Dear Dr. Wachifo,

Please submit your revised manuscript by Mar 28 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.

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Xiaohong Li

Academic Editor

PLOS ONE

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Additional Editor Comments:

1. The background section of the article needs to be modified. 1) Certain repetitive expressions should be simplified, such as the harm of undernutrition to children's growth and development. 2) Please simplifying and merging the first and second paragraphs into one paragraph in the background. 3) The website is not recommended to be shown in the third paragraph and can be used as a reference. 4) Please explain the statement 'The CIAF of children has a transient nature, which needs to be addressed using a multi-state model.' 5) I don't quite understand the theoretical and practical basis of this study. The author listed many studies in detail in the last section, but it seems that the connection to the theme of this study is not so direct. I personally strongly agree with the author's viewpoint of that more research is required to determine the effects of improved food diversity on children's nutritional status and to examine the intervention's consequences. However, this study did not directly address this issue. Please elaborate on the theoretical and practical basis that is more directly related to the purpose of this research. For example, regarding the topic of changes in nutritional status and influencing factors, what problems have been solved in previous research, what problems have not been solved, and what social significance does solving this problem have.

2. Methods section: 1) Please show some details about the process of sampling. 2) I am very confused about what the authors want to say by citing many references when describing the independent variables. Is the selection of independent variables based on these references, or are the definitions of these independent variables referenced from these literature sources? 3) Please describe the specific version of the statistical software, including R and SPSS. You should even specify which R package program was used.

3. The results section needs to be streamlined and reorganized. 1) There are so many tables and figs shown in the results section, so that the result appears to be without focus. Here are my some suggestions. Table 2 can be presented as an appendix and briefly described in the main text. The results section should present the basic characteristics of the sample at first to the readers. Table 4 and Table 5 can be merged into one table. Figures 3 and 4 provide too little information for readers. In other words, readers cannot interpret useful information from the Figures. Delete these two figs. If the authors think they are very important, they can be attached in the appendix. 2) The description of Figure 5 needs to be modified. What kind of result does Figure 5 want to express. 3) In the table 4, "Spouse or partner is a member of the hh?", what's meaning for 'hh'? 4) I'm not sure what kind of result the author wants to describe in Figure 6? Many of the results statement described are the author's speculations and should not be included in the results. The description of the results should be objective. 5) The results of Table 10 are difficult to be understood. For example, a child at normal only state has probability 0.71 being in under-nutrition in the next , and 0.29 being in over-failure, What is the probability of the state remaining unchanged? The author should provide the total probability of transitioning to the next state (not including unchanged state).

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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: Yes

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: Yes

Reviewer #2: Yes

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

Reviewer #1: No

Reviewer #2: Yes

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Reviewer #1:  Thanks for the opportunity to review this manuscript.

The study analyzes transition rates, durations, and factors influencing the movement between different nutrition states using data from three survey rounds conducted by the International Food Policy Research Institute.

I suggest to put multi state among the keywords

Abstract

In the method section there is a minor grammatical issue in "The institute was performed the three consecutive follow-up surveys rounds." Consider revising to "The institute conducted three consecutive follow-up survey rounds."

The results section is detailed, but some of the findings could be presented more concisely. For example, the phrase "The results indicated that the probability being in the under-failure state in the next time for a healthy infant is higher (0.71)" could be revised to "The probability of a healthy infant transitioning to the under-failure state is high (0.71)."

Introduction

- The introduction is lengthy and could benefit from being more concise. Consider breaking it into shorter paragraphs to enhance readability and separating the background information from the study's objectives.

- There are repeated references to data from UNICEF, WHO, and other organizations. Condense the references to these organizations by summarizing the main points.

- The study's objective is introduced at the end of a very long paragraph. Consider moving it earlier for better context and rephrasing for simplicity.

Research method

- The detailed description of the IFPRI data collection process, including the virtual meeting dates and contacting procedures could be simplified

- The section describing the inclusion criteria and sample selection is clear but could be streamlined for readability.

- The description of the Multi-state Markov Model is technically dense. Consider breaking it into smaller paragraphs with simple explanations before diving into the complex equations.

- Under independent variables, provide a brief rationale for why each variable was selected. This will highlight their relevance to the study.

Equations

- The equations are not consistently formatted and use a mixture of symbols, parentheses, and notation that makes them hard to follow.

- Some symbols are not clearly defined before they are used. For instance, " ℎ ( )" appears in the equations without a prior explanation of what each component represents.

- The text mentions " ( )" as part of the multi-state model but does not define what " " specifically represents (e.g., the state of the child's nutritional status).

- The equation “(3)” is introduced, but there seems to be a mismatch between the equation numbering and the accompanying text, making it confusing to follow the derivation or steps.

- Each equation is presented without sufficient explanation of its purpose or the meaning of the symbols.

- When equations are introduced, provide a sentence that connects the mathematical expression to the research context (e.g., how the transition rates are used in analyzing children’s nutritional states).

Results

- I suggest to Move the interpretation of key findings (e.g., transition probabilities, covariate effects) into the discussion section, where you can explore the implications more thoroughly.

- The statement "Indexes in all rounds were much greater than the current national estimates" is valuable but would benefit from specifying what the national estimates are for comparison.

- For each table, provide a brief, clear interpretation of its data. For example,

- While the results provide detailed statistical outputs, there is a need to better link these findings back to the study's objectives. For example, the study aims to understand the transition rates, durations, and drivers of under-nutrition states. Explicitly stating how the results address these goals would clarify the narrative and emphasize the study's contributions.

Discussion

- Organize the discussion around key themes or findings, such as the prevalence of malnutrition, transition probabilities, and the influence of covariates. This structure will help readers easily grasp the main points

- the finding that female children are less likely to transition to under-nutrition is mentioned but not fully explained. Including possible reasons, such as differences in care or cultural practices, would provide more context and depth.

- The explanation of probabilities and transition rates is often overly technical. While it's important to be precise, translating these findings into real-world implications (e.g., the risk and duration of under-nutrition in children) would make the discussion more accessible and impactful.

- the statement, "This result is consistent with (Oduro et al., 2024) but it is in contrast with (Häkkänen et al., 2020; Hu et al., 2022; Moreira et al., 2019)" does not explain why there might be differences between these studies. Discussing possible reasons for these inconsistencies.

- The discussion section focuses heavily on the Composite Index of Anthropometric Failure (CIAF) rather than exploring the full potential and unique insights provided by the multi-state model. While the CIAF is an essential part of the study, the use of a multi-state Markov model is one of the study's most novel and complex aspects, and it deserves more thorough discussion.

Generalcomment

Fix grammatical error

Reviewer #2:  In the introduction section, it is explained that Ethiopia faces high burden of under-nutrition prevalence, ranking among 15 worst affected nations, perhaps short-term or long-term targets in that field in Ethiopia can be explained as a reference.

While the prevalence of malnutrition in Ethiopia is discussed, could comparisons to neighboring countries or regions add further perspective to the problem?

The methodology mentions anthropometric measurements as a key data source. How were these measurements standardized across different survey rounds, and what steps were taken to minimize measurement errors?

The study uses a continuous time Markov multistate model. Could the authors briefly describe why this model was chosen over other statistical models.

The results indicate that children under 5 spend 75% of their time in under-failure states. Could the authors elaborate on why recovery times are so long and suggest factors that may contribute to this? ¬

In the results section, it is explained that Girl had 1.824 times higher likelihood of recovering from an over failure state and less likely to go from a healthy state to an under-failure state compared to boy, perhaps the factors influencing this can be mentioned.

The authors can strengthen the practical recommendation section by elaborating on specific interventions for policymakers. For example, what types of maternal education programs would be most effective?

In the discussion section, it is explained that the child being live in Oromia region is less likely transit from healthy state to malnutrition as compared with child in Amhara region, perhaps the factors influencing this can be mentioned.

Considering the long recovery periods highlighted in the study, could the authors propose emergency interventions to prevent children from remaining in under-failure states for extended periods?

In the discussion section, related to the limitations mentioned, it is possible to explain recommendations for further research so as not to encounter similar limitations that can be in line with the recommendations from the research results in the conclusion section.

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Reviewer #1: No

Reviewer #2: No

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Dear Dr. Wachifo,

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.

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

ACADEMIC EDITOR: Please insert comments here and delete this placeholder text when finished.

Please address the issues further raised by the reviewer. Moreover, here are some other key areas where the manuscript can be improved to enhance its scientific rigor, clarity, and impact:

1. Abstract Clarity and Conciseness

• Issue : The abstract is information-dense and includes some awkward phrasing (e.g., “under failure,” “over failure”), which may be unclear to non-specialists.
• Suggestion :
• Avoid jargon like “under failure” and “over failure.” Consider using
• Undernutrition or Anthropometric failure, instead of Under failure
• Overnutrition instead of Over failure
• Anthropometric failure (for CIAF) instead of Under failure
• Nourished / No anthropometric failure instead of Normal only
  Example Rewrite for Clarity:
• Original :
• “Children in the under failure group had higher transition probabilities.”
• Revised :
• “Children in the undernutrition group (i.e., those with anthropometric failure) had higher transition probabilities.”
• Original :
• “Over failure children had a lower likelihood of reverting to a normal state.”
• Revised :
• “Overnourished children (classified as overweight) had a lower likelihood of reverting to a normal nutritional status.”
• Streamline sentences. E.g., “The probability of a healthy infant transitioning to the under-failure state is high (0.71)” can be simplified to “Healthy infants had a 71% probability of becoming undernourished.

 2. Theoretical and Practical Framing

• Issue : The rationale for using the Composite Index of Anthropometric Failure (CIAF) and the Markov model is presented, but the articulation of the research gap is buried in repetition and general statements.
• Suggestion : Integrate or refer the following relevant articles regarding CIAF

I.Chowdhury M, Billah B, Rashid M, Almroth M, Kader M. Prevalence and factors associated with severe undernutrition among under-5 children in Bangladesh, Pakistan, and Nepal: A comparative study using multilevel analysis. Scientific Reports 2023 Jun 22;13(1):10183.

II.Anik AI, Chowdhury MR, Khan M, Khan TA, Perera NK, Kader M. Urban-rural differences in the risk factors of severe under-5 child undernutrition based on CISAF in Bangladesh. BMC Public Health. 2021 Nov 23;21(1):2147

• Create a sharper distinction between what is already known and what is novel in this study.
• Explicitly state (if so) : “To our knowledge, no previous study in Ethiopia has used a continuous-time multistate Markov model to analyze both under- and over-nutrition transitions among under-five children using CIAF.”

 3. Methods Section

• Strength : Ethical procedures and data source are well described.
• Improvement needed :
• Clarify the logic behind grouping CIAF categories into three states (UF, NO, OF). If possible consider using a flow diagram for clarity.
• Equations need better formatting and definition. Symbols such as ℎ, , Q(t), etc., should be defined immediately when first introduced.
• The transition matrix and equations (3) and (5) lack intuitive explanation. A sentence like “This represents the instantaneous rate at which a child leaves state h and enters state j” can aid understanding.

4. Results Presentation

• The results are numerically rich but difficult to digest due to too many tables and minimal synthesis as suggested by reviewers

 5. Interpretation and Discussion

• Issue : Discussion is technically sound but lacks integration of findings into a real-world context .
• Suggestions :
• Use subsections to structure discussion around key findings: e.g., “Gender Differences,” “Duration in Malnutrition States,” “Impact of Maternal Education” .
• When discussing girls’ lower transition to undernutrition, tie findings to Ethiopian sociocultural contexts more carefully — some statements currently seem speculative (e.g., boys are prioritized but receive riskier food).
• Add more emphasis on the novelty of using a Markov model and its practical implications (e.g., forecasting malnutrition trends, guiding resource allocation).

6. Language and Grammar

• Issue : Recurrent grammar and syntax errors, such as:

“Girl had 1.824 times higher likelihood…” → should be “Girls had a 1.824 times higher likelihood…”

“Child who was older than two years of age had more likelihood…” → should be “Children older than two years were more likely…”

Suggestion : A professional language edit is strongly recommended before final acceptance.

 7. Conclusion and Policy Implication

• Issue : The conclusion is assertive but lacks specificity.
• Suggestion :
• Offer specific recommendations. Instead of “enhance adult and maternal education programs,” state what kind: “Implement targeted nutrition literacy campaigns for mothers through health extension workers.”

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

Please submit your revised manuscript by Aug 10 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,

Manzur Kader

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.

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

Reviewer #2: (No Response)

Reviewer #3: All comments have been addressed

Reviewer #4: All comments have been addressed

**********

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

Reviewer #2: Yes

Reviewer #3: Yes

Reviewer #4: Yes

**********

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

Reviewer #2: Yes

Reviewer #3: Yes

Reviewer #4: Yes

**********

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

The PLOS Data policy

Reviewer #2: Yes

Reviewer #3: Yes

Reviewer #4: Yes

**********

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

Reviewer #2: Yes

Reviewer #3: Yes

Reviewer #4: Yes

**********

Reviewer #2: I think the author did not answer some of the questions i asked, including :

1. In the introduction section, it is explained that Ethiopia faces high burden of under-nutrition prevalence, ranking among 15 worst affected nations, perhaps short-term or long-term targets in that field in Ethiopia can be explained as a reference. In this question the author did not answer what i asked.

While the prevalence of malnutrition in Ethiopia is discussed, could comparisons to neighboring countries or regions add further perspective to the problem?

2. The authors can strengthen the practical recommendation section by elaborating on specific interventions for policymakers. For example, what types of maternal education programs would be most effective? in this question i asked the author to give an example of the concrete program

Reviewer #3: Thank you for the opportunity to review the revision of this manuscript. The revised version focuses on addressing critical public health challenges related to child undernutrition in Ethiopia using a continuous-time Markov multistate model. This methodological choice, combined with longitudinal data, contributes meaningfully to understanding the dynamic nature of child nutritional status transitions and the broader implications for targeted interventions.

The respected reviewer has provided thoughtful and insightful feedback, and the author has responded in a structured and reflective manner. Particularly commendable is the reviewer’s question regarding the rationale behind choosing the multistate model, which allowed the author to clarify its advantage over other statistical approaches in capturing intermediate events. Another notable point is the reviewer’s comment on gender-based differences in recovery, which encouraged the author to delve into cultural and biological factors—this reflects a strong level of critical engagement by the reviewer and a well-appreciated elaboration by the author.

While the author has addressed the reviewer’s comments diligently, a couple of aspects could be further considered. For instance, the response to the suggestion on regional comparisons could be improved with quantitative data comparing Ethiopia’s malnutrition rates to neighboring countries like Kenya or Sudan to offer clearer regional context. Additionally, while the discussion around interventions was improved, specific examples of maternal education program formats (e.g., community-based group sessions vs. mobile health interventions) would make the recommendations more actionable.

Overall, the author’s responsiveness and the reviewer’s depth of analysis are both commendable. The paper has improved significantly in clarity and relevance.

Reviewer #4: The manuscript is clearly written and the study is well conceived and methodologically rigorous, offering an important addition to the area of child nutrition by using continuous-time multi-state Markov model rarely used in this area. The application of CIAF in measuring these dynamic nutritional shifts among children under the age of five in Ethiopia is particularly novel and adds practical value to the study. The authors are very responsive to reviewer comments, and much of the writing has been improved for clarity, justification and organization in key sections. Ethical approval is well recorded and data management seems to be appropriate and transparent. If published, this study will provide reasonable information for policy makers to act for malnutrition in vulnerable groups.

**********

what does this mean? ). If published, this will include your full peer review and any attached files.

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Reviewer #2: No

Reviewer #3: Yes:  Bushra Akter

Reviewer #4: Yes:  Taiyeba Akter

**********

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Malnutrition among Under-five Children in Amhara and Oromia Regions, Ethiopia: Continuous Time Markov Multi-State Modeling

PONE-D-24-37812R2

Dear Dafa Duge Wachifo

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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Academic Editor

PLOS ONE

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