Dear Dr.  Abbas,

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Kind regards,

Christina M. Roberts, M.D., M.P.H.

Academic Editor

PLOS ONE

Comments from peer reviewers and academic editor

Reviewer 1:

Thank you so much for providing me the opportunity to review the paper titled, “Sexual and Reproductive Health Challenges Among Street Adolescents in Sylhet City, Bangladesh: A Cross-Sectional Study”. The paper has analyzed an interesting issue, focusing on sexual reproductive health of street adolescents. The paper is well-written, including background, methodology, and results. However, I am suggesting some minor modification to the paper to make it more readable.

First, why the authors have chosen Sylhet city as study site, need explanation. As the case of Sylhet city might not be identical with other cities in Bangladesh regarding adolescent’s experience. It would be better to describe the context of Sylhet city in relation to other cities in Bangladesh.

Second, in the discussion section, the authors described and compared the results with other studies. However, they did not report convincingly the implications for policy and practice. For example, female adolescents are exposed to more sexual abuse than their male counterpart. So what? What policies and practices can be adopted in the family, community or state level to reduce risk and protect them? What is the implication for broader audiences other than the city studied or beyond Bangladesh? What are the socio-cultural barriers for not using SRH service?

Third, the authors used inferential statistics with a convenience sampling. They should report the reasons for not using probability sampling.

Fourth, there is an inconsistency in reporting results. (line no 146-47) Longer duration of street stay was also associated with 174 increased odds of abuse (OR: 1.14, 95% CI: 1.02-1.27, p=0.022) (Table 5). ) (Line 229-231) We found that adolescent girls with a younger age and a shorter duration of stay on the street were 230 significantly more likely to be sexually abused/ Which one is correct?

Reviewer 2:

I think the authors rightly addressed that the street adolescents who engage in early sexual activity, have multiple partners, and are at high risk of sexual abuse and exploitation and tried to explore the significance of this issue in Sylhet region.

Reviewer 3:

This manuscript addresses a significant and underexplored topic in public health. The objective to understand the sexual and reproductive health (SRH) needs, practices, and challenges of the study population is highly relevant and commendable. However, major methodological and analytical concerns currently preclude the acceptance of the manuscript in its present form. Addressing these issues is essential.

Major Comments:

• Sample Size Justification: The sample size was calculated using the prevalence of 'sexual exposure' (71.6%). However, the study's primary objective is to understand a broad range of SRH needs, practices, and challenges, which are not considered for the sample size calculation. Please clarify the rationale for the sample size calculation.

• Risk of Investigator Bias: The description of data collection is unclear. The term "researcher" is not defined, and the involvement of the investigator's wife is noted. As the study team was fully aware of the research objectives, their direct role in conducting sensitive face-to-face interviews introduces a significant risk of observer and interviewer bias.

• Analytical Approach and Statistical Rigor: The analytical strategy requires review. The stratification of results in Tables 1, 3, and 4 by participant sex is not clearly justified by the study objectives. If sex comparison is not a central aim, this stratification is unnecessary.

• The measuring "sexual abuse" are not clearly described. The construction of the multivariate model (Table 5) needs further revised. The model uses current factors (e.g., age, marital status, education at the time of survey) to predict a lifetime history of sexual abuse. This creates a temporal fallacy where a current state is incorrectly presented as influencing a past event. The interpretation of current age as a protective factor (AOR: 0.62) against historical abuse is not logically correct. Similar to other factors as well.

Editor Comments:

You used a semi-structured questionnaire for your research. This implies use of both qualitative and quantitative methods in your study. The qualitative methods and results for your study need additional elaboration. The Equator Network guideline for reporting the results of qualitative health research provides a useful guideline for describing the results of studies like yours.

O'Brien BC, Harris IB, Beckman TJ, Reed DA, Cook DA. Standards for reporting qualitative research: a synthesis of recommendations. Acad Med. 2014;89(9):1245-1251.

https://www.equator-network.org/reporting-guidelines/srqr/

Providing this additional information may be useful in addressing the concerns expressed by Reviewer 3 and, to a lesser extent, Reviewer 1.

While elaborating on the qualitative aspects of your study, I would like you to elaborate on the following items:

• methods for collecting and interpreting the qualitative data in your study,

• elaboration of the major themes developed, for example "sexual abuse",

• Justification for the inferential statistics used to analyze your qualitative data.

I look forward to your reply.

Christina Roberts, MD MPH

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Additional Editor Comments:

Thank you for the opportunity to review your manuscript, “Sexual and Reproductive Health Challenges Among Street Adolescents in Sylhet City, Bangladesh: A Cross-Sectional Study”. I commend you (and your wife) for tackling an under investigated topic with a hard to reach population. The novelty of your research topic is a great strength of your study. However, your peer reviewers and I have a few concerns we would like you to address to strengthen your manuscript before it is acceptable for publication.

1. I have included the comments from our reviewers to inform your efforts if you choose to move forward the revising your paper for publication in PLOS One.

Kind regards,

Christina M. Roberts, M.D., M.P.H.

Academic Editor

PLOS ONE

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

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

Reviewer #3: No

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

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: No

**********

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

Reviewer #3: Yes

**********

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

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

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Reviewer #1: Thank you so much for providing me the opportunity to review the paper titled, “Sexual and Reproductive Health Challenges Among Street Adolescents in Sylhet City, Bangladesh: A Cross-Sectional Study”. The paper has analyzed an interesting issue, focusing on sexual reproductive health of street adolescents. The paper is well-written, including background, methodology, and results. However, I am suggesting some minor modification to the paper to make it more readable.

First, why the authors have chosen Sylhet city as study site, need explanation. As the case of Sylhet city might not be identical with other cities in Bangladesh regarding adolescent’s experience. It would be better to describe the context of Sylhet city in relation to other cities in Bangladesh.

Second, in the discussion section, the authors described and compared the results with other studies. However, they did not report convincingly the implications for policy and practice. For example, female adolescents are exposed to more sexual abuse than their male counterpart. So what? What policies and practices can be adopted in the family, community or state level to reduce risk and protect them? What is the implication for broader audiences other than the city studied or beyond Bangladesh? What are the socio-cultural barriers for not using SRH service?

Third, the authors used inferential statistics with a convenience sampling. They should report the reasons for not using probability sampling.

Fourth, there is an inconsistency in reporting results. (line no 146-47) Longer duration of street stay was also associated with 174 increased odds of abuse (OR: 1.14, 95% CI: 1.02-1.27, p=0.022) (Table 5). ) (Line 229-231) We found that adolescent girls with a younger age and a shorter duration of stay on the street were 230 significantly more likely to be sexually abused/ Which one is correct?

End.

Reviewer #2: I think the authors rightly addressed that the street adolescents who engage in early sexual activity, have multiple partners, and are at high risk of sexual abuse and exploitation and tried to explore the significance of this issue in Sylhet region.

Reviewer #3: This manuscript addresses a significant and underexplored topic in public health. The objective to understand the sexual and reproductive health (SRH) needs, practices, and challenges of the study population is highly relevant and commendable. However, major methodological and analytical concerns currently preclude the acceptance of the manuscript in its present form. Addressing these issues is essential.

Major Comments:

• Sample Size Justification: The sample size was calculated using the prevalence of 'sexual exposure' (71.6%). However, the study's primary objective is to understand a broad range of SRH needs, practices, and challenges, which are not considered for the sample size calculation. Please clarify the rationale for the sample size calculation.

• Risk of Investigator Bias: The description of data collection is unclear. The term "researcher" is not defined, and the involvement of the investigator's wife is noted. As the study team was fully aware of the research objectives, their direct role in conducting sensitive face-to-face interviews introduces a significant risk of observer and interviewer bias.

• Analytical Approach and Statistical Rigor: The analytical strategy requires review. The stratification of results in Tables 1, 3, and 4 by participant sex is not clearly justified by the study objectives. If sex comparison is not a central aim, this stratification is unnecessary.

• The measuring "sexual abuse" are not clearly described. The construction of the multivariate model (Table 5) needs further revised. The model uses current factors (e.g., age, marital status, education at the time of survey) to predict a lifetime history of sexual abuse. This creates a temporal fallacy where a current state is incorrectly presented as influencing a past event. The interpretation of current age as a protective factor (AOR: 0.62) against historical abuse is not logically correct. Similar to other factors as well.

**********

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.

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Reviewer #1: Yes:  Mohammad Shahjahan Chowdhury

Reviewer #2: No

Reviewer #3: Yes:  Faisal Ahmmed

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Sexual and Reproductive Health Challenges Among Street Adolescents in Sylhet City, Bangladesh: A Cross-Sectional Study

PONE-D-25-30858R1

Dear Dr. Abbas,

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.

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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,

Christina M. Roberts, M.D., M.P.H.

Academic Editor

PLOS One

Additional Editor Comments (optional):

Thank you for your responses to the comments from myself and the reviewers.

Reviewer 3 corrently identifies that this is a cross sectional study and you are unable to make causal inferences based on this data. Reviewer 3 also notes that you cannot address this limitation except by commenting on this limitation in your discussion. I think you are careful not to make causal statements in your manuscript and I think the first statement in yout limitation section correctly aknowledges this limitation.

"Limitations and Strengths

This study has several limitations. The cross-sectional design prevents the establishment of causal relationships."

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

Reviewer #2: All comments have been addressed

Reviewer #3: All comments have been addressed

**********

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

Reviewer #2: Yes

Reviewer #3: Partly

**********

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

Reviewer #2: Yes

Reviewer #3: No

**********

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

**********

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

Reviewer #2: Yes

Reviewer #3: Yes

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Reviewer #2: (No Response)

Reviewer #3: The authors attempted to respond to the reviewer’s comments; however, it is not possible to fully address all of them at this stage, except through acknowledgment as study limitations. Thank you for the effort.

Specially, for any statistical regression analysis, two types of variables are essential: the dependent variable (e.g., sexual abuse) and independent variables (e.g., age, marital status, education). In epidemiology, exposure variables (independent variables) should occur before the outcome (dependent variable) to support causal interpretation. Although the data were collected at the time of the interview, any observed statistical association between variables, for example, marital status and sexual abuse can only be considered causal if the exposure (marital status) was measured before the occurrence of the outcome (sexual abuse). This temporal ordering should be maintained for all risk and protective factor analyses. However, it is unclear whether all exposure variables were collected prior to the occurrence of sexual abuse. I did not find clear text or procedure for the measurement of sexual abuse and exposure variables.

**********

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 #2: Yes:  Prof Dr Md Siddiqur Rahman

Reviewer #3: No

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