Dear Dr. Fenta,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

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ACADEMIC EDITOR:

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Please submit your revised manuscript by Dec 19 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,

Omar Enzo Santangelo

Academic Editor

PLOS ONE

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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: Partly

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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: No

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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: The manuscript is title is appropriate and on an important public health issue. It will contribute to knowledge.

The abstract is well structured and content appropriate. A minor grammatical error needs to be corrected.

The introduction provides the statement of the problem, magnitude of the problem and objectives of the study.

The method section is well written and detailed.

Results are well presented

The study findings are well discussed and the conclusion is appropriate

Reviewer #2: Reviewer Comments on the Article

Title: Magnitude of Childhood Immunization and Its Associated Factors in Sub-Saharan Africa: A Mixed-Effect Count Regression Analysis

This study is important because it covers a large geographical area and compares 33 countries simultaneously. It also contributes new cross-country comparisons and identifies significant predictors of childhood immunization in Africa. However, I would like to raise the following comments and questions:

1. Data Source and Time Period:

The study uses “the most recent Demographic and Health Surveys (DHS) data from 33 SSA countries between 2012 and 2022.” Since this period spans ten years, do you believe that meaningful comparisons are possible across such a wide time frame? Knowledge, attitudes, and practices regarding childhood immunization have improved considerably over the years. For example, increasing trends in immunization coverage are reported at https://doi.org/10.1371/journal.pgph.0004206.

It is recommended to restrict the data range to surveys conducted within a 5-year window or, alternatively, include survey year as a covariate or random effect to control for temporal variability.

2. Operational Definition of the Dependent Variable:

Please include a clear operational definition for the dependent variable, specifying that it represents the total of eight vaccine doses. Other studies categorize childhood immunization as including one dose of BCG, three doses of pentavalent DPT–HepB–Hib, three doses of PCV, three doses of OPV, two doses of Rota virus, and one dose of MCV1 (see https://doi.org/10.1186/s12199-021-00984-8).

3. Statistical Analysis Section:

The statement “Logistic regression and survival analysis are two techniques for modeling such data after the count is converted to binary values [21, 32]” duplicates information already presented in the introduction. Moreover, since your main analytical approach is count regression, this section should emphasize the advantages of mixed-effect count regression (e.g., handling over dispersion, accounting for clustering, and managing zero-inflated data).

Elaborating on why this model was preferred based on your data structure would strengthen the methodological justification.

4. Clarification Needed:

The statement “The traditional count regression model’s application is inappropriate and reasonable since it assumes that there is no relationship between individual data [30]” is unclear. Please clarify what you mean — specifically, how the assumption of independence among individual observations affects model suitability.

5. Model Selection and Over dispersion Issue:

Expanding the explanation of why MZIP was finally chosen if overdispersion was detected (variance-to-mean ratio = 1.53), then a Negative Binomial–based approach might have been more appropriate than ZIP.

6. Interpretation and Policy Relevance

The discussion should better link statistical results with public health implications. For example, highlight how maternal education, socioeconomic status, or healthcare accessibility influence vaccination uptake. The policy implications of these predictors should be explicitly discussed to enhance the paper’s applied relevance.

Overall Recommendation

The manuscript addresses an important topic and uses an appropriate analytical framework. However, before publication, the paper requires revisions to improve methodological clarity, consistency in model selection, and explicit operational definitions. Once these issues are addressed, the study has strong potential to contribute valuable evidence to the literature on childhood immunization and health equity in Sub-Saharan Africa.

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

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Reviewer #1: Yes: Prof. Tanimola Makanjuola Akande

Reviewer #2: Yes: Alebachew Taye Belay

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Attachments

Attachment

Submitted filename: PONE-D-25-19476_reviewer1.pdf

Magnitude of childhood immunization and its associated factors in Sub-Saharan Africa: A mixed effect count regression analysis

PONE-D-25-19476R1

Dear Dr. Fenta,

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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Kind regards,

Omar Enzo Santangelo

Academic Editor

PLOS One

Additional Editor Comments (optional):

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

Reviewer #2: All comments have been addressed

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

Reviewer #2: Yes

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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

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

Reviewer #2: Yes

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Reviewer #2: The authors are thanked for their careful and constructive responses to all reviewer comments. All previously raised concerns have been adequately addressed, and the revisions have significantly improved the clarity, methodological rigor, and overall quality of the manuscript. I have no further concerns regarding research ethics, publication ethics, or dual publication.

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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: No

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