PONE-D-24-00891Determinants of depression and/or anxiety among the adult community in Kenya: Multilevel analysis of Kenya Demographic Health Survey of 2022PLOS ONE

Dear Dr.Mamaru Melkam Amsalu,

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Kamalakar Surineni, MD, MPH

Guest Editor

PLOS ONE

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Additional Editor Comments (if provided):

As noted by the reviewers, the paper needs considerable improvements but it still holds value. Please address and resubmit for further consideration.

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

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

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

Reviewer #1: No

Reviewer #2: No

Reviewer #3: Yes

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

Reviewer #1: No

Reviewer #2: I Don't Know

Reviewer #3: I Don't Know

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

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

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

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

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

Reviewer #1: No

Reviewer #2: No

Reviewer #3: 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: As the reviewer, I have conducted a detailed assessment of the manuscript titled "Determinants of depression and/or anxiety among the adult community in Kenya: Multilevel analysis of Kenya Demographic Health Survey of 2022" using the STROBE Statement checklist for observational studies. Here is an in-depth report addressing each of the checklist items and providing specific line references where issues have been identified:

Title and Abstract:

1. (a) The title accurately indicates the study's design as a multilevel analysis of Kenya demographic health survey of 2022.

• But it was also better to put the specific statistical model like multilevel binary logistic regression analysis as a study design.

(b) The abstract did not effectively describe what was indicated the title.

• The study revealed the overall prevalence of depression and/or anxiety among the community in Kenya from Kenya Demographic and Health Survey data of 2022, but the title you indicated and the objective you described in the abstract are completely unrelated. So, how do you relate the title with that of line 29-30?

• Line 32-33 needs to be rewrite.

• Line 33-34 is better suited for only multilevel analysis, as it’s reasoned for both Multilevel and logistic regression is inappropriate. Because the clustering nature of the data is not a reason for both multilevel and binary logistic regression analysis.

• Line 35 “The overall prevalence of 3.84% with a 95% CI of (3.56, 4.14)”, Whose prevalence, is it? It needs to be corrected.

• Line 36 “In multivariant multilevel logistic regression”, what does that mean multivariant? How do you relate with the word “multivariate” and “multivariable”.

• The keywords (line 45) you indicated is not enough.

• Overall, the abstract is not effectively described what was done.

Introduction:

2. The introduction section presents several issues:

• Line 54 and line 60: DSM-5 and WHO need to be abbreviated at first.

• Line 91-98: font size is not similar with others.

• Line 97-98: “This study aims to determine the associated factors of depression and anxiety with their burden among adult communities in Kenya from Kenya Demographic and Health Survey data of 2022”, how do you relate with the indicated objective in the abstract part? Even with that of indicated title? What is the difference between “Determinants” and “associated factors”?

• The introduction lacks the prevalence of depression in Africa particularly in Keny and lacks relevant literature to establish the rationale.

• Overall, the introduction is poorly written.

Objectives:

3. The manuscript does not clearly state specific study objectives, which is a critical omission. Specific objectives should be explicitly defined, including any prespecified hypotheses.

Methods:

4. The manuscript accurately presents the key elements of the study design, appropriately considering it as a secondary data analysis.

5. The description of the setting, locations, and data collection dates is correctly provided.

6. Since this is a secondary data analysis, the absence of eligibility criteria and participant selection details is acceptable so I didn’t see such thing.

7. The dependent and independent variables are not well-defined. How do you measure your dependent variable? Even if, the dependent variable was used from the KDHS definitions as reported in 2022, you should have established its measurement with relevant literature or you can operationalize it as well. Mention its indictor.

8. While all independent variables of the study indicated, sources of data for each variable and their method of data collection are not mentioned. You should have to describe each independent variable.

9. Why Stata version 14? Why not 17?

10. The manuscript explains how quantitative variables were handled in the analyses, including the use of different analytical techniques. However, irrelevant sentences types are described (Lines 126-127), which should be removed.

11. The statistical methods, including multilevel logistic regression to control for potential confounding variables, are well-described. However, it is not indicated how missing data were analyzed.

Results:

12. There are several issues in the results section:

• Line 170:” deviation” how do you relate with that of deviance?

• The reference error "Error! Reference source not found" needs clarification.

• Missing data in baseline variables should be explained, along with the methods used to address the missing data.

• The manuscript should clarify the model fit statistics referenced in the text (Line 376). It is not clear how someone knows whether the given result is COR or AOR.

• While the third model contained community-level variables (Residence: lines 135-136), it is not statistically significant at 5% level of significance as presented in Table 3. So, do you think that multilevel analysis is suitable or appropriate statistical method for the given data set? Is it relevance?

Discussion:

13. The 'Discussion' section can be generally divided into 3 separate paragraphs. 1) Introductory paragraph/rationale of the study, 2) Intermediate paragraphs/compare and contrast with the most recent and relevant literature, 3) Concluding paragraph/indicating future directions. The introductory paragraph contains the main idea of performing the study question.

• While the manuscript mentions the large sample size as a strength indicating there is adequate power to detect the true effect of the independent variable. However, it does not provide a power calculation to support this claim.

• Some limitations are discussed, but the limitation related to the 24-hour recall for bias is not mentioned and there is potential social desirability bias that could impact on the results. Discuss finding should be interpreted with caution.

Recommendation

This comprehensive report outlines the issues identified throughout the manuscript, with specific line references and requires substantial major revisions to address these concerns and enhance the clarity, relevance, and presentation of results. After making the necessary major revisions with re-analysis of the data, a re-evaluation is recommended for considering publication.

Reviewer #2: Overall, the premise and intention of the research by the authors is notable. However, the research question appears to be limited. The paper only calculates the percentage of individuals who received a diagnosis of depression and anxiety by a physician, and this ultimately is too limited to be generalized as prevalence of these conditions in the general population. Taking this alone does not adequately answer the question of general prevalence in Kenya.

The research question also appears to be simply a calculation from a dataset. It would be beneficial to have a more involved research question that takes into account other factors either in addition to prevalence or factors influencing prevalence. Other potential factors that are listed (such as being sexually violated) appear to be seen by chance rather than postulated or hypothesized in the beginning. There does not appear to be a clear hypothesis from the authors in the beginning and this can make the findings appear random and incohesive in nature. The limitations of the study were also not clarified adequately. Lastly, there appears to be a lack of clarity in the English grammar at times.

Although the intention of the authors is commendable, and this is a good topic for research, the overall methodology and research question requires significant revision.

Reviewer #3: The study presents an insightful multilevel analysis of the determinants of depression and anxiety in Kenya using the Kenya Demographic Health Survey 2022 data. The strengths of the study are:

1. Addressing mental health issues in Kenya is significant, considering the limited number of studies in this area.

2. Using data from a nationally representative survey enhances the validity and generalizability of findings.

3. The use of multilevel logistic regression considers the clustering nature of the data, which is methodologically appropriate.

4. The study identifies critical determinants like sexual violence, chronic illness, HIV status, and marital status, which can guide interventions.

I have the following recommendations:

1. There are many grammatical errors and some sentences are disjointed. Would advise a recheck of the manuscript or use assistance of writing services.

2. The study design and data extraction methods are described but lack clarity regarding the tools used for measuring depression and anxiety. Provide details on how depression and anxiety were diagnosed (e.g., DSM criteria, specific screening tools).

3. The reported prevalence of 3.84% seems low compared to global studies, potentially underestimating the problem. Discuss the implications of relying on physician-diagnosed cases rather than standardized screening tools.

4. While statistical methods are robust, the discussion of model fit (AIC, BIC) and ICC is limited. Elaborate on these metrics to justify the selection of the final model.

5. The discussion relies heavily on previous studies without critically analyzing the study's unique findings. Expand the discussion to include potential cultural or systemic explanations for the identified associations.

6. Recommendations for interventions are broad and not Kenya-specific. Propose tailored policy measures considering Kenya's healthcare infrastructure and cultural context.

7. Reorganize the introduction to clearly define the study's objectives and significance.

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Reviewer #1: No

Reviewer #2: No

Reviewer #3: Yes:  Nikhil Tondehal

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Submitted filename: Reviewer comments_plosOne.docx

Prevalence and determinants of depression and/or anxiety among adults using Kenya Demographic and Health Survey of 2022: Multilevel logistic regression analysis

PONE-D-24-00891R1

Dear Dr. Mamaru Melkam Amsalu, 

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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Kind regards,

Kamalakar Surineni, MD, MPH

Guest Editor

PLOS ONE

Additional Editor Comments (optional):

Thank you so much for improving the manuscript based on the reviewer feedback. I'm pleased to share that the manuscript now meets the publication criteria, and I’m happy to announce that it has been accepted!

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: All comments have been addressed

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

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

Reviewer #1: Yes

Reviewer #3: Yes

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

Reviewer #1: Yes

Reviewer #3: Yes

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

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: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: (No Response)

Reviewer #3: (No Response)

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7. PLOS authors have the option to publish the peer review history of their article (what does this mean? ). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy .

Reviewer #1: Yes:  Abdu Hailu Shibeshi

Reviewer #3: Yes:  Nikhil Tondehal

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