Dear Dr. Kuwawenaruwa,

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.

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

The manuscript will need a reorganization. First, authors present Findings and include references. This is not a common practice in Plos ONE. As a consequence, the Discussion is skeletal and needs flesh out. Second, the manuscript needs to clarify variables levels and all Tables to be presented as such. In its current form, it mixes all-level variables which is not easy to follow. Third, other comments in the annotated manuscript.

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

Please submit your revised manuscript by Feb 22 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,

Zacharie Tsala Dimbuene, 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. Thank you for stating the following financial disclosure:

“This project was funded with UK International Development from the UK government and New Zealand’s Ministry of Foreign Affairs and Trade (MFAT) contract PO number 10087; however, the views expressed do not necessarily reflect the UK or New Zealand’s government official policies”

Please state what role the funders took in the study.  If the funders had no role, please state: "The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript."

If this statement is not correct you must amend it as needed.

Please include this amended Role of Funder statement in your cover letter; we will change the online submission form on your behalf.

3. In the online submission form, you indicated that [The dataset(s) supporting the conclusions of this article is owned by the Demographic and Health Surveys (DHS) Program, ICF, 530 Gaither Road, Suite 500, Rockville, MD 20850, USA and available upon request.].

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.

4. We note that Figure 1 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 (1) present written permission from the copyright holder to publish these figures specifically under the CC BY 4.0 license, or (2) remove the figures from your submission:

a. You may seek permission from the original copyright holder of Figure 1 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?

Reviewer #1: Partly

Reviewer #2: No

**********

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

Reviewer #1: Yes

Reviewer #2: Yes

**********

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

Reviewer #1: Yes

Reviewer #2: No

**********

Reviewer #1: I have uploaded a file with my comments. Overall, the study is well-conducted, but the methodology section lacks important details. The authors are advised to revise this section to include the missing information. Additionally, the entire manuscript should be reviewed and revised to address the identified issues.

Reviewer #2: The manuscript examines the changes in stunting among children under five in Tanzania in the last 30 years. While this trend analysis is important is understanding trend in stunting among children, the style of presenting the results makes the manuscript unnecessarily long and difficult to follow. The manuscript also requires a through edit for sentence structure in some paragraphs. Some detailed comments below.

Abstract

1. In the sentence “The frequency of stunted children was higher in households with the lowest socioeconomic status”, frequency should be percentage rather

2. “was significant associated” significant should be significantly

3. What is percentage change(decrease/increase) in stunting in Mainland Tanzania within the specified time? What is rate of change as well? Since the main objective was examine the change, the authors should consider specifying the rate of change

4. In the abstract, the author need to clarify that the analysis of the factors associated with stunting was done only for the 2022 data

Introduction

Well written

Methods

5. Data source: Did you obtain the actual DHS data for analysis, or you are simply reporting data/results presented in the Tanzania DHS report? The last sentence in this sub-heading “All data presented in the graphs as cross-sectional data points and tables are from the Tanzania DHS, 1991/92 – 2022” suggest that you are simply presenting results from the DHS reports. This needs clarity

6. This sentence is unnecessary in my opinion since the present manuscript has nothing to do with biomarkers or urine. “All biomarker questionnaires and urine specimens were dispatched weekly to the nearest TFNC laboratory.”

7. It is unclear from the statistical analysis if the authors considered strata and cluster effects in the analysis. The DHS data usually multistage sampling with clusters and strata and weighting is usually calculated with resulted reported as weighted. It will therefore be very appropriate if survey regression procedure accounting for the cluster and strata effects will be used for the analysis.

8. Consider re-writing for clarity “Both backward and forward elimination have been used to arrive at the final model for statistically significant le”

Results

9. “In Figure 1A, we can see that at least some of the policies and guidelines introduced over time have likely contributed to an improvement in the general trends in stunting in Tanzania;”. This sentence looks more like a discussion point rather than results. I suggest just describing what you observed from the analysis without making assumptions from the results here

10. Overall, the style of presenting the results is a mixed of results and discussion while a separate discussion heading remains making the manuscript unnecessarily long. Can the authors simply summary their results in 3-4 pages and then write 4–5-page discussion of their main findings. This will make the flow and reading easier to follow

Discussion

11. Another limitation to add is that since the data is cross-sectional, causality cannot be attributed to the associations presented for the predictors of stunting in 2022

**********

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:  Amon Exavery

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: Peer review report for the manuscript by Elisaria et al.docx

Attachment

Submitted filename: PONE-D-24-53994.pdf

Dear Dr. Kuwawenaruwa,

Please submit your revised manuscript by Jul 06 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.

• 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 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,

Susan Horton

Academic Editor

PLOS ONE

Journal Requirements:

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

Additional Editor Comments:

I am incoming to replace the previous Academic Editor. My suggestions are:

1. Please fill out a STROBE checklist and supply to PLOS. (This does not need to be in the published article).

2. Please provide a written response to Reviewer 3: I was not able to find this in the online files, but I apologize in advance if it is there and I missed it.

3. Please follow Reviewer 3's request to shorten the discussion. Good practice is to state a point based on your results and succinctly compare to other articles in the literature.

4. Please also remove the list of abbreviations. This is not the style for this journal. You simply spell out the abbreviation on first use, and then after that just use the abbreviation.

5. I thought that PLOS required line numbers on a revised version. Please include these.

6. I have also provided a list of typos, as follows:

Abstract: suggest “maternal secondary education” rather than “secondary education”

P5: top line: consider saying “only” 19% of children aged…..”

Section entitled “TDHS sampling of households”: In first sentence, consider saying “took” rather than “considered”

Table 1: number of ANC visits: one of these categories should be either “greater than or equal to” or “less than or equal to” (later it seems that the first category is “less than or equal to 4”; the same issue is observed in table 2 and table 3.

P13, section on stunting and diarrhoea: it would be helpful to specify the period referred to in terms of episodes of diarrhoea, i.e. the question asked by DHS

P13: discussion of regions: given that the Abstract mentions Southwest Highlands and Southern Highlands specifically, it would be helpful to identify which regions belong in each of these Highland areas (Google didn’t seem to distinguish Southern Highlands and Southwestern, but indicated that Iringa, Mbeya and Ruvuma, all listed here, were part of the Southern Highlands)

Table 3: birth order and birth interval should be spelled out in full

P22: reference to Qadri et al – suggest specify the country to which this study refers.

P23: I couldn’t find Mtongwa et al (2022) in the reference list, and in any case this reference should be given a numbered reference, not (2022).

P23, second last line: “Ideally” should be deleted.

P24, last paragraph: delete first mention of “influence”. Should read “Child age was found to influence stunting”.

P25: don’t give date of publication for Karlsson et al, since that isn’t consistent with the style for this journal.

P25: first sentence of last paragraph: Suggest rephrasing as “The household factors include socio-economic status which was significantly associated with…”

P26, in first complete paragraph: capitalize Infant (in Infant and Young Child Feeding guidelines)

Section on Limitations: do you mean that “no new primary data were collected”?

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

Reviewer #1: (No Response)

Reviewer #3: All comments have been addressed

**********

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

Reviewer #1: Yes

Reviewer #3: No

**********

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

Reviewer #1: No

Reviewer #3: No

**********

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

The PLOS Data policy

Reviewer #1: Yes

Reviewer #3: Yes

**********

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

Reviewer #1: Yes

Reviewer #3: No

**********

Reviewer #1: I appreciate the authors for making substantial revisions to the manuscript in response to my earlier comments. Their efforts to improve the clarity and presentation of the study are commendable.

1. However, my major concern is that the term "multilevel" has been replaced with "multivariate." If this change was merely in terminology, without a corresponding revision in the analysis, then the approach remains incorrect. In revising the analysis, the authors should first declare the data as 'survey' in design through the 'svyset' command in Stata (as mentioned, Stata was used). I think it takes this form... "svyset [pweight=v005], psu(v021) strata(v022)". Following this, each syntax for both descriptive and multivariate analyses should begin with the 'svy:' prefix to account for the survey design.

Currently, the analysis does not account for the inherent clustering of DHS data. Given the survey design, it is essential to either conduct a weighted analysis that accounts for stratification and primary sampling units (PSUs), or to use a multilevel approach to properly address the hierarchical structure of the data. Ignoring clustering can lead to incorrect standard errors and potentially biased estimates.

I strongly encourage the authors to either incorporate survey weights and adjust for clustering, or implement a multilevel model that aligns with the hierarchical nature of the data. Clarifying these methodological choices in the manuscript would greatly strengthen the rigor and validity of the findings.

2. Consider using 'multivariable' instead of 'multivariate' because multiple predictors or covariates are being associated with a single outcome - stunting.

3. Consider marking p-values of '0.000' as 'p<0.001'

Reviewer #3: Thank you for your valuable feedback and insightful comments. The manuscript needs to revised sections to enhance clarity, ensuring logical flow and coherence throughout the manuscript. The methodology to provide additional details on data analaysis. The discussion need to strengthened the discussion by incorporating relevant literature. The study adheres to ethical guidelines, and necessary approvals have been obtained since the study was based on secondary data analysis.

**********

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:  Amon Exavery, PhD

Reviewer #3: Yes:  Sampurna Kakchapati

**********

[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

Attachments

Attachment

Submitted filename: Reviwers comments PLOS.docx

Thirty Years of Declining Stunting in Tanzania: Trends and Ongoing Challenges

PONE-D-24-53994R2

Dear Dr. Kuwawenaruwa,

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,

Susan Horton

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Thank you for your careful response to the reviewers' comments, and for providing the STROBE checklist.

Reviewers' comments: