-->PONE-D-25-40831-->-->"Spatial Disparities and Multilevel Determinants of Diarrhea Among Under-Five Children in Mozambique: Evidence from the 2022/2023 Demographic and Health Survey"-->-->PLOS One

Dear Dr. Yewodiaw,

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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PLOS One

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Additional Editor Comments:

This is a report of an interesting analysis. It aims to study the geographic and multilevel determinants of diarrhea among under-5 children in Mozambique using the latest available DHS data. Certainly, it will help to inform the next steps for policy action. However, there are critical issues that must be addressed:

1. There is no contextual setting information about Mozambique despite 72 citations! Under-5 diarrhea has been an important cause of death and morbidity in Mozambique for decades, and year to year, there have been reductions due to actions (e.g., introduction of new vaccines, guidelines, personnel training, and infrastructure). What were those actions?

2. There are two analyses independent of each other. One is based on four multilevel models that show substantial unaddressed variation is present as random effects, even after household and regional characteristics were accounted for. Another is purely spatial univariate, and it shows some potential spatial autocorrelation. We lack an analysis that accounts for both simultaneously.

3. About the spatial analysis:

• Is this conducted at the individual or cluster level? This is unclear.

• Were the weights or other elements of the sampling accounted for? This must be clarified.

4. Please revise line 218 - there are some parentheses unbalanced.

5. Why is the multilevel analysis presented in the discussion section and not in the results? Please move it to the results.

6. Please merge table 2 and table 3. Do not sort provinces by prevalence.

7. Table 5 - Why do model 3 estimates have asterisks but not those of other models?

Please add the variance of the random-effects.

8. Figures 1 and 2 are taking up space. They should be in the supplementary materials.

9. Figure 6 - The forest plot. This plot is unneeded. However, if the authors want to keep it a few changes must be applied:

- The horizontal axis must be on a logarithmic scale. Currently, an OR of 0.5 seems to be weaker than an OR of 2, when actually they have the same strength in opposing directions.

- Do not sort OR from all coefficients. Keep them separated for each variable

[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

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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: Dear editor, thank you very much for giving me a chance to review the paper entitled ``Spatial Disparities and Multilevel Determinants of Diarrhea Among Under-Five Children in Mozambique: Evidence from the 2022/2023 Demographic and Health Survey``

Manuscript Number: PONE-D-25-40831

General Comments – Minor Revision Required

This manuscript offers a valuable and timely contribution by addressing the spatial and sociodemographic determinants of childhood diarrhea in Mozambique using recent DHS data. The study is methodologically sound, policy-relevant, and aligned with global health priorities, demonstrating strong analytical rigor through multilevel and spatial analysis. The findings are well-referenced and contextualized, offering clear implications for targeted interventions. Minor revisions are needed to improve clarity and presentation—specifically in reference formatting, language polish, and deeper discussion of spatial findings and study limitations. With these addressed, the manuscript will be well-positioned for publication.

Specific comments

Title

1. Line 2: I suggest to change to lower case latter, ``Among`` to ``among``

Abstract

1. Line 24 and 25: I suggest to rephrase ``with its burden varying across regions.`` to ``with regional variations in its burden.`` for clarity

2. Line 29: I suggest to rephrase ``assess diarrhea prevalence and determinants. `` to ``examine the prevalence and determinants of diarrhea.``

3. Line 33: results, I suggest to re-write the result to make it clear for reader

Introduction

1. Line 53: I suggest to change to lower case latter, ``Disease`` to ``disease``

2. Line 54: I suggest to remove ``But`` and ``both`` or rephrase, ``But, it is both preventable and treatable`` to ``However, it is preventable and treatable``

3. Line 61: I suggest to write ``teta to Tete

4. Line 77 – 78: I suggest to revise the sentence, ``Regarding to SDG goal three the Mozambique planned to reduce under five children mortality by 25/1000 (18, 19).`` to ``In alignment with SDG Goal 3, Mozambique has committed to reducing under-five mortality to 25 per 1,000 live births (18, 19).``

5. Line 55 – 57: I suggest to explain and clarify, If 444,000 deaths is the newest estimate, how it compares with previous estimates (e.g., 390,000 in 2021).

6. Line 70 – 72: I suggest to group risk factors as individual-level, household-level, environmental

7. Line 83 – 86: I suggest to re-write the objective as ``Therefore, this study aims to assess the spatial distribution and multilevel determinants of diarrhea among children under five in Mozambique using recent DHS data and spatial modeling tools such as SaTScan and ArcGIS``

Methods and materials

1. Line 89: Methods and materials, I suggest to arrange subheading or subsections in logical order to improve readability

2. Line 92: I suggest to revise the phrase, ``the bulk of whom live in rural areas(23-25).`` to ``with the majority residing in rural areas (23–25).``

3. Line 99: I suggest to correct the vague phrase and insert missed number, ``from a national representative sample of approximately households``

4. Line 103 – 104: I suggest to revise the phrase, ``The second stage involves updating household listings`` to `` In the second stage, household listings were updated`` to correct tense

5. Line 108: I suggest to clarify how the final analytic sample (9,799 children) was derived.

6. Line 108 and 109: I suggest to rephrase,`` concentrating on the past two weeks of diarrhea history before to the survey.`` to ``in the two weeks prior to the survey``

7. Line 183 and 184: I suggest to define MOR, ICC, and PCV in simpler terms and provide formulas or references.

Results

1. Line 205: I suggestion maintain consistency of decimal places, ``60% (585)`` to ``60.0% (585)``

2. Line 210 and 211: I suggest to revise the phrase, ``Nutritional status was largely normal 94% (9,214)``to ``94.0% (n = 9,214) of children were classified as having normal nutritional status``

3. Line 218: I suggest to avoid redundancy here, ``Weighted case = 817 children``

4. Line 221: I suggest to clarify that the higher prevalence among educated mothers statistically significant or due to reporting bias

5. Line 243 and 244: I suggest to add a threshold as Gi* Z-score > 1.96, p < 0.05

6. Line 275: I suggest to explain the implication of RR = 2.79 matter

Discussion

1. Line 289: I suggest to review the phrase,`` shows a slight decline`` to ``declined modestly``

2. Line 334: I suggest to review, ``considerable clusters`` to ``statistically significant high-risk clusters``

3. Line 353 – 355: I suggest to clarify, higher diarrhea in more educated mothers

4. Line 359: I suggest to see back to caregiver reporting in DHS

5. Line 367: I suggest to review phrase,`` having improved toilets`` to ``greater access to improved sanitation``

6. Line 388: I suggest to avoid vague phrases like ``unmeasured factors``

Conclusion

1. Line 395: I suggest to clarify ``maternal support systems`` to avoid vague

References

1. Line 434: I suggest to rephrase, ``Organization WH`` to World Health Organization ``(WHO)``in the reference number 1

2. Line 437: I suggest to remove the repeated phrase in reference number 2

3. Line 457: I suggest to correct `` USIAD C, AND UNICEF`` to ``USAID, CDC, and UNICE`` in the reference number 10

4. Line 484 and 485: I suggest to merge reference number 24 and 25 as they are similar

5. Line 503: I suggest to add publication organization in the reference number 35

6. Line 516: I suggest to put proper format in the reference number 41

**********

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Reviewer #1: Yes: Abdulwase Mohammed Seid

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-->PONE-D-25-40831R1-->-->"Spatial Disparities and Multilevel Determinants of Diarrhea Among Under-Five Children in Mozambique: Evidence from the 2022/2023 Demographic and Health Survey"-->-->PLOS One

Dear Dr. Yewodiaw,

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 May 01 2026 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 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,

Khin Thet Wai, MBBS, MPH, MA

Academic Editor

PLOS One

Journal Requirements:

If the reviewer comments include a recommendation to cite specific previously published works, please review and evaluate these publications to determine whether they are relevant and should be cited. There is no requirement to cite these works unless the editor has indicated otherwise.

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:

Please do minor revisions as required.

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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: (No Response)

Reviewer #2: (No Response)

**********

-->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 #2: Yes

**********

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

Reviewer #1: Yes

Reviewer #2: Yes

**********

-->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 #2: Yes

**********

-->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 #2: 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: Dear editor, thank you very much for giving me a chance to re-review the paper entitled "Spatial Disparities and Multilevel Determinants of Diarrhea among Under-Five Children in Mozambique: Evidence from the 2022/2023 Demographic and Health Survey"

Manuscript Number: PONE-D-25-40831R1

General Comments – Minor Revision Required

This manuscript presents a relevant and timely analysis of the spatial and sociodemographic determinants of childhood diarrhea in Mozambique using recent Demographic and Health Survey (DHS) data. The topic is of clear public health importance and aligns well with global child health and equity priorities. The use of multilevel modeling combined with spatial analytical techniques strengthens the methodological rigor and enhances the policy relevance of the findings. Overall, the results are well-supported by the literature and offer useful insights for geographically targeted interventions.

However, several minor revisions are required to improve clarity, consistency, and presentation. These include clearer description of the study design and sample, improved precision and consistency in language and formatting (e.g., decimals, spacing, references), and clarification of potentially ambiguous interpretations—particularly regarding education and urban-related findings and spatial patterns. In addition, deeper discussion of spatial results and clearer articulation of study limitations would further strengthen the manuscript. Addressing these minor issues will enhance readability and scientific clarity and will position the manuscript well for publication.

Specific Comments

Line 49: I suggest to write the keywords in alphabetical order

Line 55 – 57: I suggest to explain and clarify, If 444,000 deaths is the newest estimate, how it compares with previous estimates (e.g., 390,000 in 2021).

Line 95: I suggest to mention study design

Line 113-115: I suggest to make the sentence clear, ``A study interviewed households of 9,799 in 619 clusters, including 4,767 males and 5,032 females aged 0-59 months, in rural and urban areas. The study looked at 9,799 children aged 0 to 59 months, in the two weeks prior to the survey.``.

There is repetition and inconsistency in how the sample is described (households vs. children).

The phrase “households of 9,799” is unclear—households and children are being mixed.

Sex distribution (males/females) is mentioned, but it applies to children, not households.

Line 223: I suggestion maintain consistency of decimal places, ``60% (585) `` to ``60.0% (585) ``

Line 231-232: I suggest to write, `` and a majority lived in medium 37.5% (3,673) or high 35.2% (3,452) education-level communities`` to `` In terms of community education level, the majority resided in medium (37.5%; n = 3,673) or high (35.2%; n = 3,452) education-level communities. ``

Line 238: I suggest to clarify that the higher prevalence among educated mothers statistically significant or due to reporting bias

Line 273: I suggest to writ ``(clod spot)`` to ``(cold spot)``

Line 334: I suggest to keep consistence spacing, ``conditions[45]`` to ``conditions [45]``and similar to others

Line 422: I suggest to clarify ``maternal support systems`` to avoid vague

Line 434: I suggest to rephrase, ``Organization WH`` to World Health Organization `` (WHO) ``in the reference number 1

Line 90: I suggest to correct `` USIAD C, AND UNICEF`` to ``USAID, CDC, and UNICE`` in the reference number 12

Line 522 and 523: I suggest to merge reference number 26 and 27 as they are similar

Reviewer #2: I apperciate the team for doing this policy relevant research and the manuscript is public health important with so modification of grammar, clarity and coherence.

**********

-->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: Abdulwase Mohammed Seid

Reviewer #2: No

**********

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-->

Attachments

Attachment

Submitted filename: Diarrhea Mozambique.docx

-->PONE-D-25-40831R2-->-->Spatial Disparities and Multilevel Determinants of Childhood Diarrhea in Mozambique: Evidence from the 2022–2023 DHS-->-->PLOS One

Dear Dr. Yewodiaw,

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 May 20 2026 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 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.

As the corresponding author, your ORCID iD is verified in the submission system and will appear in the published article. PLOS supports the use of ORCID, and we encourage all coauthors to register for an ORCID iD and use it as well. Please encourage your coauthors to verify their ORCID iD within the submission system before final acceptance, as unverified ORCID iDs will not appear in the published article. Only the individual author can complete the verification step; PLOS staff cannot verify ORCID iDs on behalf of authors.

We look forward to receiving your revised manuscript.

Kind regards,

Khin Thet Wai, MBBS, MPH, MA

Academic Editor

PLOS One

Journal Requirements:

If the reviewer comments include a recommendation to cite specific previously published works, please review and evaluate these publications to determine whether they are relevant and should be cited. There is no requirement to cite these works unless the editor has indicated otherwise.

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.

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

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: (No Response)

Reviewer #2: All comments have been addressed

**********

-->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 #2: Yes

**********

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

Reviewer #1: Yes

Reviewer #2: Yes

**********

-->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 #2: Yes

**********

-->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 #2: 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: Dear Editor, thank you for the opportunity to re-review the revised version of the manuscript titled “Spatial Disparities and Multilevel Determinants of Childhood Diarrhea in Mozambique: Evidence from the 2022–2023 DHS”

Manuscript ID: PONE-D-25-40831R2

I have carefully reviewed the authors’ revised manuscript and their detailed responses to my previous comments. Most of the prior concerns have been addressed; however, a few minor issues remain. Abbreviations in the abstract should be defined at first use and applied consistently. Some formatting inconsistencies persist (e.g., spacing between words and reference numbers, line 415,430, 434) as well as terminology (e.g., “hotspot” vs. “hot spot”). Several sentences remain lengthy and could be further refined for clarity and conciseness. Additionally, the discussion of reporting bias is somewhat repetitive and would benefit from streamlining. A final thorough proofreading is recommended to ensure overall consistency throughout the manuscript.

Reviewer #2: (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.

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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: Abdulwase Mohammed Seid

Reviewer #2: No

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NAAS will assess whether your figures meet our technical requirements by comparing each figure against our figure specifications.

-->

-->PONE-D-25-40831R3-->-->Spatial Disparities and Multilevel Determinants of Childhood Diarrhea in Mozambique: Evidence from the 2022–2023 Demographic and Health Survey (DHS-->-->PLOS One

Dear Dr. Yewodiaw,

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 processPlease submit your revised manuscript by Jun 04 2026 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 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'.
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-->

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As the corresponding author, your ORCID iD is verified in the submission system and will appear in the published article. PLOS supports the use of ORCID, and we encourage all coauthors to register for an ORCID iD and use it as well. Please encourage your coauthors to verify their ORCID iD within the submission system before final acceptance, as unverified ORCID iDs will not appear in the published article. Only the individual author can complete the verification step; PLOS staff cannot verify ORCID iDs on behalf of authors.

We look forward to receiving your revised manuscript.

Kind regards,

Khin Thet Wai, MBBS, MPH, MA

Academic Editor

PLOS One

Journal Requirements:

If the reviewer comments include a recommendation to cite specific previously published works, please review and evaluate these publications to determine whether they are relevant and should be cited. There is no requirement to cite these works unless the editor has indicated otherwise.

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.

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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: (No Response)

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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

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

Reviewer #1: 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

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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

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-->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: Dear Editor, thank you for the opportunity to re-review the revised version of the manuscript titled “Spatial Disparities and Multilevel Determinants of Childhood Diarrhea in Mozambique: Evidence from the 2022–2023 Demographic and Health Survey (DHS)”

Manuscript ID: PONE-D-25-40831R3

I have carefully reviewed the authors’ revised manuscript and their detailed responses to my previous comments. Most of the prior concerns have been addressed; however, a few minor issues remain. Some formatting inconsistencies persist (e.g., spacing between words and reference numbers not between reference numbers, line 82,378, 401) as well as terminology (e.g., “hotspot” vs. “hot spot”), I recommend you to use hotspot analysis through the manuscript. Additionally, from line 290-293, 304-307 and 326-329, I recommend you to correct the space between sentences for consistency. I also recommend you to revise table 1 and 2 the lines for category under variable to prevent ambiguity for reader.

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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: Abdulwase Mohammed Seid

**********

[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.]

To ensure your figures meet our technical requirements, please review our figure guidelines: https://journals.plos.org/plosone/s/figures

You may also use PLOS’s free figure tool, NAAS, to help you prepare publication quality figures: https://journals.plos.org/plosone/s/figures#loc-tools-for-figure-preparation.

NAAS will assess whether your figures meet our technical requirements by comparing each figure against our figure specifications.

-->

Spatial Disparities and Multilevel Determinants of Childhood Diarrhea in Mozambique: Evidence from the 2022–2023 Demographic and Health Survey (DHS)

PONE-D-25-40831R4

Dear Dr. Yewodiaw,

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. For questions related to billing, please contact billing support.

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,

Khin Thet Wai, MBBS, MPH, MA

Academic Editor

PLOS One

Additional Editor Comments (optional):

Reviewers' comments: