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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: Yes

Reviewer #2: Yes

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Reviewer #1: Comments to the Author

� Technical Soundness & Data Support for Conclusions

The study is technically sound, with data largely supporting conclusions. However, clarify causality limitations due to cross-sectional design and address counterintuitive findings

� Statistical Rigor

� Assessment:-

� Generally acceptable with minor clarifications needed

� Spatial analyses are robust, but provide:-

� Timeframe of DHS data per country

� Multicollinearity assessment in GWR

� Criteria for cluster/household inclusion.

� Methodological Standards

� Adheres to spatial epidemiology standards but requires:-

� Enhanced documentation of variable selection for GWR

� Justification for bandwidth selection in spatial analyses.

� Conclusion Support

� Conclusions align with results, but strengthen by:-

� Discussing drivers behind spatial clusters

� Integrating policy implications for identified hotspots.

� Data Repository Compliance

� Data availability statement is appropriate, citing DHS program access. Ensure supplementary country-level statistics are included.

� Presentation & Language

� Generally intelligible but requires:-

� Minor English editing for conciseness

� Higher-resolution maps with clear legends/scales.

� Detailed Feedback

� Strengths

� Addresses critical public health challenge aligned with SDG 6

� Rigorous spatial methodology with large representative sample

� Clear structure and contextualization.

� Major Issues

� Methods Detail:-

� Specify temporal range of DHS datasets used.

� Detail handling of missing data and variable coding.

� Please clarify the time frame of the DHS data included for each country. Specify inclusion/exclusion criteria for clusters and households, and provide more detail on how variables were selected and handled in the GWR, including how you addressed multicollinearity

� Interpretation of Spatial Results and Conclusion:-

� Assessment:-Valid but requires more cautious language

� The conclusion that larger households are negatively associated with open defecation may seem counterintuitive and could benefit from referencing cultural/family dynamics or sanitation sharing behavior.

� Statements like “richest households negatively associated” need caution:-correlation ≠ causation, and the pathways should be clarified.

� Explain mechanisms driving East/West African hotspots beyond statistical identification.

� The spatial analyses are robust, but the discussion would benefit from deeper interpretation of the drivers behind identified hotspots and coldspots, and more explicit policy implications for regions with high prevalence

� Causal Inference and Confounding:-

� Emphasize cross-sectional limitations regarding causal inference in discussion.

� Discuss potential unmeasured confounders

� Urban vs. Rural Residency:-

� The finding that both urban and rural residency are negatively associated with open defecation is counterintuitive. Please clarify this result and discuss possible explanations or limitations in the data or analytic approach.

� Minor Issues

� Tables/Figures:-

� Ensure that all figures/maps are high-resolution and include legends and scales for clarity.

� Ethics and Data Statements:-

� Assessment:-Fully compliant

� The ethics and data availability statements are appropriate and transparent, but consider explicitly listing the countries and IRBs where possible IRBs.

� Clearly stated that this is a secondary analysis of DHS data, which had ethical clearance and informed consent in all countries.

� Language:-

� The manuscript is generally clear but would benefit from minor English language editing for conciseness and flow.

� Suggestions

� Include a limitations subsection addressing:-

� Regional data gaps (e.g., unstable regions not covered)

� Temporal variations in DHS collection.

� Expand policy recommendations targeting hotspot interventions.

� Comments to the Authors

� Strengths

� The study addresses a major public health and development challenge in sub-Saharan Africa, with direct relevance to SDG 6.

� Use of large representative DHS datasets and advanced spatial methods adds rigor and regional nuance.

� The Study is generally well-structured, with clear aims, methods, and results.

Reviewer #2: Reviewers comment

The article investigates “The Prevalence, Spatial Distribution, and Geographic Weighted Regression of Open Defecation Practices in sub-Saharan Africa Using Demographic and Health Survey (DHS) Data.” The authors establish a strong foundation for their study by clearly identifying research gaps and employing appropriate methodologies to address these deficiencies. The sample size is adequate, and the data analysis tools used are sufficient. The methodology of the study is robust, ensuring reproducibility. Overall, it offers valuable insights into open defecation in sub-Saharan Africa, providing evidence that could inform WASH interventions, policy, and practice. However, the authors do not emphasise the key novel contributions of the study. Although a wealth of results is presented, the discussions fail to thoroughly build on the results, explore the practical implications of these findings and how they can be applied to stimulate interventions to effectively reduce open defecation. I suggest authors improve the level of English used for the write-up.

Specific comments:

1.The section on abstract: The abstract gives a summary of the study, providing essential details such as the basis for the study, sample size, methodology, results, and discussions. The abstract can be strengthened by the following modifications.

•The conclusion is a repeat of the methodology and the last sentence of the background. The conclusion should highlight the key finding(s) and their implication on policy and future research. What makes this study novel?

•The study asserts 23.24% of open defecation practices in Sub-Saharan Africa. How does this compare to the value obtained by the JMP? This should be highlighted briefly.

2.The section on introduction: The introduction provides a good background to the study, citing relevant literature and establishing the basis for the study. However, the write-up is disjointed and lacks chronology. Literature on prevalence, access to WASH services, and global and regional contexts of OD has been intertwined. It is recommended that the introduction be rewritten to follow a chronology of thought. Minor comments include:

•There should be spacing between the square brackets and words. Eg. …global crises [1] NOT global crises[1]. This seems to appear throughout the write-up.

•Line 71-71 It would be essential to state the most current prevalence of OD in SSA. What is the prevalence?

•Line 77-78 Authors state OD is prevalent in parts of SSA? Authors should state or give examples of which countries of SSA.

3.The section on study area:

•Line 118 to 123 should be added as part of the introduction

4.The section on methodology: The methodology discussed is robust and reproducible. This gives credence to the data collected.

5.The section on Results and Discussion:

•Line 373 Separate bracket from “Leone”

•Lines 406 to 409: Authors provide reasons for the disparity in OD observed in SSA, Haiti and Indonesia. The reasons given are generic but written as though empirical. Authors should reword based on available evidence.

•Line 420 Check punctuations. Separate punctuations from words.

•Lines 430 to 436, Ghana is missing from the hotspot and coldspot classification. The authors measured access to water, and it will be interesting to highlight how this corresponds to the coldspot and hotspot classification of the OD region.

•Line 443-44 “Significant clusters were observed across nearly all regions of the region” should be reworded for clarity.

•Line 467 The GWR analysis predicted the influence of family size on OD. It would be interesting to triangulate family size, access to water and OD.

•Lines 467 to 480 Family size has a bearing on family income. Family income level determines creditworthiness and, by extension, access to targeted WASH loans for sanitation infrastructure. This could be a reason for the disparity in OD observed for different family sizes within the regions. Authors can consider this in the discussion.

oAge bracket of head of household is too wide (11 to 35 years). Better inferences can be drawn if the age brackets are reduced further into more categories. For example, lower age brackets can influence inferences on household size, income, access to water and OD.

6.The section on Conclusion:

•The conclusions and recommendations seem to be an extension of the results and discussion. Authors must only highlight the novelty of the study, the key findings, and their implications for policy, practise, and future research.

7.Figures

•For Fig 1: Countries like Seychelles, Equatorial Guinea, Mauritius and Cape Verde have been duplicated

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Reviewer #1: Yes:  Achiso, Yisihak

Reviewer #2: No

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Attachments

Attachment

Submitted filename: PLOS ONE Review.pdf

Attachment

Submitted filename: Reviewers comment_Open Defecation.docx

Dear Dr. Demoze,

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: 

2. Also, table 5 is not really necessarily in one specific table. You can put it under table 4.

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

Please submit your revised manuscript by Nov 21 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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We look forward to receiving your revised manuscript.

Kind regards,

D. Daniel, Ph.D.

Academic Editor

PLOS ONE

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

Reviewer #2: All comments have been addressed

**********

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

Reviewer #2: Yes

**********

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

Reviewer #2: Yes

**********

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

The PLOS Data policy

Reviewer #2: Yes

**********

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

Reviewer #2: Yes

**********

Reviewer #2: Line 522

increasing awareness of health risks related to open defecation [65].Such kind of families are...

Authors should space the full stop from the word "such"

**********

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If you choose “no”, your identity will remain anonymous but your review may still be made public.

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Reviewer #2: No

**********

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The Prevalence, Spatial Distribution and Geographic Weighted Regression of Open Defecation Practice in sub-Saharan Africa Using Demographic and Health Survey (DHS) Data

PONE-D-25-12133R2

Dear Dr. Demoze,

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,

D. Daniel, Ph.D.

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments: