Dear Dr. Bongomin,

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.

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ACADEMIC EDITOR:

• Provide more background on the refugee population (origin, duration in camps), healthcare structure, and the number of facilities serving refugees in Adjumani District.
• Clarify the selection method for the three health facilities specify if it was random, purposive, or otherwise and how the sample size was distributed among them.

Methods 

• Explain if haematinics are routinely provided at ANC and whether their use was assessed.
• Clarify the procedures for malaria and stool testing, including why these were done and ensure results are reported.
• Justify the collection of anthropometric data (e.g., weight) and blood samples state how much was collected, how often, and include SOPs on sample handling and transport if done across sites.
• Explain how questionnaire data were matched with lab results and whether any systems were used to prevent data errors.

Results, clarity and consistency 

• Account for the reduced sample size and report the response rate.
• Resolve inconsistencies in income and breadwinner data and align variable categories across tables (e.g., education and marital status).
• Clarify variable definitions such as “time at camp,” “soil eating,” and how diagnoses (e.g., gastritis, HPV/cancer) and deworming history were established.

Discussions and limitations 

• Compare findings with studies among similar populations (i.e., pregnant refugees).
• Explain unexpected findings (e.g., higher anaemia in educated women).
• Discuss limitations of RDT-based malaria diagnosis and the omission of key variables like haematinic use.
• Add a brief section on the strengths of the study.

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We look forward to receiving your revised manuscript.

Kind regards,

Henry Komakech, MHSR, B.A

Academic Editor

PLOS ONE

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Additional Editor Comments:

The manuscript would benefit from additional contextual details about the study setting and clearer descriptions of methods, including sampling procedures, data collection processes, and justification for measurements conducted. Please also ensure consistency between the methods and results sections by including findings for all procedures mentioned and clarifying any discrepancies in tables and terminology used.

The authors should clarify discrepancies and definitions in the tables, particularly regarding income sources, education, marital status, and newly introduced variables like ‘soil eating.’ Additionally, explanations should be provided for how certain health conditions and variables were assessed, and missing methodological details should be included to ensure alignment between the methods and results sections.

The authors should provide appropriate comparisons with anaemia prevalence among pregnant refugee women in similar contexts and offer a clear, logical explanation for the unexpected association between education and anaemia in their findings. Additionally, they should explain the absence of gestational age data, expand on the study’s limitations, and highlight its key strengths.

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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?

Reviewer #1: Yes

Reviewer #2: Yes

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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

Reviewer #1: No

Reviewer #2: Yes

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

Reviewer #1: Yes

Reviewer #2: Yes

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Reviewer #1: General comments

The study addresses a critical public health issue in a vulnerable population and provides valuable localized data. There are however some issues the needs to be addressed or clarified to improve the quality of the manuscript.

Specific comments and recommendations

Study settings: The manuscript will benefit from more information on the setting eg – the geopolitical structure of the country, how healthcare delivery is structured in the country, who are the refugees and where did they migrate from, how long have they settled there, socio-economic context, etc.

What about the provision of routine haematinics, is it not part of the services offered at the ANC?

Line 116 – Please explain this process of ‘random’ selection of 3 facilities. How many facilities in all were available? Did you do simple, systematic, or cluster selection? Or were the 3 facilities rather purposively selected?

Line 117 – there is no reflection of Ayiri HC III in Table 1

Line 135: In order to avoid confusion with qualitative interviews, I would suggest authors rephrase the use of the term “face-to-face interview” to ‘survey’ or a more unambiguous term.

Anthropometry: Measurement of weight is mentioned. Why was it done? There was no reflection of this in the results.

Malaria test: Blood film microscopic examinations were done along with parasite density. There was no reflection of this in the results

Line 185 – There was no mention of stool analysis in the methods

Results

Line 191 – Please state the reason(s) why the final sample was less than the calculated sample size i.e. why were the others excluded from the final analysis

Table 1:

Please rephrase ‘Mother’s age’ to simple ‘Age’

Source of income – Please clarify and reconcile the fact that 261 had no source of income, yet everyone had ‘estimated monthly income’. Furthermore, 267 were the bread-winners despite the majority not having a source of income?

“Time at the camp’ – Does this mean that the refugees got to the area at different times? This underscores the earlier comment regarding more background information about the setting

Table 2:

Gastritis/Ulcer – how were these determined? Please include in the methods

“HPV infection or cancer” – how were these diagnoses determined?

“Dewormed in last 6 months” – Please clarify how this was determined, and include the definition in the relevant section of the methods

Table 3:

Highest education level: please clarify those described as ‘none’, are they the same as ‘informal’ on Table 1?

Marital status: Pls clarify the components of the ‘single’ marital group, did this include those who were described as ‘separated’ on Table 1

‘Soil eating…’ is appearing for the first time here in a multivariable analysis?

Discussion

Lines 251-254: You should rather proffer possible explanations for your own counter-intuitive finding instead of focusing on explaining the findings by others.

Limitations: The use of haematinics (yes or no) is a critical confounding variable not mentioned in the manuscript. Was this left out of the data collected? It appears this potentially compromised the validity of the findings.

The authors should also discuss the limitations associated with dependence on RDT for malaria diagnosis as presented in the results.

Reviewer #2: This study presents an investigation into the prevalence and severity of anaemia among pregnant refugee women settled in the West Nile region of Uganda, addressing a significant public health concern in a vulnerable population. The manuscript is clearly written, methodologically sound, and the findings are well presented. Nonetheless, several important areas require clarification and refinement. I have provided some constructive comments to improve the manuscript. Thank you

Abstract and Background

1. They are precise and well-written.

Methods

2. How did you randomly select the three facilities included in the study?

3. For the reader's context, could you provide more details about which areas of the Adjumani district have refugees and how many facilities, among which you chose, serve them?

4. Explain how the sample size was distributed among the three facilities.

5. Line 138: Provide references to the studies alluded to.

6. I note that complete blood count tests were all conducted at one facility (Mungula HCIV laboratory). Did you transport samples from other sites to this laboratory? If so, please provide a summary of the SOPs you followed (i.e vacutainers in which blood was collected, sample labelling, storage and transportation of the sample to the laboratory, time from collection to running the test etc). Please also attach the detailed SOPs used as a supplement file.

7. You collected 4 mLs of CBC and another 4 mLs for malaria testing, a total of 8 mLs? According to your write-up, it seems you bled the patient twice. Is it so? Include a blood sampling section in the methods and clearly explain the procedures related to this.

8. How did you synchronize patient records from the questionnaires to the test results from the laboratory? Did you use any system, was it pre-programmed to prevent mix-up of data. Please provide these details under your data collection procedures.

9. You mention that patients were provided results of stool analysis, but that has not been elaborated in the study procedures. Please provide it, and what was the stool analysis performed for?

Results

10. Line 191: Note the response rate of your study

11. In the study procedures, you performed microscopy and quantification of malaria parasites for participants, but none of this was reported in the results.

Discussion

12. Line 233-237: From the references, I note that the studies from Tanzania, Ethiopia, India, Sudan and Ghana are not explicitly among refugee pregnant women, unless otherwise. You need to do some comparisons with the prevalence of pregnant refugee women elsewhere.

13. Line 246-254: I found no explanation for why educated women in this study were likely to have anaemia, contrary to many other studies, as you noted. You instead gave a reason why educated women may have a lower prevalence of anaemia, as reported in different studies. Please provide a logical explanation for your finding.

14. Why were gestational ages not collected despite having access to the patients and their ANC card records as well?

15. Limitations of this study have not been exhaustively stated.

16. Please also state the strengths of your study.

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Anemia prevalence and severity among pregnant refugee women settled in the west Nile region, Uganda

PONE-D-24-37952R1

Dear Dr. Bongomin,

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.

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Kind regards,

Henry Komakech, MHSR, B.A

Academic Editor

PLOS ONE