PONE-D-24-22278Food taboo practices among pregnant women in Deder town, Eastern Ethiopia, 2024PLOS ONE

Dear Dr. Jibro,

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 Feb 21 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,

Sandra Boatemaa Kushitor, 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.  In the online submission form, you indicated that [Data available on request from the corresponding author].

All PLOS journals now require all data underlying the findings described in their manuscript to be freely available to other researchers, either 1. In a public repository, 2. Within the manuscript itself, or 3. Uploaded as supplementary information.

This policy applies to all data except where public deposition would breach compliance with the protocol approved by your research ethics board. If your data cannot be made publicly available for ethical or legal reasons (e.g., public availability would compromise patient privacy), please explain your reasons on resubmission and your exemption request will be escalated for approval.

3. Your ethics statement should only appear in the Methods section of your manuscript. If your ethics statement is written in any section besides the Methods, please delete it from any other section.

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 If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references.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 If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

Additional Editor Comments:

Dear Authors,

Kindly address the comments I have raised and those of the reviewer.

Thank you.

[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: Yes

**********

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

Reviewer #1: Yes

**********

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

**********

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

**********

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: Below, I summarize my evaluation:

1. Technical Soundness: The study is technically sound, with well-conducted statistical analysis. The data provided adequately supports the conclusions drawn.

2. Statistical Analysis: The statistical analyses are rigorous and appropriate for the study design. The authors have clearly described their methods and adhered to best practices in reporting and interpretation.

3. Data Availability: The authors have complied with the PLOS ONE data-sharing policy, making all data underlying the findings available without restriction. The Data Availability Statement is clear and detailed.

4. Manuscript Presentation: The manuscript is well organized, written in clear and standard English, with minor typographical or grammatical errors. Minor improvements to phrasing or formatting could further enhance clarity but are not critical.

Additional Comments

The manuscript provides valuable insights into food taboos and is a meaningful contribution to the field. I have no major concerns regarding the research ethics, data availability, or publication ethics. Minor revisions to address points in my review of this manuscript could strengthen the presentation.

Overall, I recommend this manuscript for publication pending minor revisions.

Below is the full review:

Manuscript Number: PONE-D-24-22278

Manuscript Title: Food taboo practices among pregnant women in Deder town, Eastern Ethiopia, 2024

Abstract

Background

The background effectively sets the context for the study but could be more specific. Consider briefly mentioning why food taboos are significant and how they impact maternal and foetal health.

Grammatical Corrections:

• Line 25-27: Consider rephrasing to "Maternal nutrition during pregnancy is influenced by food taboo practices, which vary across cultural contexts. Understanding these practices in Eastern Ethiopia is crucial for designing culturally appropriate interventions."

Method

You might want to include more details about the sampling method (e.g., random sampling, convenience sampling) to give readers insight into how participants were selected.

The phrase "56% ((95% CI: 51.2–60.8%)" has an extra parenthesis. Correct this for precision

Results

Ensure consistency in presenting confidence intervals (CIs). For example, use either "AOR=2.04" or "AOR: 2.04" throughout for uniformity.

• Consider clarifying what "ANC" stands for when first mentioned (Antenatal Care) to ensure all readers understand the acronym.

Conclusion

While the recommendation for "nutrition education and awareness creation" is valid, the conclusion should emphasize the need for culturally tailored strategies, given the study's context.

• Suggested revision:

"More than half of pregnant women practiced food taboos, indicating a significant public health concern. Culturally sensitive nutrition education and awareness programs at health facilities are necessary to address these practices and improve maternal nutrition outcomes."

Introduction

1. Opening Sentences: The introduction begins with a definition of food taboos, which is effective. However, it could benefit from a more engaging opening that highlights the significance of the topic. Consider starting with a statement about the importance of maternal nutrition or the prevalence of food taboos globally. Also, consider rephrasing the first sentence (Line 48) to: "Food taboos refer to dietary restrictions influenced by religious, cultural, or health beliefs.

2. Contextualization of Studies: When referencing studies from other countries (e.g., Malaysia, South Africa), briefly explain how these findings relate to the Ethiopian context. This will strengthen the rationale for your study by showing how it fits into a broader framework.

3. Cultural Context: The introduction mentions that Eastern Ethiopia's cultural context differs from other regions but does not specify how or why this is significant. Providing specific cultural beliefs or practices related to food taboos in this region could enhance understanding.

4. Research Gap: While you mention that food avoidance during pregnancy is an unresolved health concern, explicitly stating what previous studies have found lacking in Eastern Ethiopia would clarify the research gap your study aims to fill.

5. Minor Technical Suggestions:

Line 58: Add a full-stop after "learning"

Line 83: The statement about food taboos being potentially adaptive seems abrupt and could use more context

Ensure consistent formatting of citations (some have spaces, some don't)

6. Clarity and Flow:

Global Prevalence and Context (Lines 59–66):

The presentation of prevalence rates across countries lacks a logical flow. Transitioning from global to regional (Africa) and then to Ethiopia would improve readability.

Suggested Structure:

Global: "Globally, food taboo practices are prevalent, with rates reported at 70.2% in Malaysia [16], 37% in South Africa [13], and 66% in Nigeria [17]."

Regional (Ethiopia): "In Ethiopia, reported prevalence ranges from 11.5% to 55.3% [7, 9, 10, 18], with a systematic review estimating an average of 34.22% [11]."

7. Precision in Language:

"Widespread food taboo practices around the world" (Line 60): Avoid vague phrases like "widespread" in technical writing.

Suggested Revision: "Food taboo practices have been reported globally, with varying prevalence across regions."

"Sizable portion of pregnant women" (Line 71): Replace with specific or technical terms.

Suggested Revision: "A significant proportion of pregnant women..."

8. Evidence and Citations:

Line 75: "Women have strong beliefs in their culture" is vague and not fully supported. Provide a clearer, evidence-based statement.

Suggested Revision: "Cultural traditions strongly influence dietary practices during pregnancy, as women often inherit food taboos through familial and societal transmission [7, 13]."

Line 86–88: The interventions listed (e.g., nutritional counseling, micronutrient supplementation) are well-referenced but could briefly mention their implementation gaps to tie into the study rationale.

"Despite interventions such as nutritional counseling and micronutrient supplementation [28–33], gaps remain in addressing culturally driven food taboos."

9. Study Rationale and Objective:

The study's rationale is clear but somewhat repetitive. Condense the justification and emphasize the research gap more succinctly.

Suggested Revision:

"While Ethiopia has made strides in improving maternal nutrition, food avoidance during pregnancy remains a significant concern, particularly in Eastern Ethiopia, where cultural contexts differ. Understanding these practices is crucial to designing targeted, culturally sensitive interventions. This study aims to assess the extent and determinants of food taboos among pregnant women in Eastern Ethiopia."

MATERIALS AND METHODS

1. Study Design and Area

Geographical Context: Consider including more information about the socio-economic context or health infrastructure that might influence maternal health practices.

2. Populations and Criteria

• Consider rephrasing to: "The study included all pregnant women attending ANC follow-ups at Deder Hospital and health centers, except those unable to respond during the data collection period."

3. Sample Size Determination and Sampling Procedure

Sample Size Calculation: Briefly explain the significance of a 10% non-response rate which would also clarify its importance.

The description of the sample size calculation is clear but could benefit from a formula citation or equation.

Also, the sampling procedure explanation is slightly wordy.

Suggestion:

"Systematic random sampling was used to select participants using ANC identification numbers, with the first sample chosen randomly between the first and second attendees."

4. Data Collection Procedure and Quality Control

• The phrase "Seven different health professions gathered the data" is unclear. Consider clarifying the roles, eg: "Data were collected by seven trained health professionals, including [specify roles if possible]."

• The phrase "Data collection were started on February 01, 2022 and ends on February 30, 2022" contains grammatical errors.

• Briefly explain the purpose of Cronbach's alpha for readers unfamiliar with it:

"The reliability of the questionnaire was assessed using Cronbach's alpha, yielding a value of 0.83, indicating good internal consistency."

5. Model Evaluation: Mentioning that Hosmer and Lemeshow tests were used for goodness-of-fit evaluation is important. Consider briefly explaining what this entails for readers who may not be familiar with this statistical method.

6. Ethical Considerations

The ethical considerations are adequately addressed. It might be useful to mention how confidentiality was maintained during data collection and whether participants could withdraw from the study at any time without repercussions.

7. Minor Technical Corrections:

Line 142: "Data collection started" instead of "Data collection were started"

"Ends" should be "ended" on the same line

Some citation formatting could be standardized

RESULTS

1. Minor Formatting Issues:

• Typographical error in line 208: Extra percentage sign

• Ensure consistent formatting of statistical presentations

2. I suggest authors alter this sentence: "Of the total study participants, 409(97.8%), 175(41.9%), and 198(47.4%) women who were married attended primary school and had a family size of 1-3 respectively (Table 1)" to “Among participants, 409 (97.8%) were married, 175 (41.9%) had attended primary school, and 198 (47.4%) reported a family size of 1–3 (Table 1)."

3. Authors should re-consider this sentence: "Of the 418 respondents, 226 (54.1%) and 240 (57.4%) never consumed fruits and vegetables respectively during the current pregnancy..." to "Among respondents, 54.1% (n = 226) and 57.4% (n = 240) reported never consuming fruits and vegetables, respectively, during the current pregnancy."

DISCUSSION

1. Introduction to the Discussion: The opening sentences effectively summarize the main findings regarding food taboo practices and their associations with various factors. However, consider starting with a broader statement about the significance of food taboos in maternal health to engage readers more effectively.

2. Minor Writing Improvements:

Line 276-279: Some grammatical refinements needed

Ensure consistent formatting of citations

3. Lines 271–273:

This sentence lacks actionable detail "Policymakers must prioritize education and awareness campaigns to address prevalent food taboos among pregnant women." Consider changing it to: "Policymakers should implement community-based education campaigns, promote male partner involvement, and integrate targeted nutritional counseling into ANC visits to address food taboos."

4. Consider rephrasing this sentence "We found a strong correlation between food aversion and food taboo practices. Studies conducted in southwest India, Sendafa Bake town, Ethiopia, and Sidama Zone, Ethiopia, confirm this conclusion (10, 27, 45)" to "In addition to educational factors, food aversion was strongly associated with food taboo practices. Similar trends have been observed in southwest India and Ethiopian regions like Sendafa Bake and Sidama Zone (10, 27, 45)." In lines 296-298

5. The concluding sentence could benefit from a strong conclusion statement, eg: Overall, addressing food taboos through education, improved ANC follow-up, and community engagement is crucial for enhancing maternal and child health outcomes."

STRENGTHS AND LIMITATIONS

The limitation regarding the use of only quantitative methods is well-stated. To strengthen this point, consider suggesting how qualitative methods (e.g., interviews or focus groups) could complement your findings. For instance: "Future studies could incorporate qualitative methods to explore the underlying reasons for food taboo practices among pregnant women."

CONCLUSION

• Cultural Context: The mention of perceived advantages to food taboos is important. It would strengthen your conclusion to briefly explain how these perceived advantages can be addressed in interventions. For example, "While some women may perceive benefits from food taboos, it is essential to address these beliefs through culturally sensitive educational programs."

• Nutritional Counseling: The recommendation for culturally appropriate interventions and nutritional counseling during ANC visits is a strong point. You might want to specify what these interventions could entail. For example, "Culturally appropriate interventions might include community workshops that educate women about the nutritional value of restricted foods and debunk myths surrounding their consumption."

Other: Editing to resolve typo related issues

**********

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: Yes:  Marian Yenupini Kombat

**********

[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: PONE-D-24-22278_ReviewerComments.pdf

Attachment

Submitted filename: Food Taboo Manuscript.docx

Food taboo practices among pregnant women in Deder town, Eastern Ethiopia, 2024

PONE-D-24-22278R1

Dear Dr. Tofik,

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,

Sandra Boatemaa Kushitor, Ph.D.

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Dear Authors,

Congratulations!!!

Reviewers' comments: