PONE-D-24-37907Addressing Food Insecurity in Early Childhood Programs through a Health Equity Lens: A Qualitative Case Study of Brazil’s Criança Feliz Program.PLOS ONE

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Hamufare Dumisani Mugauri, Ph.D. Medicine and Health Sciences

Academic Editor

PLOS ONE

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Reviewers' comments:

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Reviewer #1: Yes

Reviewer #2: Partly

Reviewer #3: Partly

Reviewer #4: Yes

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Reviewer #1: N/A

Reviewer #2: N/A

Reviewer #3: N/A

Reviewer #4: Yes

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Reviewer #1: No

Reviewer #2: No

Reviewer #3: No

Reviewer #4: No

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Reviewer #2: Yes

Reviewer #3: Yes

Reviewer #4: No

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5. Review Comments to the Author

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Reviewer #1: Dear Authors,

Congratulations on an impressive and innovative article! The manuscript is well-written and offers valuable insights highly relevant to the creation and implementation of policies. I have provided a few minor suggestions, but overall, your work is thorough and thoughtfully crafted.

Thank you for your contribution to this important field.

Best regards!

Reviewer #2: I think this is a brilliant study, and provides some vital insight and guidance as to how these programs can be further improved to protect against food insecurity. I also thought it was very clear and well-written.

However, I would like to suggest some improvements to the link between the results and the discussion, including the Getting to Equity framework. Firstly, whilst this framework is a brilliant way to organise recommendations, I think in places it feels a little shoehorned in. The Nutrition and Food Security framework may also be of benefit to reference to, especially in the introduction when discussing the bigger picture of food insecurity. This would also better link consequences such as stress (mentioned on page 4), which is currently referred to as a mechanism.

This is also the case in the discussion - see comments below.

Please clarify the logistics of the PCF, is this state run or run by an NGO or CSO?

The different demographics and locations that have been taken into account to make the sample as generalisable as possible - big strength of the study.

Please provide brief details of the TRIA screening tool - what dimensions of FI do they look at?

On page 10, line 199 - it could be argued that it is underlying equities that cause FI, and therefore FI is not the root cause but a metric to understand who is most affected by the root issues. The equities that the GTE framework is addressing contribute to FI as a consequential issue.

Line 202/203 - were the GTE recommendations adapted before or after the results were considered? If it was after, should this be in Results as a finding of the study to inform the adaptation of the framework. If it was adapted through literature searches then just clarify that this is how you came to it.

Line 204: Is this deterrents to participating in the programs? As the initial framework is for obesity, this would usually refer to reducing deterrents that cause obesity. Here,you are reflecting it for FI, but I understand you are not reducing deterrents to be food insecure, so should it rather be reducing barriers to the program and engaging with it etc.

Table 1: What does high frequency and levels mean? Is there a high prevalence, and within this a lot of people are severely food insecure?

Line 296: Tie some of the results back to the objectives more clearly, looking at the effects on the children.

Line 315: Please clarify here who's governance this affects or the relevance.

Line 411: How would this help to address fear of discrimination? Discrimination of or due to what?

Table 2 & discussion: If affordability is the biggest issue, should it be increasing access to affordable healthy, budget-friendly options. Some families may know what to do but the finances seems to be the biggest barrier here. As the quotes suggest, engaging with the children on games etc didn't seem to make too much of an impact when families were hungry. I assume the same will be the case if households are starving, they will not want to sit through talks about food. It would be beneficial if the GTE framework better reflected this - as there feels to be a sort of disconnect between the findings demonstrating that affordability and a lack of financial help or food baskets is the issue and the recommendations?

Also impressive to see a return of data to the community. Clear impact in discussion demonstrated.

Also, the data is only available on request and is not publicly available.

ECD abbreviation not stated before first use.

Line 477: Could a recommendation be better advertisement of what the program entails to correct expectations?

Reviewer #3: Overall

- This is an important and timely topic. The manuscript provides a comprehensive descriptive analysis of food insecurity in Brazil. The manuscript is well-written and organized.

- The use of multiple uncommon acronyms throughout the manuscript can be confusing for readers. Please reduce the number of acronyms and limit them to conventionally used ones. Avoid using the acronym “FI.”

Introduction

- The introduction defines food security as a lack of access to food but does not address its multidimensional aspects (e.g., availability, utilization, stability). Please include these dimensions https://doi.org/10.4060/cc3017en

- There appears to be a typo on line 64.

- Lines 60-64 mention that addressing food insecurity is a complex problem but do not explain why. Please elaborate on the complexity beyond just its prevalence.

- Define key terms when first introduced, such as “social determinants of health” on line 81.

Methods

- Are the five municipalities representative of Brazil?

- Lines 123-126: Please clarify your sampling approach. What specific characteristics were you targeting? Is “e.g.” used correctly, or should it be “i.e.”?

- Confirm if all interviews were conducted virtually (line 127). Did any include video?

- On line 145, clarify the term “loosened.” Provide an overview of COVID-19 restrictions prior to June 2021 and any changes during data collection.

- Confirm whether participants provided consent before interviews.

- Explain why in-depth interviews were chosen as the best method for answering your research question. Provide justification for this approach.

- Consider including the interview guide or key questions relevant to this study for transparency.

- Clarify lines 182-184 regarding if the findings were presented as a form of member checking and how this feedback informed further analysis.

- Specify how food security was defined in the methods. What tool or criteria were used?

Results

- Please include more descriptives in the response to the quotes. Important information for caregivers that provides necessary context but does not reveal any identifiable information for the caregivers is household size and food security status. Please also consider what important and relevant information is for the other participant sources and include these in the results section.

- The current organization by levels (e.g., family, system) makes it difficult to clearly see how the results address the research question (barriers and facilitators). Please reorganize or explicitly align the results with the research question to improve clarity and linkage to the discussion.

Discussion

- The linkage on the results to ECD is not strong. Avoid making broad claims unsupported by the data.

- "Public health" should not be capitalized on line 531.

- Discuss potential biases that may have influenced participant responses and include them in the limitations section.

Reviewer #4: All: The article needs to be reviewed for spelling, grammar and academic language. There are quite a few language and punctuation issues throughout, and issues with formatting of the references.

Abstract: I think that 'home visiting' needs explaining earlier on - as it assumes knowledge.

Keyword: I think the article would benefit from Keywords.

Introduction: I think it would be welcome to provide some illustrative examples of the ten recommendations in the introduction.

There are some unqualified statements such as 'as no children should go hungry' which need more academic rigour attached to them.

Methods: I think the theories behind the methods need to be summarised up front.

I think the methods section would benefit from research questions, and subsequently how the methods used were chosen to answer the research questions.

The method structure should be reviewed for clarity and ensuring the right information is in the right headings. Data management talked about when and how visits were conducted, which wasn't related to data management for example.

Line 249 - what are Dyads?

Results: The results section would benefit from having better signposting and sub-sectioning of the themes, as it was at times hard to follow.

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Reviewer #1: No

Reviewer #2: Yes:  Jessica Boxall

Reviewer #3: No

Reviewer #4: No

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Submitted filename: PONE-D-24-37907_reviewer JB 05-12-2024.pdf

PONE-D-24-37907R1Addressing Food Insecurity in Early Childhood Programs through a Health Equity Lens: A Qualitative Case Study of Brazil’s Criança Feliz Program.PLOS ONE

Dear Dr. Buccini,

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. May you check the following before a final decision on your manuscript:

PLOS ONE considers qualitative and mixed-methods studies for publication. We recommend that authors use the COREQ checklist, or other relevant checklists listed by the Equator Network, such as the SRQR, to ensure complete reporting (http://journals.plos.org/plosone/s/submission-guidelines#loc-qualitative-research). In general, we would expect qualitative studies to include the following: 1) defined objectives or research questions; 2) description of the sampling strategy, including rationale for the recruitment method, participant inclusion/exclusion criteria and the number of participants recruited; 3) detailed reporting of the data collection procedures; 4) data analysis procedures described in sufficient detail to enable replication; 5) a discussion of potential sources of bias; and 6) a discussion of limitations. In your role as Academic Editor, we appreciate your consideration of whether the manuscript meets reporting standards in the field, in addition to the journal’s other publication criteria (https://journals.plos.org/plosone/s/criteria-for-publication).Please contact plosone@plos.org with any questions or concerns.

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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 .

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Kind regards,

Hamufare Dumisani Mugauri, Ph.D. Medicine and Health Sciences

Academic Editor

PLOS ONE

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Addressing Food Insecurity in Early Childhood Programs through a Health Equity Lens: A Qualitative Case Study of Brazil’s Criança Feliz Program.

PONE-D-24-37907R2

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Hamufare Dumisani Mugauri, Ph.D. Medicine and Health Sciences

Academic Editor

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