Spatial variations and predictors of overweight/obesity among under-five children in Ethiopia: A geographically weighted regression analysis of the 2019 Ethiopian Mini Demographic and Health Survey

Agmasie Damtew Walle; Shimels Derso Kebede; Jibril Bashir Adem; Ermias Bekele Enyew; Habtamu Alganeh Guadie; Teshome Bekana; Habtamu Setegn Ngusie; Sisay Maru Wubante; Sisay Yitayih Kassie; Addisalem Workie Demsash; Wabi Temesgen Atinafu; Tigist Andargie Ferede

doi:10.1371/journal.pone.0312025

Peer Review History

Original SubmissionNovember 17, 2023
26 Apr 2024 Decision Letter - Clement Ameh Yaro, Editor PONE-D-23-34960Spatial variations and associated factors of overweight/obesity among under-five children in Ethiopia: application of geographically weighted regression analysisPLOS ONE Dear Dr. Walle, Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process. Please submit your revised manuscript by Jun 10 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, Clement Ameh Yaro, Ph.D Academic Editor PLOS ONE Journal Requirements: When submitting your revision, we need you to address these additional requirements. 1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. 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 2. We note that your Data Availability Statement is currently as follows: All relevant data are within the manuscript and its Supporting Information files. Please confirm at this time whether or not your submission contains all raw data required to replicate the results of your study. Authors must share the “minimal data set” for their submission. PLOS defines the minimal data set to consist of the data required to replicate all study findings reported in the article, as well as related metadata and methods (https://journals.plos.org/plosone/s/data-availability#loc-minimal-data-set-definition). For example, authors should submit the following data: - The values behind the means, standard deviations and other measures reported; - The values used to build graphs; - The points extracted from images for analysis. Authors do not need to submit their entire data set if only a portion of the data was used in the reported study. If your submission does not contain these data, please either upload them as Supporting Information files or deposit them to a stable, public repository and provide us with the relevant URLs, DOIs, or accession numbers. For a list of recommended repositories, please see https://journals.plos.org/plosone/s/recommended-repositories. If there are ethical or legal restrictions on sharing a de-identified data set, please explain them in detail (e.g., data contain potentially sensitive information, data are owned by a third-party organization, etc.) and who has imposed them (e.g., an ethics committee). Please also provide contact information for a data access committee, ethics committee, or other institutional body to which data requests may be sent. If data are owned by a third party, please indicate how others may request data access. 3. We note that Figures 3-9 in your submission contain map/satellite images which may be copyrighted. All PLOS content is published under the Creative Commons Attribution License (CC BY 4.0), which means that the manuscript, images, and Supporting Information files will be freely available online, and any third party is permitted to access, download, copy, distribute, and use these materials in any way, even commercially, with proper attribution. For these reasons, we cannot publish previously copyrighted maps or satellite images created using proprietary data, such as Google software (Google Maps, Street View, and Earth). For more information, see our copyright guidelines: http://journals.plos.org/plosone/s/licenses-and-copyright. We require you to either (a) present written permission from the copyright holder to publish these figures specifically under the CC BY 4.0 license, or (b) remove the figures from your submission: a. You may seek permission from the original copyright holder of Figures 3-9 to publish the content specifically under the CC BY 4.0 license. We recommend that you contact the original copyright holder with the Content Permission Form (http://journals.plos.org/plosone/s/file?id=7c09/content-permission-form.pdf) and the following text: “I request permission for the open-access journal PLOS ONE to publish XXX under the Creative Commons Attribution License (CCAL) CC BY 4.0 (http://creativecommons.org/licenses/by/4.0/). Please be aware that this license allows unrestricted use and distribution, even commercially, by third parties. Please reply and provide explicit written permission to publish XXX under a CC BY license and complete the attached form.” Please upload the completed Content Permission Form or other proof of granted permissions as an "Other" file with your submission. In the figure caption of the copyrighted figure, please include the following text: “Reprinted from [ref] under a CC BY license, with permission from [name of publisher], original copyright [original copyright year].” b. If you are unable to obtain permission from the original copyright holder to publish these figures under the CC BY 4.0 license or if the copyright holder’s requirements are incompatible with the CC BY 4.0 license, please either i) remove the figure or ii) supply a replacement figure that complies with the CC BY 4.0 license. Please check copyright information on all replacement figures and update the figure caption with source information. If applicable, please specify in the figure caption text when a figure is similar but not identical to the original image and is therefore for illustrative purposes only. The following resources for replacing copyrighted map figures may be helpful: USGS National Map Viewer (public domain): http://viewer.nationalmap.gov/viewer/ The Gateway to Astronaut Photography of Earth (public domain): http://eol.jsc.nasa.gov/sseop/clickmap/ Maps at the CIA (public domain): https://www.cia.gov/library/publications/the-world-factbook/index.html and https://www.cia.gov/library/publications/cia-maps-publications/index.html NASA Earth Observatory (public domain): http://earthobservatory.nasa.gov/ Landsat: http://landsat.visibleearth.nasa.gov/ USGS EROS (Earth Resources Observatory and Science (EROS) Center) (public domain): http://eros.usgs.gov/# Natural Earth (public domain): http://www.naturalearthdata.com/ [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: Partly Reviewer #2: Partly ******** 2. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: Yes Reviewer #2: 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 ****** 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: No ****** 5. Review Comments to the Author Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters) Reviewer #1: Overweight review About the novelty of the title I can see that the title ha has been published through various ways. Hence, the authors should have a justification regarding it (few of them are listed below based on EDHS 2019,) 1. Spatial variation and determinants of underweight among children under 5 y of age in Ethiopia: A multilevel and spatial analysis based on data from the 2019 Ethiopian Demographic and Health Survey 2. Spatial distribution and associated factors of severe malnutrition among under-five children in Ethiopia: further analysis of 2019 mini-EDHS 3. Prevalence of overweight/obesity and associated factors among under-five children in Ethiopia: A multilevel analysis of nationally representative sample Title Suggestions for Improvement: Consider including the specific timeframe of the study. For example, if the data collection period is mentioned, it can provide additional context and make the title more precise. To enhance clarity, consider specifying the exact type of geographically weighted regression analysis utilized in the study. This will provide more detail on the specific approach used and could be of interest to readers familiar with different variations of geographically weighted regression. Revised Example: "Spatial variations and associated factors of overweight/obesity among under-five children in Ethiopia: a geographically weighted regression analysis of 2019 DHS data" Abbreviation/acronyms utilization Starting from your abstract the authors should re-arrange the utilization of abbreviations and acronyms accordingly Introduction The introduction section provides an overview of the global prevalence of childhood obesity/overweight and highlights the increasing burden in low-income countries, specifically focusing on Ethiopia. Here are some comments on the introduction: Outdated references: The introduction section relies on references that are outdated, as indicated by the reference numbers (e.g., reference numbers 1, 2, 3, etc.). It is important to ensure that the references used are current and reflect the latest available data and research on the topic. Some of the reference also incorrectly cited. The authors should find the primary source and let the authors acknowledge them Lack of global to local context: The introduction does not provide a clear transition from the global context of childhood obesity/overweight to the specific local context of Ethiopia. It would be beneficial to link the global prevalence statistics to the situation in Ethiopia and highlight the unique factors contributing to childhood obesity/overweight in the country. Limited attention to childhood obesity in Ethiopia: The introduction suggests that Ethiopia does not consider childhood obesity as an emergent public health concern and mentions limited attention given to this issue. However, they did not put the references for their investigation or justification, and it would be helpful to provide more context or evidence to support this claim and explain the potential reasons for the lack of attention. Need for spatial analysis: The introduction mentions that previous research in Ethiopia did not consider the spatial distribution of overweight/obesity and spatial regression analysis. It correctly highlights the importance of spatial analysis for policymakers to allocate resources effectively. However, it would be beneficial to provide more context on why spatial analysis is specifically relevant in the Ethiopian context and how it can contribute to addressing the issue. Research gap: The introduction identifies a research gap by stating that few studies have explored community-level factors influencing overweight/obesity in Ethiopia. This highlights the need for the current study and its contribution to filling this gap. However, it would be helpful to provide more context on the specific aspects of community-level factors that have been underexplored in previous research. Importance of the study: The introduction briefly mentions that the study aims to determine the spatial variations of overweight/obesity and its associated factors among under-five children in Ethiopia. It also emphasizes the potential implications of the study for policymakers, health planners, researchers, and health professionals. However, it would be beneficial to provide more specific details on how the findings of this study can inform policy and practice in Ethiopia. Methods and materials Study design, period, and area What is EMDHS Please clearly define the study setting, and related concepts or feeding practices and sources in the country. It will help readers Try to put regionals states based on their order, and indicate there also another additional emerging region Source and study population The authors declared that their population was from 0-59 months. The question is Body Mass Index (BMI) is generally not measured for newborns. BMI is a measure of body fat based on height and weight, typically used in older children, adolescents, and adults. For newborns, different measures are used to assess growth and development, such as weight-for-age, length-for-age, and weight-for-length percentiles. These measures help evaluate whether a newborn's growth is within the expected range for their age and sex. BMI calculations require both height and weight measurements, which are not practical or accurate to obtain in newborn infants. Additionally, BMI is not considered an appropriate indicator of body fat for infants due to their rapidly changing body composition and growth patterns. What about those children whose day of birth is missing or unknown How did you manage other missing values. The authors should put the detail regarding their management Data collection tool and procedures In this section the author mentioned about other than the given topic No sample size determination and sampling methods section The authors need to create new session about sample size determination and sampling methods Reference 14, 19…were not the appropriate references for the Data collection tool and procedures and outcome variable. Kindly use the correct one Data management and statistical analysis What does it mean “Using the STATA drop command in conjunction with a logical or conditional expression, we remove missing values from our analysis”. Autocorrelation Why the authors applied “The outcome variable has a Bernoulli distribution”. Have you appreciated that the continuous nature was also used in your model? Why did not use the poison one Results Do not use the new sentence with “of” and the like How many unweighted participants did you included Have the authors found primary clusters only in the SaTscan analysis “Spatial scan analysis” what do you mean by “Spatial scan analysis” did you mean “Spatial SaTScan analysis” Discussion The provided discussion contains valuable information about the geographical variations in overweight/obesity and related factors among Ethiopian children under the age of five. However, there are a few areas that could be improved: Consistency in referencing: The discussion refers to various studies to compare the prevalence of overweight/obesity in Ethiopian children, but the references are not consistently cited using proper citation format. It would be helpful to ensure that the references are cited correctly and consistently throughout the discussion. There are also miss citations. The author should have the primary source for their citation Clarity in reporting findings: While the discussion provides some numerical findings regarding the prevalence of overweight/obesity in different regions, it would be beneficial to present the findings in a more organized and structured manner. Consider using tables or concise bullet-point format to clearly present the prevalence rates and comparisons between regions and previous studies. Explanation of findings: The discussion mentions various factors that may explain the observed variations in overweight/obesity, such as delivery via cesarean section, socioeconomic status, and urban residence. It would be helpful to provide more detailed explanations for each factor, including the underlying mechanisms and potential implications for interventions or preventive measures. Expansion of limitations and implications: The discussion briefly mentions methodological differences, cultural feeding practices, and nutrition assessment methods as possible explanations for the observed discrepancies in overweight/obesity prevalence. It would be beneficial to expand on these limitations and discuss their implications for future research or interventions in more detail. Furthermore, it was not clear how and why authors excluded missing values Consistency in language and terminology: Some sentences in the discussion use different terminology or language styles. It is important to maintain consistency in terminology and language throughout the discussion to ensure clarity and coherence Write clearly the implication of your study findings to the policymakers Reviewer #2: Abstract: 1. Result : please support by statistics the following result “The spatial distribution of overweight/obesity among under-five children in Ethiopia was clustered” 2. Please support by statistics the following finding in the result “In the geographically weighted regression analysis, urban residence, cesarean section, rich households, and male children were statistically significant factors. 3. conclusion: please put yours recommendation based on the result , means against the identified factors 4. what is the contribution of 12 authors in secondary analysis Background 1. please put citation for the following statement “The majority of overweight and obese children live in developing countries, where the pace of increase is more than 30% greater than in industrialized countries. 2. The following statement is not clear please rewrite “Globally, the prevalence of children under five who are obese was 7% in 2012, and by 2025, it was expected to drop to less than 11% (5)” can we say 7% to 11 % is drop???. 3. Please rephrase the following statements “From 5.4 million in 1990 to 10.3 million in 2014, the number of overweight and obese children in Africa has almost doubled (2, 6)” 4. Rephrase the following statement as “6.8% of children between the ages of 0 and 59 months are overweight or obese, according to 26 Demographic and Health Surveys that have been carried out in the SSA since 2010 (7) “.you can rephrase as : according to the Demographic and Health Surveys conducted in SSA, about 6.8% of children between the ages of 0 and 59 months were overweight or obese in 2010. Generally, the introduction is not well written, incoherence, and many of the statement were written without citation, my recommendation for the authors, please remove unnecessary details and put your evidence or citation for some of statements that reported without citation. Methods: 1. When do you score "1," else marked as "0" for the outcome variable “Overweight/obesity “ 2. The following statement is not clear “STATA was used to tabulate the weighted proportions of outcome variables and prospective predictor variables, which were then exported to Excel and imported into ArcGIS 10.6 for additional analysis”, please remove 3. How the authors handle the two levels hierarchy nature of MEDHS data (multi-stage stratified cluster). That the Level one units were individual children in households and level two units were enumeration areas (community level). That Level one children were nested in the households, then the households were nested at the next higher level of enumeration areas ( community level). With is reality, Is Geographic Weighted Regression model is the appropriate model to identify the individual level and community-level factors as you claim in the bottom of your introduction???. I firmly recommend the authors to run multilevel mixed effect logistic regression rather Geographic Weighted Regression model to identify the individual level and community-level factors as you claim to identify factors at respective level. 4. How you weight the variables Results 5. Please, specify the individual level and community-level factors separately in result 6. Discussion :generally the discussion need rewriting and grammar correction 7. Please write the clinical and public health importance of this study ,just at end of discussion ****** 6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files. If you choose “no”, your identity will remain anonymous but your review may still be made public. Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy. Reviewer #1: No Reviewer #2: No ******** [NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.] While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step. Attachments Attachment Submitted filename: Overweight review.docx Attachment Submitted filename: Comment to reviewer.docx https://doi.org/10.1371/journal.pone.0312025.r001
Revision 1
18 Jul 2024 Author Response Date: 08/07/2024 Dear editorial board member (s) of PLOS ONE journal The authors have been recalled to revise the manuscript entitled “Spatial variations and associated factors of overweight/obesity among under-five children in Ethiopia: a geographically weighted regression analysis of 2019 DHS data” identified by unique manuscript number: PONE-D-23-34960, which was submitted for publication. So, we received the editor(s)’ and reviewer's revision comments for the improvement of the manuscript before its publication. Thank you for receiving comments, suggestions, directions, and questions from the editor and reviewer. As we said usually, we are very happy in receiving constructive and valuable comments for making a better manuscript. Accordingly, we have considered all the comments, questions, directions, and suggestions and provided a point-by-point response letter. Finally, we have submitted all the required documents in their revised form. We hope that we have addressed all the suggestions, directions, and raised questions and if you believe that point(s) is not addressed, please let us know. Thank you very much to all editor (s), and reviewers On the behalf of the authors Yours sincerely, Correspondence author PLOS ONE academic editor Point-by-point response letter Reviewer comments 1 About the novelty of the title I can see that the title ha has been published through various ways. Hence, the authors should have a justification regarding it (few of them are listed below based on EDHS 2019,) 1. Spatial variation and determinants of underweight among children under 5 y of age in Ethiopia: A multilevel and spatial analysis based on data from the 2019 Ethiopian Demographic and Health Survey 2. Spatial distribution and associated factors of severe malnutrition among under-five children in Ethiopia: further analysis of 2019 mini-EDHS 3. Prevalence of overweight/obesity and associated factors among under-five children in Ethiopia: A multilevel analysis of nationally representative sample Author reply: Thank you for your essential comment. Even though the titles was done by multilevel analysis, this study focused on Geographically Weighted Regression (GWR) analysis that allows for a nuanced understanding of the spatial variations in factors contributing to overweight among children under five, revealing how relationships between overweight prevalence and predictors like socioeconomic status, dietary patterns, physical activity, and environmental factors differ across geographic locations. This localized insight identifies specific hotspots and cold spots, enabling policymakers to tailor interventions to regional needs, thus optimizing resource allocation and intervention strategies. By providing detailed spatial patterns and enhancing understanding of underlying mechanisms, GWR supports the development of targeted, effective, and contextually appropriate health policies and programs. Title Suggestions for Improvement: Consider including the specific timeframe of the study. For example, if the data collection period is mentioned, it can provide additional context and make the title more precise. To enhance clarity, consider specifying the exact type of geographically weighted regression analysis utilized in the study. This will provide more detail on the specific approach used and could be of interest to readers familiar with different variations of geographically weighted regression. Revised Example: "Spatial variations and associated factors of overweight/obesity among under-five children in Ethiopia: a geographically weighted regression analysis of 2019 DHS data" Author reply: thank you for your fruitful comment and based on your comment we revised the title accordingly. Abbreviation/acronyms utilization Starting from your abstract the authors should re-arrange the utilization of abbreviations and acronyms accordingly Author reply: thank you for your suggestion and based on your comment we revised the the abbreviation and acronym accordingly. Introduction The introduction section provides an overview of the global prevalence of childhood obesity/overweight and highlights the increasing burden in low-income countries, specifically focusing on Ethiopia. Here are some comments on the introduction: Author reply: Thank you for your input. We presented the statement of the problem starting from a global perspective, then focusing on Africa, and finally narrowing down to our specific study context. We aimed to describe the prevalence, risk factors, and burden of overweight in a hierarchical manner. Thank you! Outdated references: The introduction section relies on references that are outdated, as indicated by the reference numbers (e.g., reference numbers 1, 2, 3, etc.). It is important to ensure that the references used are current and reflect the latest available data and research on the topic. Some of the reference also incorrectly cited. The authors should find the primary source and let the authors acknowledge them Author reply: thank you for your suggestion and based on your comment we revised the reference by incorporating only the recent references thank you! Lack of global to local context: The introduction does not provide a clear transition from the global context of childhood obesity/overweight to the specific local context of Ethiopia. It would be beneficial to link the global prevalence statistics to the situation in Ethiopia and highlight the unique factors contributing to childhood obesity/overweight in the country. Author reply: thank you for your suggestion and based on your comment we revised the introduction section to include context from the global to the Ethiopian perspective, highlighting previous studies. Limited attention to childhood obesity in Ethiopia: The introduction suggests that Ethiopia does not consider childhood obesity as an emergent public health concern and mentions limited attention given to this issue. However, they did not put the references for their investigation or justification, and it would be helpful to provide more context or evidence to support this claim and explain the potential reasons for the lack of attention. Author reply: thank you for your suggestion and based on your comment we revised the introduction section to include childhood obesity as an emergent public health concern and mentions limited attention given to this issue with updated reference. Need for spatial analysis: The introduction mentions that previous research in Ethiopia did not consider the spatial distribution of overweight/obesity and spatial regression analysis. It correctly highlights the importance of spatial analysis for policymakers to allocate resources effectively. However, it would be beneficial to provide more context on why spatial analysis is specifically relevant in the Ethiopian context and how it can contribute to addressing the issue. Author reply: thank you for your fruit full comment and based on your comment we revised the introduction section by incorporating the need of spatial analysis for the study. Please have a look. Thank you! Research gap: The introduction identifies a research gap by stating that few studies have explored community-level factors influencing overweight/obesity in Ethiopia. This highlights the need for the current study and its contribution to filling this gap. However, it would be helpful to provide more context on the specific aspects of community-level factors that have been underexplored in previous research. Author reply: We appreciate your comment, which has guided the revision of our introduction. In response to identified gaps in existing literature, our study utilizes secondary data from the Demographic and Health Surveys (DHS), incorporating a comprehensive array of relevant variables. Our study emphasizes the underexplored community-level factors which included in the data were consider that influences on overweight and obesity in Ethiopia. By employing Geographically Weighted Regression (GWR), we analyze spatial variations in these factors across different regions, aiming to provide nuanced insights that inform targeted public health interventions tailored to local contexts. Importance of the study: The introduction briefly mentions that the study aims to determine the spatial variations of overweight/obesity and its associated factors among under-five children in Ethiopia. It also emphasizes the potential implications of the study for policymakers, health planners, researchers, and health professionals. However, it would be beneficial to provide more specific details on how the findings of this study can inform policy and practice in Ethiopia. Author reply: Thank you for your best and fruit full comment based on this we revised as, the study aims to investigate spatial variations of overweight/obesity and associated factors among under-five children in Ethiopia, utilizing Geographically Weighted Regression (GWR) with Demographic and Health Survey (DHS) data. The findings hold significant implications for policymakers, health planners, researchers, and health professionals. Policymakers can use the results to develop targeted policies and interventions to reduce childhood overweight/obesity rates across different regions. Health planners will benefit from insights to strategically allocate resources, focusing on areas with higher prevalence and specific risk factors identified by the study. Researchers can build upon these findings to explore causal relationships and refine intervention strategies, while health professionals can implement evidence-based approaches tailored to local contexts. Ultimately, these actions can collectively contribute to improving public health outcomes for under-five children in Ethiopia by addressing both prevention and management of overweight/obesity. Methods and materials Study design, period, and area What is EMDHS Author reply: thank you for your concern and for more understanding of the abbreviation we were incorporate in the abbreviation section as Ethiopian Mini Demographic Health Survey. Please clearly define the study setting, and related concepts or feeding practices and sources in the country. It will help readers Try to put regionals states based on their order, and indicate there also another additional emerging region Author reply Thank you for your suggestion and based on your comment we were describe the study setting clearly in the method section, thank you Source and study population The authors declared that their population was from 0-59 months. The question is Body Mass Index (BMI) is generally not measured for newborns. BMI is a measure of body fat based on height and weight, typically used in older children, adolescents, and adults. For newborns, different measures are used to assess growth and development, such as weight-for-age, length-for-age, and weight-for-length percentiles. These measures help evaluate whether a newborn's growth is within the expected range for their age and sex. BMI calculations require both height and weight measurements, which are not practical or accurate to obtain in newborn infants. Additionally, BMI is not considered an appropriate indicator of body fat for infants due to their rapidly changing body composition and growth patterns. Author reply: Thank you for your concern and in our study the outcome was measured using the World Health Organization (WHO) standards for child growth monitoring. Specifically, they used the weight-for-height z-score, which is a reliable method for assessing growth and nutritional status in children. According to WHO guidelines, a child is classified as overweight or obese if their weight-for-height z-score exceeds +2.0 standard deviations (SD) from the mean. This approach allows for accurate monitoring of growth and development, ensuring that children who are at risk of overweight or obesity are correctly identified based on globally recognized standards. This method accounts for the rapidly changing body composition and growth patterns in infants and young children, making it a suitable alternative to BMI for this age group. What about those children whose day of birth is missing or unknown. How did you manage other missing values? The authors should put the detail regarding their management Author reply: Thank you for your concern and we were handling missing data, imputation techniques are employed to estimate or replace missing values based on existing data. Methods like mean, mode, or median imputation replace missing values with summary statistics of observed data, assuming similarity among values. More advanced techniques include regression-based imputation, where missing values are predicted using relationships with other variables. Data collection tool and procedures In this section the author mentioned about other than the given topic No sample size determination and sampling methods section The authors need to create new session about sample size determination and sampling methods Reference 14, 19…were not the appropriate references for the Data collection tool and procedures and outcome variable. Kindly use the correct one Author reply: thank you for your suggestion and we revised it accordingly. Thank you! Data management and statistical analysis What does it mean “Using the STATA drop command in conjunction with a logical or conditional expression, we remove missing values from our analysis”. Author reply: thank you very much for your input to improve the manuscript. Accordingly, we revised it clearly. Autocorrelation Why the authors applied “The outcome variable has a Bernoulli distribution”. Have you appreciated that the continuous nature was also used in your model? Why did not use the poison one Author reply: thank you for your best concern. In our study, the decision to model the outcome variable with a Bernoulli distribution instead of a continuous distribution like Poisson was guided by the nature of the data and statistical considerations. The outcome variable in our analysis is binary, representing a dichotomous response (yes and no). A Bernoulli distribution is well-suited for such binary outcomes as it directly models the probability of a single binary event occurring. While the outcome variable is binary, our modeling approach incorporates continuous predictors or covariates to capture relationships with the probability of the binary outcome. This enables us to examine how these predictors influence the likelihood of the outcome, enhancing both the interpretability and predictive accuracy of our model. Comparisons during model selection supported the use of the Bernoulli distribution over alternatives like Poisson, aligning with the characteristics of our data and facilitating clearer interpretation of model results in the context of binary outcomes. Thank you! Results Do not use the new sentence with “of” and the like Author reply: ok thank you! How many unweighted participants did you included Author reply: thank you for your concern and before weighting the participant’s number we have got 3,602. It was below the weighted participants. Have the authors found primary clusters only in the SaTscan analysis “Spatial scan analysis” what do you mean by “Spatial scan analysis” did you mean “Spatial SaTScan analysis” Author reply: yes, we want to write as Spatial SaTScan analysis, so we were revised it clearly, thank you! Discussion The provided discussion contains valuable information about the geographical variations in overweight/obesity and related factors among Ethiopian children under the age of five. However, there are a few areas that could be improved: Consistency in referencing: The discussion refers to various studies to compare the prevalence of overweight/obesity in Ethiopian children, but the references are not consistently cited using proper citation format. It would be helpful to ensure that the references are cited correctly and consistently throughout the discussion. There are also miss citations. The author should have the primary source for their citation Clarity in reporting findings: While the discussion provides some numerical findings regarding the prevalence of overweight/obesity in different regions, it would be beneficia Attachments Attachment Submitted filename: point by point response.docx https://doi.org/10.1371/journal.pone.0312025.r002
9 Sep 2024 Decision Letter - Clement Ameh Yaro, Editor PONE-D-23-34960R1Spatial variations and associated factors of overweight/obesity among under-five children in Ethiopia: a geographically weighted regression analysis of 2019 DHS dataPLOS ONE Dear Dr. Walle, 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 Oct 24 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, Clement Ameh Yaro, Ph.D 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. [Note: HTML markup is below. Please do not edit.] 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 #3: All comments have been addressed Reviewer #4: (No Response) ******** 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 #3: Yes Reviewer #4: Yes ****** 3. Has the statistical analysis been performed appropriately and rigorously? Reviewer #3: No Reviewer #4: (No Response) ****** 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 #3: Yes Reviewer #4: 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 #3: No Reviewer #4: (No Response) ****** 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: Title: Please write DHS's full name in the title; it is recommended that abbreviations be avoided. Introduction: Kindly add the clear SMART objectives of the study at the end of the introduction/ background. Methods: The study omitted several potentially influential factors, such as dietary habits, breastfeeding practices, maternal nutritional status, and physical activity levels. Including these variables would provide a more comprehensive analysis of the determinants of childhood obesity. The paper could benefit from more detailed descriptions of the statistical methods, particularly the GWR analysis. Readers unfamiliar with these techniques might find that the current explanation needs to be revised. Including a brief introduction to how these methods work and why they were chosen would enhance understanding. Results and Analysis: While the study identifies significant factors like urban residence and cesarean delivery, further adjustments for potential confounders (e.g., parental BMI, socio-economic status) could refine these associations Conclusion: The conclusions could benefit from including more actionable steps or strategies for stakeholders. Suggestions for immediate actions based on the findings would make the study more practical and applicable. Highlighting specific areas for future research, such as longitudinal studies to track changes over time or interventions tailored to specific regions, would provide a clear direction for advancing the understanding of childhood obesity. Reviewer #4: Editor Comments: The manuscript presents an interesting study on the effects of inulin on Spatial variations and associated factors of overweight/obesity among under-five children in Ethiopia: a geographically weighted regression analysis of 2019 DHS data. The manuscript is well written and comprehensive, and the methodology used seems robust as the sample is large and covers many locations in Ethiopia. However, there are some points that require revision to enhance the clarity and scientific accuracy of the manuscript. •The introduction section provides a good overview of the global and regional context of childhood obesity. However, I suggest adding more recent data or references to give a more current picture of the situation. I would also recommend moving from the global context to the specific local context of Ethiopia to understand the factors contributing to obesity in Ethiopian children. •In the results section, clarify the reporting of statistical analyses. For example, when discussing clustering patterns (Moran’s I and Z scores), consider providing more context on what these values indicate in practical terms. •The section on “Factors influencing spatial variation in obesity/overweight” could benefit from more clearly separating individual-level and community-level factors, or at least providing a clearer explanation of why these factors are presented together. •In the discussion section: I suggest providing a more explanation of the possible mechanisms underlying the associations of factors such as cesarean delivery, urban residence, and wealth index. These factors may provide a better explanation of childhood overweight/obesity. •Finally, I suggest that rather than summarizing the main findings of the research in a general way in the conclusion, highlight how the study’s insights can be used to develop public health strategies to combat childhood obesity in Ethiopia, and provide more specific recommendations that policymakers can take based on the study’s findings. •Ensure that all abbreviations are defined on first use and check for consistency throughout the manuscript. Following the suggested comments, the manuscript will become more clear and impactful about the spatial patterns of childhood obesity in Ethiopia. Best regards, ****** 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 #3: Yes: A Alyafei Reviewer #4: Yes: Dr. Mai Albaik ******** [NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.] While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step. Attachments Attachment Submitted filename: Editor Comments- PONE-D-23-34960 Article.docx https://doi.org/10.1371/journal.pone.0312025.r003
Revision 2
13 Sep 2024 Author Response Date: 10/09/2024 Dear editorial board member (s) of PLOS ONE journal The authors have been recalled to revise the manuscript entitled “Spatial variations and associated factors of overweight/obesity among under-five children in Ethiopia: a geographically weighted regression analysis of 2019 DHS data” identified by unique manuscript number: PONE-D-23-34960, which was submitted for publication. So, we received the editor(s)’ and reviewer's minor revision comments for the improvement of the manuscript before its publication. Thank you for receiving comments, suggestions, directions, and questions from the editor and reviewer. As we said usually, we are very happy in receiving constructive and valuable comments for making a better manuscript. Accordingly, we have considered all the comments, questions, directions, and suggestions and provided a point-by-point response letter. Finally, we have submitted all the required documents in their revised form. We hope that we have addressed all the suggestions, directions, and raised questions and if you believe that point(s) is not addressed, please let us know. Thank you very much to all editor (s), and reviewers On the behalf of the authors Yours sincerely, Correspondence author PLOS ONE academic editor Point-by-point response letter Editor comments The manuscript presents an interesting study on Spatial variations and associated factors of overweight/obesity among under-five children in Ethiopia: a geographically weighted regression analysis of 2019 DHS data. The manuscript is well written and comprehensive, and the methodology used seems robust as the sample is large and covers many locations in Ethiopia. However, there are some points that require revision to enhance the clarity and scientific accuracy of the manuscript. • The introduction section provides a good overview of the global and regional context of childhood obesity. However, I suggest adding more recent data or references to give a more current picture of the situation. I would also recommend moving from the global context to the specific local context of Ethiopia to understand the factors contributing to obesity in Ethiopian children. Author reply: Thank you for your fruitful comments and suggestion and based on your comment we revised the introduction section by incorporating global to Africa to Ethiopian context clearly please have a look. • In the results section, clarify the reporting of statistical analyses. For example, when discussing clustering patterns (Moran’s I and Z scores), consider providing more context on what these values indicate in practical terms. Author reply: Thank you for your essential suggestion and we describe the indication of the Morans I and Z score in the result section line 346-349 as well as in the method section of spatial analysis heading, line 270-272, please have a look the highlighted colour in the tracked change of the manuscript. • The section on “Factors influencing spatial variation in obesity/overweight” could benefit from more clearly separating individual-level and community-level factors, or at least providing a clearer explanation of why these factors are presented together. Author reply: Thank you for your concern and valuable feedback on the section Thank you for your feedback on the section “Factors Influencing Spatial Variation in Obesity/Overweight.” In this analysis, which utilizes Geographically Weighted Regression (GWR), we focused on identifying spatial variations in how different factors influence obesity/overweight rather than performing a traditional multilevel analysis. GWR allows us to examine how the impact of these factors varies across different geographic areas, providing insights into localized patterns and interactions. This approach is well-suited for capturing the spatial heterogeneity of factors and understanding how their effects differ regionally. To clarify, we were include a detailed explanation in the revised manuscript of how this method specifically addresses variations across different areas in introduction section clearly. Thank you! • In the discussion section: I suggest providing a more explanation of the possible mechanisms underlying the associations of factors such as cesarean delivery, urban residence, and wealth index. These factors may provide a better explanation of childhood overweight/obesity. Author reply: Thank you very much for your critical comment to improve the manuscript before publication and we revised the given comments in discussion section accordingly. Please have a look the discussion section of the manuscript. • Finally, I suggest that rather than summarizing the main findings of the research in a general way in the conclusion, highlight how the study’s insights can be used to develop public health strategies to combat childhood obesity in Ethiopia, and provide more specific recommendations that policymakers can take based on the study’s findings. Author reply: Thank you very much for your suggestion to improve the manuscript before publication and we revised the conclusion section accordingly. Please have a look the conclusion section of the manuscript. • Ensure that all abbreviations are defined on first use and check for consistency throughout the manuscript. Author reply: Thank you for your valuable suggestion regarding the definition and consistency of abbreviations. We have reviewed the manuscript to ensure that all abbreviations are defined upon first use and have checked for consistency throughout. As a result, all of them were consistent and defined clearly. Reviewer 3 comments Reviewer #3: Title: Please write DHS's full name in the title; it is recommended that abbreviations be avoided. Author reply: Thank you for your fruitful comments and suggestion and based on your comment we revised as “Spatial Variations and Predictors of Overweight/Obesity among Under-Five Children in Ethiopia: A Geographically Weighted Regression Analysis of the 2019 Ethiopian Mini Demographic and Health Survey “ Introduction: Kindly add the clear SMART objectives of the study at the end of the introduction/ background. Author reply: Thank you for your fruitful comments and suggestion and based on your comment we revised the introduction section by incorporating SMART object at the end of the introduction section. Please have a look. Methods: The study omitted several potentially influential factors, such as dietary habits, breastfeeding practices, maternal nutritional status, and physical activity levels. Including these variables would provide a more comprehensive analysis of the determinants of childhood obesity. Author reply: Thank you for your valuable comments to improve the manuscript before publication. Based on your feedback, we have revised the conclusion section by suggesting that future researchers include the factors you mentioned to enhance the representativeness of the findings. Kindly review the updated conclusion section. The paper could benefit from more detailed descriptions of the statistical methods, particularly the GWR analysis. Readers unfamiliar with these techniques might find that the current explanation needs to be revised. Including a brief introduction to how these methods work and why they were chosen would enhance understanding. Author reply: Thank you for your valuable feedback. Based on your suggestion, we have revised both the Introduction and Methods sections to provide a more detailed explanation of the Geographically Weighted Regression (GWR) analysis. In the introduction, we now include a brief overview of how GWR works and the rationale for selecting this method. In the methods section, we have expanded the description of the statistical process, explaining the steps taken in the GWR analysis, including how the model accounts for spatial heterogeneity and the reasoning behind the chosen parameters. These additions aim to enhance understanding for readers unfamiliar with GWR techniques. Results and Analysis: While the study identifies significant factors like urban residence and cesarean delivery, further adjustments for potential confounders (e.g., parental BMI, socio-economic status) could refine these associations Author reply: Thank you for your valuable comments to improve the manuscript before publication. Based on your feedback, we have revised the conclusion section by suggesting that future researchers include the factors you mentioned to enhance the representativeness of the findings. Kindly review the updated conclusion section. Conclusion: The conclusions could benefit from including more actionable steps or strategies for stakeholders. Suggestions for immediate actions based on the findings would make the study more practical and applicable. Highlighting specific areas for future research, such as longitudinal studies to track changes over time or interventions tailored to specific regions, would provide a clear direction for advancing the understanding of childhood obesity. Author reply: Thank you very much for your suggestion to improve the manuscript before publication. We have revised the conclusion section to incorporate your feedback and have made the necessary adjustments for clarity. Please review the updated conclusion section of the manuscript. With regards! Agmasie Damtew Walle Corresponding author Attachments Attachment Submitted filename: point by point response.docx https://doi.org/10.1371/journal.pone.0312025.r004
1 Oct 2024 Decision Letter - Clement Ameh Yaro, Editor Spatial Variations and Predictors of Overweight/Obesity among Under-Five Children in Ethiopia: A Geographically Weighted Regression Analysis of the 2019 Ethiopian Mini Demographic and Health Survey PONE-D-23-34960R2 Dear Dr. Walle, 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, Clement Ameh Yaro, Ph.D Academic Editor PLOS ONE Additional Editor Comments (optional): Reviewers' comments: Reviewer's Responses to Questions Comments to the Author 1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation. Reviewer #3: All comments have been addressed Reviewer #4: 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 #3: Yes Reviewer #4: Yes ****** 3. Has the statistical analysis been performed appropriately and rigorously? Reviewer #3: Yes Reviewer #4: I Don't Know ****** 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 #3: Yes Reviewer #4: 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 #3: Yes Reviewer #4: (No Response) ****** 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: The study addresses the Innovative Use of Geospatial Techniques, which provide important insights into the spatial variations of childhood obesity and enable targeted intervention strategies. Furthermore, the study focuses on an emerging public health concern. Robust Analysis: The study’s use of a large, nationally representative dataset and advanced statistical techniques like the GWR model enhances the credibility of the findings and strengthens the implications for policy interventions. Points for improvement in future studies to determine Causal Relationship: longitudinal data might help clarify the temporal relationship between identified predictors and childhood obesity. While the study provides excellent data on spatial variations, the intervention discussion could benefit from more specific policy recommendations. For example, what kind of localized physical education programs or nutritional campaigns would be most effective in the identified hot spot areas? Future studies could consider expanding on parental factors, such as parental BMI, education levels, and health behaviors, to provide a more nuanced understanding of risk factors. Reviewer #4: The authors have carefully reviewed and made all the necessary corrections as requested. They have ensured that each of the suggested revisions has been addressed thoroughly, reflecting the feedback provided for the improvement of the manuscript. ****** 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 #3: Yes: Anees Alyafei Reviewer #4: Yes: Dr. Mai Albaik ******** https://doi.org/10.1371/journal.pone.0312025.r005
Formally Accepted
4 Oct 2024 Acceptance Letter - Clement Ameh Yaro, Editor PONE-D-23-34960R2 PLOS ONE Dear Dr. Walle, I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now being handed over to our production team. At this stage, our production department will prepare your paper for publication. This includes ensuring the following: * All references, tables, and figures are properly cited * All relevant supporting information is included in the manuscript submission, * There are no issues that prevent the paper from being properly typeset If revisions are needed, the production department will contact you directly to resolve them. If no revisions are needed, you will receive an email when the publication date has been set. At this time, we do not offer pre-publication proofs to authors during production of the accepted work. Please keep in mind that we are working through a large volume of accepted articles, so please give us a few weeks to review your paper and let you know the next and final steps. Lastly, if your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. 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. If we can help with anything else, please email us at customercare@plos.org. Thank you for submitting your work to PLOS ONE and supporting open access. Kind regards, PLOS ONE Editorial Office Staff on behalf of Dr. Clement Ameh Yaro Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0312025.r006

Open letter on the publication of peer review reports

PLOS recognizes the benefits of transparency in the peer review process. Therefore, we enable the publication of all of the content of peer review and author responses alongside final, published articles. Reviewers remain anonymous, unless they choose to reveal their names.

We encourage other journals to join us in this initiative. We hope that our action inspires the community, including researchers, research funders, and research institutions, to recognize the benefits of published peer review reports for all parts of the research system.

Learn more at ASAPbio .