entire study.

6. Minor typo errors need to be corrected throughout the MS.

Regards,

Reviewer #3: Comments to the authors:

Thank you for the opportunity to review this paper. This manuscript specifically compared the social determinants, NCD risks and prevalence among different wealth categories and determined the factors associated with different NCDs among urban population in Nepal. Given the limited epidemiological evidence on the risk factors and determinants of NCDs in low- and middle-income countries, including Nepal, this study had tried to address a growing concern of the impact of increasing urbanization and how socioeconomic status affects NCD risk and prevalence within urban settings using the recent data from a 2019 STEPS survey from Nepal. However, I have several comments and suggestions which might be helpful to improve the manuscript.

Abstract:

Methods:

• Study design is not mentioned

• You can specify the age group of the participants.

Results: You may include some important result data from table 1

Conclusion: Recommendations are quite general and are not specific based on the study findings. I would suggest making them more specific that align with the study findings.

Minor points:

• In line 32, you can add acronym for STEPwise approach to NCD risk factor surveillance

• In line 41, spell out AOR when it appeared for the first time in the abstract also.

Introduction:

• Please cite more previous studies from Nepal to explain why this study is important among urban population in Nepal.

• In the last paragraph, the authors mentioned “this study aims to inform effective strategies that mitigate the burden of NCDs and enhance the overall well-being of the urban population in Nepal.” Was this also the study objective and how was this done from this study?

• Line 74: grammar, ‘for’ after behavioral risk factors may be removed.

• Line 94-95: add citation to the sentence ‘The dynamics of urban health in Nepal is associated with a complex and interlinked range of wider determinants’

• Lines 99-100: add citation to the line “Furthermore, increasing rates….complexity to public health challenges”.

• Lines 102-104: add citation to the line “the co-influence of socio-economic factors…..social determinants and health outcomes.

Methods:

Study design and sampling size:

• Please provide reference of the STEPS survey.

• The section title mentions "sampling size", but no specific information on sample size calculation is provided. Sampling size may not be the right word, instead sampling technique might be better.

• Under ‘Study design and sampling size’, information about data collection and survey instrument is also mentioned. You may create a separate section for this, and you can explain more about survey questions.

Study setting:

• It might be better to include ‘study setting’ first, followed by study design and sampling. Study setting can help establish the context of the study design and sampling methods.

• While the description of Nepal's geography is informative in study setting, the description is a bit long compared to other sections. It would be better to make it shorter and link it with the study design and sampling in next paragraph.

• There is an error in the urbanization statistics. Line 144 "66% of the population living in urban areas in 2021 compared to just 23% in 2021" uses the same year twice, which does not make sense. The years should be different for this comparison.

• Please provide a citation for the urbanization and population distribution statistics provided in the study setting, particularly if they are not from the STEPS survey data.

Participant:

• First sentence has already been mentioned in the section ‘study design and sampling size section’ and has been repeated here.

• Authors have mentioned that they included 3,460 individuals from urban areas in the analysis. It is not clear how 3,460 participants for this study were selected from the total population (6,475). The definition of urban area is not clear in the study and should be clearly defined.

• This section also includes information about sampling technique.

Variable definitions:

• How was salt consumption measured in the STEPS survey and how was this defined in this study? Given that salt is necessary nutrient for our body in smaller amount and over consumption could be harmful, did the participants respond as ‘yes’ or ‘no’ for salt consumption in the past 24 hours as shown in table 1?

• Please check the definition of pre-hypertension, hypertension, and pre-diabetes.

Statistical analysis:

• Three categories were created from 5 wealth quintiles creating unevenly distributed categories. What was the reason for authors to merge categories? Did you try to analyze data using five original categories (5 quintiles)?

• In the analysis, authors mentioned that they included variables one at a time in the univariate analysis and then including significant variables only in the multivariate analysis. This approach may have some limitations. It may miss important confounding variables that are not significantly associated with the outcome in bivariate analysis but become significant when controlling for other factors. It can also lead to overfitting of the model. It is suggested to include variables based on theoretical importance and prior research evidence showing significant associations, regardless of their bivariate significance.

Minor points:

• In line 167, “Quantitative variables” may not be a suitable title, as it includes the explanation of conceptual framework of the variable.

• In the first sentence under ‘Quantitative variables’ section, the authors mentioned that the primary outcomes of interest in this study were two (diabetes and hypertension). I believe, authors missed obesity.

• In figure 1, for the full form of SDH, ‘of health’ might be missing.

• In line 184, Rstudio 1314 is mentioned. Is this correct?

Results:

• The distribution of participants were into urban poor, urban middle, and urban rich categories with the following proportions: Urban Rich: 49% (1694/3460), Urban Middle: 17% (590/3460), and Urban Poor: 34% (1176/3460). In urban populations, we typically expect to see a larger middle class and smaller proportions of the wealthiest group. However, this distribution shows a very large "rich" category and a relatively small "middle" category. The large proportion of "Urban Rich" (49%) is unusually high for most urban populations. Given that originally the wealth was categorized in wealth quintile with five categories, what was the logic behind for merging highest and fourth wealth quintile making urban rich and first and second into urban poor categories.

• In table 1, while in the total population, the sum of proportions make 100% vertically, the sum of proportions make 100% horizontally in urban rich, urban middle and urban poor, which makes table confusing.

• Please specify the variables that were considered in bivariate analysis but not included in the final model.

• As I mentioned earlier in statistical analysis, it is suggested to include variables based on theoretical importance and prior research evidence, regardless of their bivariate significance. Conducting sensitivity analyses to test the robustness of the results of multivariate analysis by including variables which were not significant in bivariate analysis might be helpful.

Minor points:

• Table 1 should be named as Table 2 because there is already table 1 in the method section.

• Add necessary footnotes in the tables1, 2, 3 and 4, for eg. Adding the variables adjusted in the adjusted model, specify where different analysis (chi-square or t-test) were conducted using markers such as * or #, full from of IQR, level of significance etc.

• Obesity can be replaced with BMI categories because obesity can have further categories, and replace ‘normal’ with ‘normal weight’.

• Instead of sufficient fruit and vegetable consumption, you may write fruit and vegetable consumption only and same for physical activity

• In table 2, 3 and 4, if it is wealth quintile, there should be five categories, however, there are only three categories.

• Consistency in tables: for eg., in eduction status category secondary, please add (12 years) in all tables and add space between secondary and (12 years). Add the same number of digits after decimal in all cases.

Discussion:

• In the first paragraph, how relevant are references 18 and 19 in context of Nepalese urban population. Are there any references from Nepal?

• In fourth paragraph, the authors mentioned that the lower oxygen levels in mountainous regions may influence glucose metabolism, potentially reducing diabetes risk. This sentence needs reference, and what could be a potential mechanism behind it?

• Limitation is missing. I believe, there must be some limitations in the study.

Minor points:

• Please include line number in discussion and some parts of results.

• It may be better to rearrange the paragraphs based on the table numbers arranged in the results section, for eg., discussing the results of table 1, followed by 2, 3 and 4, respectively, which might be easier for the readers to follow.

• In the second sentence of the first paragraph, the phrase “between the urban population” is not logical. The word “between” could be replaced with “within” the urban population or can be rephased as “among different groups within the urban population”.

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Reviewer #1: No

Reviewer #2: Yes:  Pitambar Dhakal

Reviewer #3: No

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Submitted filename: PONE-D-24-27355_reviewer.pdf

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Submitted filename: PONE-D-24-27355_Reviewer-comments.docx

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Submitted filename: Comments to authors_Manuscript PONE-D-24-27355.docx

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Submitted filename: 2_Editors Report@@PONE-D-24-27355.pdf

PONE-D-24-27355R1Social determinants and risk factors associated with non-communicable diseases among urban population in Nepal: A comparative study of poor, middle and rich wealth categories of urban population using STEPS surveyPLOS ONE

Dear Dr. Kakchapati,

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 revise the MS very carefully as suggested by Reviewer 3 with additional analysis as supplementarymaterials  ==============================

Please submit your revised manuscript by Jan 29 2025 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,

Rajendra Prasad Parajuli, PhD

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:

Follow the Reviewer 3 suggestions & revise carefully as suggested

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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

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 #2: Yes

Reviewer #3: Yes

**********

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

Reviewer #1: Yes

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 #1: Yes

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 #1: Yes

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 #1: (No Response)

Reviewer #2: Dear Authors

With regard to your submission PONE-D-24-27355R1, entitled "Social determinants and risk factors associated with non-communicable diseases among urban population in Nepal: A comparative study of poor, middle and rich wealth categories of urban population using STEPS survey", the response you provided sounds complete and satisfactory.

Regards,

Reviewer #3: (No Response)

**********

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:  Lauren Ward

Reviewer #2: Yes:  Pitambar Dhakal

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

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Submitted filename: Comments_to_authors_Manuscript_PONE-D-24-27355_declet_1.docx

PONE-D-24-27355R2Social determinants and risk factors associated with non-communicable diseases among urban population in Nepal: A comparative study of poor, middle and rich wealth categories of urban population using STEPS surveyPLOS ONE

Dear Dr. Kakchapati,

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.

==============================

Comments to the authors:

The authors have made substantial efforts to address most of the previous comments. For further clarity of the manuscript and to strengthen the methodology, I would like to suggest a few minor revisions. The manuscript can be considered for acceptance once all these minor revisions are made.

1. While the definition of pre-hypertension has been corrected in Table 1 and the authors responded that they use standard guidelines in the response letter, I would suggest adding references to these guidelines in Table 1 of the manuscript as well, as multiple definitions exist. This will ensure clarity for the readers.

2. In the conceptual framework, the link between structural factors and intermediary factors is missing, which is important for understanding the pathways leading to inequities. A minor suggestion is to add an arrow to illustrate these relationships, making the framework clearer for readers. Additionally, was this framework developed based on any existing models or established frameworks? If so, please provide appropriate reference in the manuscript. A brief explanation of the model in the manuscript would make readers easy to understand the framework.

3. The authors have provided the original quintile sample sizes and clarified that the 'Urban Poor' category is disproportionately large in the revised manuscript. However, the justification for merging these groups should be clearly presented in the main text, rather than only in the response to reviewers, to ensure that all readers understand the reasoning behind the decision. Additionally, since the authors mentioned that further analyses were conducted to support the merging, these analyses could be included in the manuscript, preferably as a supplementary table. Without this supporting evidence or explanation in the text, I still feel that it remains unclear for readers whether the merging was justified.

Please submit your revised manuscript by Mar 17 2025 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,

Rajendra Prasad Parajuli, PhD

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:

Please Carefully address the Reviewers 3 Comments

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Reviewers' comments:

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Comments to the Author

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Reviewer #3: (No Response)

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

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Reviewer #3: Yes

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

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 #3: Yes

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

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Reviewer #3: Yes

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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 #3: Comments to the authors:

The authors have made substantial efforts to address most of the previous comments. For further clarity of the manuscript and to strengthen the methodology, I would like to suggest a few minor revisions. The manuscript can be considered for acceptance once all these minor revisions are made.

1. While the definition of pre-hypertension has been corrected in Table 1 and the authors responded that they use standard guidelines in the response letter, I would suggest adding references to these guidelines in Table 1 of the manuscript as well, as multiple definitions exist. This will ensure clarity for the readers.

2. In the conceptual framework, the link between structural factors and intermediary factors is missing, which is important for understanding the pathways leading to inequities. A minor suggestion is to add an arrow to illustrate these relationships, making the framework clearer for readers. Additionally, was this framework developed based on any existing models or established frameworks? If so, please provide appropriate reference in the manuscript. A brief explanation of the model in the manuscript would make readers easy to understand the framework.

3. The authors have provided the original quintile sample sizes and clarified that the 'Urban Poor' category is disproportionately large in the revised manuscript. However, the justification for merging these groups should be clearly presented in the main text, rather than only in the response to reviewers, to ensure that all readers understand the reasoning behind the decision. Additionally, since the authors mentioned that further analyses were conducted to support the merging, these analyses could be included in the manuscript, preferably as a supplementary table. Without this supporting evidence or explanation in the text, I still feel that it remains unclear for readers whether the merging was justified.

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Reviewer #3: No

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Attachments

Attachment

Submitted filename: Comments_to_authors_Manuscript_PONE-D-24-27355_declet_2.docx

Social determinants and risk factors associated with non-communicable diseases among urban population in Nepal: A comparative study of poor, middle and rich wealth categories of urban population using STEPS survey

PONE-D-24-27355R3

Dear Dr. Kakchapati,

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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