PONE-D-24-20290Spatial distribution and determinants of shared toilet facilities among households in Ethiopia: Using 2019 mini-Ethiopian Demographic and Health SurveyPLOS ONE

Dear Dr. Amlak,

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. Both reviewers have raised substantial concerns which need careful attention before the paper can be accepted.

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Reviewers' comments:

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Comments to the Author

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

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Reviewer #1: Partly

Reviewer #2: Partly

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

Reviewer #1: I Don't Know

Reviewer #2: Yes

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

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

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

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

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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: NB - on quations 1 and 3 above, I don't know the answer, as I am not a statistician. There is much I cannot comment on in the statistical aspects of this work. I can only comment on the discussion of the data analysis, and whether the arguments make sense.

Thank you for the opportunity of reviewing this paper.

Overall:

1. This paper addresses a critical issue of shared sanitation and its role in reaching the goal of safely managed sanitation by 2030. Understanding the extent of shared sanitation use in Ethiopia may support strategies for realising SDG6 and for understanding what the barriers to achieving this might be.

2. I think that there is a useful paper in here, but there needs to be a bit more clarity

about what is arising from the study, what is new in the study, and what is a confirmation of other studies on the issue of shared sanitation. It also needs to be clearer when the other literature is arising from a case study in a particular country, and so may not be generalisable (will clarify below in the line by line review when this comes up). I think that there are times that other studies are used to illustrate something that does NOT arise out of this study (for example on domestic violence) and this is confusing to the reader.

3. The study could benefit from more clarity on the definitions used, particularly given the move from MDGs to SDGs and the greater focus on whether a service is safely managed rather than on the technologies used.

4. One important clarification would be whether this study assumes that people who are not using SS are practicing OD – is that correct? If so, that needs to be spelled out – that SS is the better option. Because at the moment we just read, those who use SS and those who do not, but without the clarity of what the options are of those who do not use SS. This could be my lack of statistical knowledge, but even so, it would be good to clarify in the text. To the same end, it would be useful to have a graphic of the overall breakdown of sanitation used in Ethiopia – from SMS, to SS, to OD.

5. For the results / discussion / conclusion, you could provide recommendations that arise from this study – what does the data tell you that will help planners etc. to increase access to shared sanitation, or more specifically to move people from OD to shared sanitation?

Abstract

Lns 29 -33 This starts as a good argument for including shared toilets in statistics but lines 33-34 does not clarify how understanding the prevalence of shared sanitation (SS) further supports this argument

Lns 35-50 – I am not a statistician so cannot comment

Lns 51-54 It would be useful to have a few headline results – what age or education means for the prevalence of shared sanitation

Introduction

I recommend that the discussion on the move from MDGs to SDGs happens here, and what that means for the indicators etc., as the data is from the SDG era.

e.g. lines 70-78 – are these MDG definitions, or SDG definitions?

Line 79 – check the numbers, something is not right – an increase of 3-6 million is not worth mentioning if the total using SS is 600 million

Line 80-82 – check the numbers 0.96 is not 18% of the population of SSA.

Line86 – is a word missing after ‘easy’

Lines 103-104 – what is the source of this statement (it is not SDG 6.2 as suggested by the reference)

Line 110 – they may be superior to OD – but what are the criteria?

Lines 115-117 – are you drawing a link between using , or not using SS and child mortality? Are you drawing that from your data?

Lines 118-119 – what is the relevance for planners – so that they can target particular households?

Lines 138-143 – I am confused by these numbers – there are 8663 households across 645 EAs? That doesn’t make 20-30 households per EA – please clarify here

I regret that the rest of the methods section doesn’t mean anything to me!

Results

Line 212 – can you define what a male head of household denotes and what a female head of household denotes? Is a head of household only female if there is no adult male in the house? Or how is it defined?

Line 215 I think here you could summarise up front that an increase in age, and decrease in education, wealth etc. leads to a household being more likely to use SS. Then you can go into the detail

Lines 235 – 239 Where is the risk of DV data coming from? And is SS a DV risk or a GBV risk? What is the correlation?

does this suggest a corellation? A causation? Or just two random connected indicators of increased vulnerability?

Line 244 – 247 – write this as clearly as possible also for a non-statistician audience – as I understand it, this is your main finding.

From line 306 onwards I cannot comment! Sorry!

Discussion

Again – I think it needs to be clarified what the non-SS households are using, to be clear that it is worse than SS.

Line 329 - this is not a strong reference, as it is a webpage without links to the claims it references.

Lines 331-332 Did you get this from the data in the study? Or from somewhere else (if so reference) Also add “Studies in Zambia and Ethiopia show…..” I think that the context is critical.

Line 334 – is this an assumption? |Or does education lead to households using SS (which is what your data says, I think)

Line 341 – the reference you use for the tragedy of the commons is rather old-fashioned, and the tragedy of the commons itself may not be relevant to sanitation usage. More work has been done on this more recently, e.g. by Ostrom, or by McGranahan.

Line 344 – 346 – is this speculation or from the data?

Line 346-348 it would be better to say “a study in Kenya shows….” Because otherwise it can be taken as a general truth and it may not be.

Line 347 – is ‘consistent income’ one of the indicators in the data, it’s the first time I see the qualifier ‘consistent’?

Lines 358 – 361 – this seems to be a circular argument – rewrite for clarity?

Line 361 – does ‘governments’ here refer to local governments in Ethiopia or other national governments?

Line 365 – blanket statement not support by the reference as far as I can see

Conclusion

The conclusion could usefully contain some recommendations arising from the study – how can planners / government used this data analysis to make changes to how they promote SS? What are the lessons that can be acted upon?

What still remains to be researched and analysed. What is new from this study, and what confirms previous studies?

Also – be careful what assumptions are embedded in the analysis – for example if women care so much about sanitation, why do households with a male head of household have increased access to SS?

Another still to be resolved quesiton, critical for acceptance of SS as safely managed sanitaiton is what types of shared toilet facility people are using, and whether they are properly maintained? I believe that the main issue with shared sanitation is that it is difficult to judge if they are indeed improved, or safely managed or barely better than OD.

Reviewer #2: Summary and overall impression.

The paper addresses important issue of shared sanitation facilities and puts it in the individual household and community perspective. As it uses well recognised and reliable EDHS survey data, the analysis should yield dependable results that could support policy decision makers and other stakeholders when developing interventions at local and country level. It should also provide reference points for researchers and sanitation experts alike.

From a reader point of view there is a confusion related to the definition of shared sanitation and improved sanitation. I find it difficult to see how shared sanitation is assessed in the context of the type of primary toilet type available to the household. In terms of proportions, methodology and modelling sections are broad and detailed but the outcome of the analysis that is supposed to address research questions is incomplete. Although the discussion section provides many valid points, the paper in my opinion requires major revisions to communicate its points clearly and develop more substantial recommendations that should be developed in closing (conclusions) section. Grammar, spelling mistakes and clarity of writing style must be addressed as well.

Evidence and examples

Major issues

The introduction that is to include an overview of previous research is narrow and lacks currency. It should have a clearer structure and include more recent research-based evidence. Indeed, the most recent reference cited is from 2022 (only one position). I recommend Shared sanitation in informal settlements: A systematic review and meta-analysis of prevalence, preferences, and quality. https://doi.org/10.1016/j.ijheh.2024.114392. to provide broader perspective for this paper in the context of previously published research.

Definition of shared sanitation is unclear – contradicting statements 78 vs 75.

Research question 2 (118, 119) is unclear – contributing factors (contributing to what?).

Results section needs to be re-written to address gaps (e.g. explanation of how cluster with high risk of domestic violence was identified/taken from original data set?) and improve readability by providing more detailed interpretations (see e.g. 257, 258).

Minor issues

More recent population figures are available for Ethiopia now; 2023 as opposed to cited value for 2021 (131).

Table 1 (149) does not present the logic of questions well.

Miscellaneous comments

Formatting of references requires attention – there are issues with numbers and completeness of the records.

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Reviewer #1: No

Reviewer #2: No

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PONE-D-24-20290R1Spatial distribution and determinants of improved shared sanitation facilities among households in Ethiopia: Using 2019 mini-Ethiopian Demographic and Health SurveyPLOS ONE

Dear Dr. Amlak,

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. Apologies for the delay in getting this back to you, one of the reviewers was not available for a while.   Both reviewers have some minor comments that still need to be addressed before we can accept the manuscript.

Please submit your revised manuscript by Jan 27 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,

Alison Parker

Academic Editor

PLOS ONE

Journal Requirements:

Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

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

Reviewer #1: All comments have been addressed

Reviewer #3: (No Response)

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

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #3: Yes

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

Reviewer #1: I Don't Know

Reviewer #3: Yes

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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 #3: Yes

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

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #3: No

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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 #1: (No Response)

Reviewer #3: Most of the comments were addressed correctly. Here are additional comments with regards to revision1:

1) In the response to reviewers' comments you gave 3 research questions: " 1. What was the

magnitude of improved shared sanitation facilities in Ethiopia? 2. What do the spatial

distributions of improved shared sanitation facilities in Ethiopia look like? 3. What are

the associated factors with improved shared sanitation facilities?" In the text you have only 2 questions 119-121.

2) In your Multilevel model results you state:

"A household

236 from a cluster with a high risk of domestic violence had 28.75 times higher odds of having shared

237 toilet facilities than a household from a cluster with a lower risk of shared toilet facilities, according

238 to the MOR value in the null model (28.75), on the other hand, if you randomly selected two

239 households from two different clusters."

You can see you are referring to a cluster with high risk of domestic violence. How this cluster characteristics has been arrived to? Is it one of the characteristics of EA? This needs to be clarified before you report your results.

3) There is a need for further proof reading of the text. See e.g. the paragraph copied above for style and clarity and 241 (valve - should be value?).

4) Referencing - also requires additional check to make sure all statements made are link to this study results or specific source(s) see e.g. 322.

5) Recommendations are basic and could have been developed better taking into account findings and discussion. (E.g. if other countries mentioned have higher standards of sanitation are there any lessons to be learned from their experiences?

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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 #3: No

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Attachments

Attachment

Submitted filename: PONE-D-24-20290_R1.pdf

Spatial distribution and determinants of improved shared sanitation facilities among households in Ethiopia: Using 2019 mini-Ethiopian Demographic and Health Survey

PONE-D-24-20290R2

Dear Dr. Amlak,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

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Alison Parker

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PLOS ONE

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