Prevalence and determinants of non-communicable diseases risk factors among reproductive aged women of Nepal: Results from Nepal Demographic Health Survey 2016.

INTRODUCTION: Non-Communicable Diseases (NCDs) are the major killer diseases globally. They share the common risk factors such as smoking, harmful use of alcohol, physical inactivity, and low fruits/vegetable consumption. The clustering of these risk factors multiplies the risk of developing NCDs. NCDs affect women inequitably causing significant threats to the health of women and future generations. But, the distribution and clustering of NCDs risk factors among Nepalese women are not adequately explored yet. This study aimed to assess the clustering and socio-demographic distribution of major NCD risk factors in Nepalese women.
METHODS: We used the data of 6,396 women age 15 to 49 years from the recent Nepal Demographic and Health Survey (NDHS). The survey applied a stratified multi-stage cluster sampling method to select the eligible women participants from across Nepal. We analyzed data using the multiple Poisson regression and reported the adjusted prevalence ratio (APR).
RESULTS: A total of 8.9% of participants were current smokers, 22.2% were overweight and obesity and 11.5% of the participants were hypertensive. Around 6% of participants had co-occurrence of two NCDs risk factors. Smoking, overweight and obesity and hypertension were significantly associated with age, education, province, wealth index, and ethnicity. Risk factors were more likely to cluster in women of age40-49 years (ARR = 2.95, 95%CI: 2.58-3.38), widow/separated (ARR = 3.09; 95% CI:2.24-4.28) and among Dalit women (ARR = 1.34; 95% CI:1.17-1.55).
CONCLUSION: This study found that NCDs risk factors were disproportionately distributed by age, education, socio-economic status and ethnicity and clustered in more vulnerable groups such as widow/separated women and the Dalit women.

Introduction

Globally, non-communicable diseases (NCDs) are the number one cause of death and disability. NCDs account for 41 million deaths each year out of which 85% of the deaths occur in low and middle-income countries (LMICs), and nearly half of the deaths (15 million out of 41 million) occur between the age of 30 and 69 years [1-3]. Cardiovascular diseases, cancers, diabetes, and respiratory diseases, also called the ‘Group of Four’ are responsible for 80% of all NCDs deaths [3]. NCDs are mostly linked with the behavioral (such as tobacco use, harmful use of alcohol, low intake of fruits and vegetables, and physical inactivity) and metabolic (such as obesity, blood sugar, blood pressure, and cholesterol level) risk factors [3] The co-occurrence of two or more of these factors in an individual is referred to as clustering of the risk factors that increase the risk of developing NCDs [4, 5]. Evidence shows that women are more likely to experience the co-occurrence of behavioral and metabolic risk factors thus increasing the risk of NCDs among themselves and in a future generation [6-8]. In Nepal, 15.5% of the population in general, and 11.4% of women reported have three or more risk factors for NCDs [9]. This is rather indication of a higher prevalence of NCDs risk factors in Nepal that may place Nepalese women to the highest disease burden. Compared to men, women also experience fewer symptoms and show less apparent signs of certain NCDs like cardiovascular disease. They are thus less likely to be identified and treated or less likely to be the focus of disease prevention [10]. Furthermore women with NCD risk factors have an adverse impact on their reproductive health as well as in fetal health [11-14]. So, tackling NCDs in women needs a systematic understanding of sociodemographic determinants of to major NCDs risk factors and their clustering [15, 16]. However, in the context of Nepal, there is a paucity of women-focused NCDs studies especially considering social determinants. This study, therefore, aims to assess the magnitude of selected risk factors, individually and in a cluster, and determines their socio-demographic distributions in Nepalese women.

Methodology

This study used data from the 2016 Nepal Demographic Health Survey (NDHS). NDHS is a periodic survey consisting of a nationally representative sample. The survey used the stratified multi-stage cluster sampling to select individual participants. Initially, 383 primary sampling units (PSU) (wards) were selected based on the probability proportional to PSU size. Then, 30 households per PSU (total 11040 households) were selected using an equal probability systematic selection criterion. A detailed description of the NDHS sampling method is reported elsewhere [17]. The NDHS 2016 adopted a universally standardized DHS questionnaire and measured blood pressure with the validated instrument for the first time in the NDHS series. Blood pressure and anthropometric measurements were only obtained from the systematically selected subsample of 12862 study participants. For this study, we only included 6396 women between 15 and 49 years who had their blood pressure recorded.

Data collection

Blood pressure

Trained enumerator measured blood pressure with UA-767F/FAC (A&D Medical, Tokyo, Japan) blood pressure machines. Enumerators took three readings of blood pressure at the interval of five minutes between each reading and averaged the last two readings to get more accurate blood pressure readings. Participants whose systolic blood pressure (SBP)at the level of 140 mmHg or higher and/or diastolic blood pressure (DBP) of≥90 mmHg or higher or currently taking antihypertensive medicines at the time of data collection were considered hypertensive [17].

Overweight and obesity

Weight and height were measured as described in the DHS standard protocol [18]. To calculate body mass index (BMI), weight in kilograms was divided by the height in meter-squared. Women having (BMI ≥ 25kg/m2) were categorized as ‘overweight and obesity” and the remaining (BMI< 25kg/m2) were categorized as “No overweight and obesity” [17].

Current tobacco use

Current tobacco use includes either daily or occasional smoking or use of smokeless tobacco (snuff by mouth, snuff by the nose, chewing tobacco and betel quid with tobacco) [17].

Explanatory variables

Information related to socio-demographic variables including the age of the participants, ethnicity, educational status, place of residence (rural/urban), province and ecological zone and wealth index were extracted from the NDHS original datasets.

Statistical analysis

All analyses were performed on STATA 15.1 version using survey (svy) set command, defining clusters and sampling weight information. All estimates were weighted by sample weights and presented with 95% confidence intervals (CI). Prevalence estimates were calculated using Taylor series linearization. Chi-square test was used for bivariate analysis to test associations between covariates and dependent variables. Furthermore, multiple Poisson regression was used to calculate the adjusted prevalence ratio (APR) [19, 20]. The numbers of risk factors present within each participant (from 0 to 3) were counted to assess the clustering of risk factors and analyzed using the multiple Poisson regression.

Ethical consideration

The NDHS 2016 sought ethical approval from the Ethical Review Board (ERB) of the Nepal Health Research Council (NHRC), Nepal and ICF Macro Institutional Review Board, Maryland, USA. Written informed consent was obtained from each participant before enrolling in the survey.

Results

Table 1 depicts the sociodemographic characteristics of the study participants. Mean age of participants was 29.54±8.92 years and just over half (53.9%) of the participants were 15–29 years. The largest proportion (36.6%) of the participants were from the Janjati group (indigenous group). One third (33.3%) had no formal schooling while 76.6% of the participants were married. Most of the participants belonged to the Terai belt (49.9%) and rural areas (63.3%). Similarly, 22.4% and 20.9% of participants belonged to richer and the richest wealth quintile. Most of the participants were engaged in agriculture or were self-employed.

Table 1

Socio-demographic distribution of participants.

Characteristics	un-weighted count	weighted percent
Age group
15–29	3,498	53.9
30–39	1,697	27.1
40–49	1,201	18.9
Educational status
No education	2,161	33.3
Primary	1,017	16.7
Secondary	2,324	35.5
Higher	894	14.5
Marital status
Never in union	1,305	20.7
Married or living together	4,919	76.6
Widowed/divorced/separated	172	2.7
Ecological region
Mountain	454	6.1
Hill	2,916	44.1
Terai	3,026	49.9
Residence
Rural	4,129	63.0
Urban	2,267	36.9
Province
Province 1	909	16.8
Province 2	1,051	19.9
Province 3	853	22.1
Gandaki	803	9.8
Province 5	988	16.9
Karnali	888	5.7
Sudurpaschim	904	8.8
Wealth index
Poorest	1,347	16.9
Poorer	1,304	19.1
Middle	1,319	20.6
Richer	1,319	22.4
Richest	1,107	20.9
Occupational status
Did not work	2,003	32.3
Services	863	15.0
Agriculture/ self-employed	3,196	46.9
Manual	331	5.8
Ethnic group
Advantage group	2,254	31.3
Dalit	851	12.6
Janjati	2,268	36.6
Other	1,023	19.5
Total	6,396	100

Fig 1 shows the NCDs risk factor prevalence by the number of factors. More than one-fourth of the participants had one NCDs risk factor and 6.3% of participants had two NCD risk factors.

Fig 1

Prevalence of number of NCDs risk factors among participants.

Distribution of non-communicable diseases risk factors

The prevalence of current tobacco use was 8.9%. Women of age 40–49 years (22.4%), with no education (18.8%) and widowed/divorced/separated women (29.1%) had the highest prevalence of current tobacco use as indicated in "Table 2". Similarly, current tobacco use was significantly associated with the ecological zone, province, wealth index, occupation, and ethnicity "Table 2".

Table 2

Prevalence (%) of non-communicable diseases risk factors among 15–49 years women.

	Current tobacco use		Overweight and obesity		Hypertension
Characteristics	n	Prevalence	n	Prevalence	n	Prevalence
Age(yrs)
15–29	3,498	2.6 [1.9–3.4]	3,169	11.9 [10.6–13.5]	3,498	4.0 [3.3–4.9]
30–39	1,697	12.1 [10.3–14.1]	1,647	33.3 [29.9–36.8]	1,697	13.1 [11.3–15.1]
40–49	1,201	22.4 [19.3–25.8]	1,197	34.2 [30.3–38.4]	1,201	24.9 [21.9–28.3]
P-value		<0.001		<0.001		<0.001
Educational level
no education	2,161	18.8 [16.6–21.2]	2,073	19.9 [17.6–22.4]	2161	12.9 [11.1–14.8]
Primary	1,017	9.9 [7.8–12.4]	936	27.8 [24.4–31.6]	1,017	12.39 [10.4–14.7]
secondary	2,324	2.5 [1.8–3.3]	2,173	20.4 [17.7–23.3]	2,324	7.8 [6.6–9.3]
Higher	894	0.7 [0.3–1.4]	831	27.0 [22.9–31.7]	894	9.1 [6.4–12.7]
P-value		<0.001		<0.001		<0.001
Marital status
never in union	1,305	1.8 [0.9–3.4]	1,305	5.3 [3.9–6.9]	1305	2.9 [2.1–4.1]
married or living together	4,919	10.1 [9.0–11.3]	4,537	27.3 [25.0–29.7]	4919	12.2 [10.9–13.6]
widowed/divorced/separated	172	29.1 [21.1–38.6]	171	25.5 [18.2–34.3]	172	16.9 [11.4–24.2]
P-value		<0.001		<0.001		<0.001
Ecological zone
Mountain	454	14.7 [10.4–19.9]	412	20.7 [15.0–27.7]	454	10.6 [7.2–15.5]
Hill	2,916	10.9 [9.2–13.1]	2,776	26.9 [23.9–30.2]	2916	12.2 [10.4–14.3]
Terai	3,026	6.4 [5.3–7.6]	2,825	18.5 [16.4–20.7]	3026	8.8 [7.7–10.1]
P-value		<0.001		<0.001		0.008
Residence
Urban	4,129	8.5 [7.1–10.2]	3,892	26.3 [23.7–29.0]	4,129	11.0 [9.6–12.6]
Rural	2,267	9.6 [8.18–11.21]	2,121	15.6 [13.7–17.9]	2,267	9.5 [8.1–11.2]
P-value		0.334		<0.001		0.171
Province
Province 1	909	10.8 [8.6–13.5]	863	27.6 [23.6–32.0]	909	10.7 [8.8–13.1]
Province 2	1,051	3.0 [2.0–4.5]	953	10.9 [8.9–13.5]	1,051	6.6 [5.4–8.1]
Province 3	853	10.1 [7.2–14.0]	815	34.9 [29.5–40.6]	853	13.3 [10.2–17.2]
Gandaki	803	10.1 [7.4–13.8]	774	31.7 [27.7–35.9]	803	15.4 [12.5–18.8]
Province 5	988	7.5 [5.6–9.9]	930	18.8 [15.7–22.3]	988	11.9 [9.5–14.8]
Karnali	888	15.9 [13.1–19.3]	833	10.6 [7.8–14.2]	888	7.4 [5.4–10.2]
Sudurpaschim	904	12.4 [10.0–15.3]	845	9.1 [5.8–14.2]	904	5.1 [3.55–7.14]
P-value		<0.001		<0.001		<0.001
Wealth index
Poorest	1,347	19.5 [17–22.3]	1,265	10.0 [8.1–12.4]	1347	8.3 [6.6–10.5]
Poorer	1,304	10.7 [9.1–12.6]	1,215	15.6 [13.5–18.0]	1304	10.8 [8.9–12.9]
Middle	1,319	6.2 [4.9–7.8]	1,227	14.1 [11.8–16.7]	1319	9.0 [7.5–10.9]
Richer	1,319	6.6 [4.1–10.4]	1,246	23.4 [20.8–26.3]	1,319	8.49 [6.8–10.5]
Richest	1,107	3.71 [2.4–5.7]	1,060	44.9 [41.1–48.8]	1107	15.4 [13.2–17.8]
P-value		<0.001		<0.001		<0.001
Occupation*
Did not work	2,003	4.4 [3.5–5.6]	1,826	24.1 [21.7–26.8]	2,003	9.92 [8.6–11.5]
Services	863	6.4 [4.3–9.4]	836	39.5 [34.8–44.4]	863	14.2 [11.1–17.9]
Agriculture(self-employed)	3,196	12.4 [10.94–13.98]	3,035	14.6 [13.0–16.3]	3,196	9.5 [8.3–10.9]
Manual	331	12.6 [8.7–17.8]	313	30.9 [23.8–38.9]	331	11.2 [7.7–16.1]
P-value		<0.001		<0.001		0.014
Ethnicity
Advantage group	2,254	7.2 [6.1–8.6]	2,142	24.5 [21.1–28.3]	2254	9.8 [8.33–11.62]
Dalit	851	14.9 [12.1–18.3]	782	18.5 [15.3–22.0]	851	10.7 [8.5–13.3]
Janjati	2,268	11.3 [9.6–13.3]	2,146	26.6 [23.3–30.1]	2268	12.1 [10.5–14.00]
Others	1,023	3.2 [2.21–4.6]	943	13.2 [10.9–15.8]	1,023	8.1 [6.64–9.72]
P-value		<0.001		<0.001		0.005
Total	6396	8.9 [7.9–10.1]	6,013	22.2 [20.5–24.0]	6396	10.4 [9.4–11.7]

*10 cases missing

The adjusted multivariate model shows significantly higher prevalence of tobacco use among women of 40–49 years of age (APR: 3.70; 95% CI: 2.65–5.17), having no education, widowed/divorced/separated (APR: 1.04; 95% CI:1.4–3.98), from province one, in the lowest wealth quintile and among women from Dalit ethnic/caste group (APR:1.68; 95% CI:1.27–2.23). However, the prevalence of tobacco use was significantly lower among poor women (APR: 0.69; 95% CI:0.55–0.86) residing on province 5 (APR: 0.64; 95% CI: 0.45–0.90)) “Table 3”.

Table 3

Relationship of socio-demographic characteristics with non-communicable disease risk factors.

	Current tobacco use APR	Overweight and obesity APR	Hypertension APR
Age group (Years)
15–29	1	1	1
30–39	2.46 [1.77–3.43]***	1.85 [1.60–2.13]***	2.8 [2.09–3.76]***
40–49	3.7 [2.65–5.17***	1.97 [1.68–2.31]***	5.73 [4.25–7.71]***
Educational status
No education	1	1	1
Primary	0.71 [0.57–0.88]**	1.27 [1.10–1.46]**	1.28 [1.03–1.59]*
Secondary	0.28 [0.20–0.40]***	1.09 [0.94–1.25]	1.2 [0.88–1.62]
Higher secondary level or more	0.09 [0.04–0.22]***	1.12 [0.93–1.36]	1.31 [0.90–1.91]
Marital status
Never in union	1	1	1
Married or living together	1.37 [0.75–2.49]	4.02 [2.98–5.40]***	1.97 [1.35–2.89]***
Widowed/divorced/separated	2.03 [1.04–3.98]*	3.29 [2.06–5.25]***	1.91 [1.11–3.30]*
Ecological region
Mountain	1	1	1
Hill	1.01 [0.72–1.43]	0.8 [0.57–1.11]	0.79 [0.55–1.13]
Terai	1.19 [0.79–1.79]	0.71 [0.50–1.01]	0.71 [0.48–1.06]
Residence
Rural	1	1	1
Urban	1.16 [0.96–1.41]	0.98 [0.85–1.13]	0.94 [0.75–1.16]
Province
Province 1	1	1	1
Province 2	0.28 [0.17–0.46]***	0.46 [0.36–0.58]***	0.61 [0.43–0.87]**
Province 3	1 [0.72–1.39]	0.9 [0.76–1.07]	1.1 [0.80–1.51]
Gandaki	0.92 [0.67–1.26]	1 [0.84–1.19]	1.3 [0.93–1.82]
Province 5	0.64 [0.45–0.90]**	0.71 [0.59–0.86]***	1.2 [0.89–1.63]
Karnali	1.02 [0.75–1.39]	0.52 [0.38–0.71]***	0.81 [0.53–1.25]
Sudurpaschim	0.89 [0.66–1.21]	0.42 [0.28–0.63]***	0.58 [0.37–0.89]*
Wealth index
Poorest	1	1	1
Poorer	0.69 [0.55–0.86]***	1.58 [1.27–1.97]***	1.34 [1.00–1.79]
Middle	0.51 [0.38–0.68]***	1.61 [1.23–2.12]***	1.22 [0.88–1.69]
Richer	0.52 [0.34–0.81]**	2.32 [1.80–2.97]***	1.04 [0.72–1.48]
Richest	0.37 [0.22–0.60]***	3.38 [2.63–4.34]***	1.45 [1.00–2.09]*
Occupational status
Did not work	1	1	1
Services	1.5 [0.98–2.27]	1.05 [0.93–1.19]	1.02 [0.81–1.28]
Agriculture(self-employed)	1.3[0.97–1.74]	0.71[0.62–0.82]***	0.78[0.64–0.96]*
Manual	1.4 [0.93–2.11]	0.9 [0.73–1.12]	0.78 [0.53–1.16]
Ethnic group
Advantage group	1	1	1
Dalit	1.68 [1.27–2.23]***	1.09 [0.86–1.36]	1.47 [1.09–1.97*]
Janjati	1.24 [0.98–1.57]	1.1 [0.97–1.26]	1.28 [1.04–1.57*]
Others	0.78 [0.49–1.26]	0.82 [0.67–1.02]	1.34 [0.97–1.86]

*** significant at p-value < 0.001.

**significant at p-value < 0.01.

* significant at p-value < 0.05.

The prevalence of overweight and obesity/obesity was 22.2%., which was significantly high in women age 40–49 years compared to that of 15–29 years (11.9%) women "Table 2". The prevalence of overweight and obesity significantly varied by education status "Table 2". Compared to never union, the prevalence of overweight and obesity was significantly higher among married/ living together women (27.3%) and divorced/widowed/separated women (25.5%). In multivariable analysis, the prevalence of Overweight and obesity was significantly higher in the elder age group (APR:1.97; 95% CI:1.68–2.31), married women (APR:4.02; 95% CI: 2.98–5.40), and those women belonging to wealthiest quintile (APR-3.38; 95% CI-2.63–4.34). However, women residing in Sudurpaschim province (APR: 0.42; 95% CI: 0.38–0.71) and employed on agriculture had lower (APR: 0.71; 95% CI: 0.62–0.82) had lower prevalence of overweight and obesity “Table 3”.

The prevalence of hypertension was 10.5%. It significantly varied by the age of participants, For instance, 40–49 years participants had the highest rate of hypertension. Secondary education was significantly associated with a higher prevalence of hypertension compared to primary and no education. Likewise, the rate of hypertension was also significantly different in the province, wealth index, occupation, and ethnicity "Table 2".

Multivariable analysis shows that higher prevalence of hypertension on elder age group women (APR; 5.73;95% CI: 4.25–7.7) among married women (APR: 1.97; 95% CI: 1.35–1.68), belonging to the wealthiest group (APR:1.45; 95% CI: 1.00–2.09), among Dalit women (APR;1.47; 95% CI: 1.09–1.97), and among the Janjati women (APR: 1.28; 95% CI: 1.04–1.57). But hypertension was less prevalent (APR: 0.58; 95% CI: 0.37–0.89) among women residing on Sudurpaschim province and engaged in agriculture (APR: 0.78; 95% CI: 0.62–0.82) “Table 3”.

Multivariable analysis of socio-demographic characteristics with noncommunicable diseases risk factors

Women of 40–49 years were more likely to experience NCD risk factors than 15–29 years aged women (ARR: 2.95; 95% CI: 2.58–3.38) "Table 4". Compared to the women with no education, women who had pursued a secondary level of education were less likely (ARR: 0.87; 95% CI: 0.77–0.98) to experience NCD risk factors. The adjusted risk ratio for married and widowed/divorced/separated women was almost 3 times (ARR: 2.91; 95% CI: 2.77–3.74) and (ARR: 3.09; 95% CI: 2.24–4.28) than that of women who had never in a union. Similarly, the richest women were more likely (ARR: 1.5; 95% CI: 1.27–1.77) to suffer from NCDs risk factors in comparison to the poorest women. Furthermore, women employed in the agriculture sector were less likely (ARR: 0.83; 95% CI: 0.75–0.92) to suffer from NCD risk factors than women who were not employed. Regarding ethnicity, Dalit women were more likely (ARR: 1.34; 95% CI: 1.17–1.55) to have NCD risk factors in comparison to advantage group "Table 4".

Table 4

Mean number of NCD risk factors and multivariable analysis of clustering of NCD risk factors.

Characteristics	Mean number	Clustering of NCD risk factors Adjusted Risk Ratio(ARR)
Age group(in yrs)
15–29	1.1[1.1,1.1]
30–39	1.2[1.2,1.3]	2.16[1.90–2.46]***
40–49	1.3[1.3,1.4]	2.95[2.58–3.38]***
Educational status
No education	1.3[1.2,1.3]
Primary	1.3[1.2,1.4]	1.07[0.97–1.19]
Secondary	1.2[1.2,1.2]	0.87[0.77–0.98]*
Higher	1.2[1.1,1.3]	0.92[0.78–1.08]
Maritial status
Never in union	1.1[1.0,1.1]
Married or living together	1.2[1.2,1.3]	2.91[2.27–3.74]***
Widowed/divorced/separated	1.3[1.2,1.4]	3.09[2.24–4.28]***
Ecological region
Mountain	1.3[1.2,1.3]
Hill	1.3[1.2,1.3]	0.88[0.74–1.04]
Terai	1.2[1.2,1.3]	0.85[0.70–1.03]
Residence
Rural	1.3[1.2,1.3]
Urban	1.2[1.2,1.3]	1.01[0.91–1.12]
Province
province 1	1.2[1.2,1.3]
province 2	1.2[1.1,1.2]	0.45[0.37–0.55]***
province 3	1.3[1.2,1.3]	0.99[0.87–1.12]
Gandaki	1.3[1.2,1.4]	1.07[0.92–1.23]
province 5	1.2[1.2,1.2]	0.8[0.69–0.93]**
Karnali	1.2[1.1,1.2]	0.73[0.62–0.86]***
Sudurpaschim	1.1[1.1,1.1]	0.61[0.51–0.74]***
Wealth index
Poorest	1.2[1.1,1.2]
Poorer	1.3[1.2,1.3]	1.05[0.92–1.18]
Middle	1.2[1.2,1.3]	0.93[0.78–1.10]
Richer	1.2[1.2,1.3]	1.1[0.94–1.30]
Richest	1.3[1.2,1.3]	1.5[1.27–1.77]***
Occupational status
Did not work	1.3[1.2,1.3]
Services	1.3[1.2,1.3]	1.09[0.97–1.22]
Agriculture(self-employed)	1.2[1.2,1.2]	0.83[0.75–0.92]***
Manual	1.2[1.2,1.3]	0.94[0.78–1.12]
Ethnic group
Advantage group	1.2[1.1,1.2]
Dalit	1.3[1.3,1.4]	1.34[1.17–1.55]***
Janjati	1.3[1.2,1.3]	1.16[1.05–1.28]**
Other	1.2[1.1,1.2]	0.95[0.80–1.13]

*** significant at p-value < 0.001.

**significant at p-value < 0.01.

* significant at p-value < 0.05.

Discussion

NCDs have different consequences for women in comparison to men [21]. In resource-challenged settings like Nepal where diagnosis and care for NCDs are less accessible and affordable to women prominently due to patriarchal society beliefs as well as limited health infrastructure, and human-resource capacity [22]. As a result, NCDs are often detected at the later stage of a woman’s life with a consequence of premature death. So, this study attempted to identify NCDs risk factors associated with women. This information could be useful in designing preventative strategies against NCDs risk factors.

Our study demonstrated that the proportion of tobacco use was nearly threefold higher in 30–40 years age group women which have also been observed in previous studies [23, 24]. Higher prevalence of tobacco use in older age group may be understood on light of low level of awareness/education and means of stress coping strategies in comparison to elder age group women. High prevalence of tobacco use in women with childbearing age deserves attention because of its adverse maternal and child health outcomes in the perinatal period [25]. Higher prevalence of tobacco use among divorced women than currently married, which is in line with previous studies [23, 26], it might be because of stress coping strategy or an option to overcome loneliness.

The study revealed the poorest wealth quintile as a key determinant of tobacco use while the prevalence of hypertension was more among participants of the highest wealth quintile. An increase in taxation could be one of the potential strategies to control tobacco use. Evidence suggests that around 10% increase in tobacco price reduces smoking by about 8% in low- and middle-income countries and by 4% in high-income countries [27]. Such strategy could be especially effective in the poorest segment of the population.

We observed the increasing trend of hypertension and overweight and obesity with increasing age and economic status. This seems to be a usual phenomenon as reported in other studies from different settings [4, 9]. On the other hand, it could be due to the reduced level of physical activity as people grew older and wealth status. The prevalence of Overweight and obesity in reproductive-age women has nearly tripled from 9% in the last ten years in Nepal [17, 28, 29]. This finding alarms the focus of maternal and child health programmes on NCDs risk factors like maternal obesity, due to their adverse consequences on maternal and child health. Maternal obesity can substantially interfere the fetal development and determines the long term health of the offspring [30]. It is also a major risk factor for gestational diabetes, preeclampsia and pregnancy-induced hypertension in women [31, 32]. Our study demonstrated a higher prevalence of hypertension in Gandaki province and the lower in Sudurpaschim province that is in line with national findings carried out in the general population [33]. Differences in the level of physical activity associated with occupational practices, dietary patterns, might have attributed the higher prevalence of hypertension in Gandaki province compared to other provinces. Furthermore higher level of urbanization and sedentary lifestyle in Gandaki province and Province 3 in comparison to other provinces may have accounted higher prevalence of hypertension.

Clustering of NCDs risk factors seems to be more with growing age, among well-off, and in Dalits and Janajatis -known as the disadvantaged ethnic groups in Nepal. Previous studies from multiple other countries have also found that the clustering of risk factors becomes increasingly common with increasing age [4, 5, 34]. As Nepal has been witnessing a rapid increase in life expectancy and the median age of the population, the problems can escalate in the coming years [35]. The country may need additional investment in prevention as well as long term care for NCDs to cater to the need of the geriatric population. Moreover, NCDs are considered to have a serious impact on the economic growth of the country. Reducing NCDs by 5–10% is thus a development agenda rather than a health problem confining it under the jurisdiction of the health sector [36]. This calls for multisectoral actions with coordinated efforts of the health sector.

Similarly, this study depicts the odds of clustering of NCDs risk factors higher among the wealthiest women which were also observed in the previous study in Bhutan [37]. Similar to individual risk factors like obesity and hypertension, the clustering of NCDs risk factors in the wealthier group can be linked with the adoption of a sedentary lifestyle. Similar factors might also be responsible for higher odds for the clustering of risk factors in province 1, province 3 and Gandaki province. Additionally, the pace of urbanization and westernization of dietary patterns might also have a role in the clustering of risk factors in specific provinces. Women who have a secondary level of education had a lower risk of clustering of NCDs risk factors which contradicts the findings from Bangladesh [38]. The difference in evidence may be due to differences in NCDs prevention and control contents in secondary level education. Furthermore, women involved in agriculture (self-employed), which generally involve vigorous physical activity, sector have low odds of clustering of NCDs risk factors. Vigorous physical activity is a protective factor against obesity and it is expected to reduce the risk of clustering NCDs risk factors [39].

Being cross-sectional in nature, the study does not establish causality. The NDHS 2016 mainly focused on maternal and child health issues, thus the NDHS did not measured other important biomarkers of NCDs risk such as elevated blood pressure, blood sugar and cholesterol level. The lack of information on biomarkers limited this to reveal the evidence around NCDs risk factors with sufficient depth.

Conclusion

Similar to most other NCD risk factors, clustering NCD risk factors seem to be more common in the richer segment of the population and higher age group among women. Nepal, that has been facing epidemiological transition with the increasing burden of NCDs while communicable diseases, maternal and neonatal conditions still bear the significant burden, need to make careful choices of the cost-effective interventions.

19 Aug 2019

PONE-D-19-15867

Socio-demographic correlates and clustering of Non-Communicable Diseases risk factors among reproductive aged women of Nepal: Results from Nepal Demographic Health Survey 2016

PLOS ONE

Dear Mr Bista,

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3. Please carefully proofread your manuscript to correct any typographical errors. For example on line 39 “Dalit and Janajati. .” Should be “Dalit and Janajati.” And on line 44 “non-communicable disease (NCDs)” should be “non-communicable diseases (NCDs)”.

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Reviewers' comments:

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Comments to the Author

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Reviewer #1: Partly

Reviewer #2: Partly

**********

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

Reviewer #1: Yes

Reviewer #2: No

**********

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Reviewer #2: Yes

**********

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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: Comments to the author

Title: Socio demographic correlates and clustering of non-communicable disease risk factors among reproductive aged women in Nepal: Results from the Nepal Demographic Health Survey.

General comments: The research article addresses a very important topic within the context of a developing country experiencing epidemiological transition. Clustering of NCD risk factors predisposes women to the risk of developing NCDs. The article is poorly written but with much improvement it has the potential to be published. There is need to consider language usage, thus the authors should not use colloquial language but statements should be supported by references to enhance authenticity of claims. The discussion section should be concise and provide reasons for any differences in findings when compared to other studies elsewhere within similar context. The authors have not followed the journal’s referencing style.

Abstract

The structure of the abstract does not follow the journal requirements. The abstract needs to be structured into the following;

• Background

• Methods

• Results

• Conclusion

Page 2 Line 31: The authors have inappropriately used the word similarly.

Page 2 line 36: Dalit) - correction has to be made.

Page 2 line 39: In the conclusion section the authors indicate that the clustering of NCD risk factors was more vulnerable groups such as widow/separated, Dalit and Janajati although for Janajati they have not shown prevalence ratios. Again there are two full stops (..).Correct that.

Introduction

Check on the referencing style…the reference number come before a full stop (period), not after.

Page 3 Line 50, 51: There is textual overlap with previously published work on the sentence; …. NCDs share the common risk factors such as low intake of fruit and vegetables, low level of physical activity, tobacco use, harmful use of alcohol, obesity, raised blood pressure, raised blood cholesterol and glucose. As a result there is need for citation and paraphrasing.

Page 3 Lines 53-60 there is need for language editing. For instance the sentence,… In context of Nepal, STEPS survey 2013, reported that 15.5% of general population and 11.4% of women had three or more risk factors of NCD in them Can be corrected to read as In Nepal, the STEPS survey 2013 indicated that 15.5% in the general population and 11.4% of women reported three or more risk factors for NCDs.

Page 3 Line 61-62: There is need for citation for this statement.

The general observation is that there is need to consider language usage, thus the authors should not use colloquial language but statements should be supported by references to enhance authenticity of claims. This section can be improved.

Methodology

The methodology for the study is well explained. Perhaps a question one would ask is that since the NDHS used a multi stage stratified sampling, how were cluster and sample design effects dealt with in the analysis of data.

Results

Page 12, Line 110: Make a correction to the first sentence ‘Just over half (53.95%) of the participants were of aged 15-29 years, the highlighted word should be ages. Make similar corrections across the result section and ensure that proper language is used for interpretation of results.

Page 14, Line 121: 26.08%, you can’t stand the sentence with a number. Kindly make correction. Moreover its ‘one risk factor’ Not ‘One risk factors’. There is need for language editing to remove typing and grammatical errors.

There is an over-use and at times misuse of the word ‘similarly’.

For interpretation of table 3, insert confidence intervals for the adjusted prevalence ratios (APR) e.g page 24 line 155, put in confidence intervals together with APRs for primary, secondary or higher education).

Under the subsection ‘Overweight’ page 24, Line 164-170 there are many typos, please make language corrections.

Discussion

Page 26 line 201-201 the sentence is not clear….So, this study aim to identify at risk women to possess NCD risk factors…. You need to rephrase the sentence.

There is no need to categorise the discussion into sub headings. The authors need only to discuss key findings, what are unique and important findings of the study. Only discuss such…what is new and emerging? There are six pages on the discussion section; it shows lack of focus and discussion of salient issues. The discussion section should be concise and provide reasons for any differences in findings when compared to other countries. There should be a subsection on strengths and limitations of the study.

References

The authors have not followed the journal’s referencing style. They use the APA style in the reference section, while in the text they use AMA.

Reviewer #2: Investigating the clustering of non-communicable diseases risk factors is important in the wake of NCDs epidemic in low and middle income countries. The strength of this study is its national representativeness. However, I doubt if there is sufficient data to explore clustering in this study population. Whereas, there are 8 common NCD risk factors – Smoking, Alcohol intake, Unhealthy diet and physical inactivity (behavioural factors), obesity, hypertension, hyperglycaemia and hyperlipidaemia (biological factors). Authors explored just three of these factors they also did not clearly define what clustering is in their study. Although, the research has merit, the paper is poorly written as it is.

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

Authors need to do more work on the manuscript. - They shoulsd make reference to articles published on the same topic particularly the clustering of NCD risk factors

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

Further comments in the attachment

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

Not particularly but the data is in the public domain

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

Needs improvement

**********

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Reviewer #1: Yes: Mpho Keetile,PhD

Reviewer #2: No

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9 Oct 2019

RESPONSE TO REVIEWER 1

Comments to the author

Title: Socio demographic correlates and clustering of non-communicable disease risk factors among reproductive aged women in Nepal: Results from the Nepal Demographic Health Survey.

General comments: The research article addresses a very important topic within the context of a developing country experiencing epidemiological transition. Clustering of NCD risk factors predisposes women to the risk of developing NCDs. The article is poorly written but with much improvement it has the potential to be published. There is need to consider language usage, thus the authors should not use colloquial language but statements should be supported by references to enhance authenticity of claims. The discussion section should be concise and provide reasons for any differences in findings when compared to other studies elsewhere within similar context. The authors have not followed the journal’s referencing style.

Abstract

The structure of the abstract does not follow the journal requirements. The abstract needs to be structured into the following;

• Background

• Methods

• Results

• Conclusion

Response- Correction has been made in revised manuscript.

Page 2 Line 31: The authors have inappropriately used the word similarly.

Response- Correction has been made in revised manuscript.

Page 2 line 36: Dalit) - correction has to be made.

Response- Correction has been made in revised manuscript.

Page 2 line 39: In the conclusion section the authors indicate that the clustering of NCD risk factors was more vulnerable groups such as widow/separated, Dalit and Janajati although for Janajati they have not shown prevalence ratios. Again there are two full stops (..).Correct that.

Response: Thank you. Correction has been made.

Introduction

Check on the referencing style…the reference number come before a full stop (period), not after.

Response: Thank you for your comment. It has been made amended on revised manuscript.

Page 3 Line 50, 51: There is textual overlap with previously published work on the sentence; …. NCDs share the common risk factors such as low intake of fruit and vegetables, low level of physical activity, tobacco use, harmful use of alcohol, obesity, raised blood pressure, raised blood cholesterol and glucose. As a result there is need for citation and paraphrasing.

Response: Thank you.Sentence has been paraphrased and reference has been added on revised manuscript.

Page 3 Lines 53-60 there is need for language editing. For instance the sentence,… In context of Nepal, STEPS survey 2013, reported that 15.5% of general population and 11.4% of women had three or more risk factors of NCD in them Can be corrected to read as In Nepal, the STEPS survey 2013 indicated that 15.5% in the general population and 11.4% of women reported three or more risk factors for NCDs.

Response: Thank you. Sentence has recomposed as advised.

Page 3 Line 61-62: There is need for citation for this statement.

Response: Reference has been provided.

The general observation is that there is need to consider language usage, thus the authors should not use colloquial language but statements should be supported by references to enhance authenticity of claims. This section can be improved.

Response: Thank you.Language has been edited and whole manuscript has been revised, without altering the technical details mentioned on original manuscript.

Methodology

The methodology for the study is well explained. Perhaps a question one would ask is that since the NDHS used a multi stage stratified sampling, how were cluster and sample design effects dealt with in the analysis of data.

Response: As this manuscript is secondary analysis of NDHS. Methodology summary has only been provided on manuscript. For full methodological details, manuscript has provided reference details. However, as per reviewer suggestion on revised version of manuscript, some additional information on methodology has been incorporated

Results

Page 12, Line 110: Make a correction to the first sentence ‘Just over half (53.95%) of the participants were of aged 15-29 years, the highlighted word should be ages. Make similar corrections across the result section and ensure that proper language is used for interpretation of results.

Response: Correction has been made as suggested.

Page 14, Line 121: 26.08%, you can’t stand the sentence with a number. Kindly make correction. Moreover its ‘one risk factor’ Not ‘One risk factors’. There is need for language editing to remove typing and grammatical errors.

Response: Thank you. It has been corrected in the manuscript.

There is an over-use and at times misuse of the word ‘similarly’.

Response: Thank you for suggestion. It has been corrected on revised version of manuscript.

For interpretation of table 3, insert confidence intervals for the adjusted prevalence ratios (APR) e.g page 24 line 155, put in confidence intervals together with APRs for primary, secondary or higher education).

Response: Thank you. Confidence interval has been inserted for every significant attributes.

Under the subsection ‘Overweight’ page 24, Line 164-170 there are many typos, please make language corrections.

Response: It has been corrected

Discussion

Page 26 line 201-201 the sentence is not clear….So, this study aim to identify at risk women to possess NCD risk factors…. You need to rephrase the sentence.

Response: It has been rephrased on revised manuscript.

There is no need to categorise the discussion into sub headings. The authors need only to discuss key findings, what are unique and important findings of the study. Only discuss such…what is new and emerging? There are six pages on the discussion section; it shows lack of focus and discussion of salient issues. The discussion section should be concise and provide reasons for any differences in findings when compared to other countries. There should be a subsection on strengths and limitations of the study.

Response: Thank you for suggestions. Whole discussion section has been revisited and edited as per PLoS one format and reviewer suggestions.

References

The authors have not followed the journal’s referencing style. They use the APA style in the reference section, while in the text they use AMA.

Response: It has been corrected.

RESPONSE TO REVIEWER 2

Title: Title is not appropriate as it is, authors should do further analysis or change the title.

Response: Thank you for your very informative suggestion. Manuscript has attempted to provide NCDs related risk factors details on reference to socio-demographic factors. Along with that, manuscript has also attempted to include clustering of NCD risk factors which are available on Demographic and Health survey. So, we believe present title justify the findings presented. However, if reviewer suggests any appropriate alternative topics, it can be considered.

Background: Fair – Can be reworked e.g. lines 62-63 “Thus to tackle with NCDs, the best strategy is to identify and modify the behavioural risk factors that causes NCDs” is not in tandem with the general objective of the work.

Response: It has been rephrased aligning with objective of study.

Methodology: Most poorly documented part of the manuscript. Authors needto follow the systematic reporting of Plos one articles. There are several articles published on NCD risk factors

1. No mention is made of the data collection instrument – was it the stepwise instrument which will allow for comparison with other studies.

Response: Methodology section has been revised. Details has been mentioned. Regarding data collection instrument, since it is Demographic and Health Survey, it has got its own universally standardized data collection tools. So, it is different than that of STEPwise instrument.

2. Variable definitions of outcome variable not precise e.g. lime 90-91 Current tobacco use includes either daily or occasional smoking or use of smokeless tobacco (snuff by mouth, snuff by nose, chewing tobacco and betel quid with tobacco)

Response: Thank you for suggestion. Definition used here is adopted from table 3.13 of NDHS 2016 .

Anthropometric measures

Response: Regarding anthropometric measures, BP measurement details have been provided on manuscript. Regarding weight and height, it has been measured by following universally standardized process and procedure. Details are mentioned on DHS Biomarker Field manual that has been mentioned reference list Biological measures

Response: No biological measures have been considered for this manuscript.

Data processing – Very little information

Response: Details of the data processing have been elaborated in the main report that has been cited in the manuscript. We considered writing specific parts of analysis relating to this manuscript to limit the length of manuscript.

3. Data Analysis – Not clear

Response: Complex survey analysis on stata 15.1 was carried out considering Taylor linearization method of calculation Standard error. Descriptive, bivariate analysis was done to assess relationship. For multivariable analysis multiple poisson regression was considered using APR (adjusted prevalence ratio)

Results

a. Table 1 should be shortened Provinces not likely to be meaningful to an international audience.

Response: Nepal has recently undergone restructuring process moving from unitary to federal structure. Although seven provinces were created by constituent assembly they are yet to be named (only three out of seven are named officially) and referred in official documents with number and we adopted the same in our study. Due to recent restricting process, Nepal lacks information on province wise fashion. So, province wise information may be useful for national as well international policy maker and decision to re-design the program related with NCDs.

b. Reformat Table 2

Response: it has been reformatted.

c. Why was prevalence ratios used and not odds ratios, but were reported as odds ratios “more likely”

Response: Considering interpretation easiness, prevalence ratio is more interpretable and easier to communicate to non-specialists than the odds ratio. Several studies have also recommended the use of prevalence ratio. Reference documents are available here:

• Alternatives for logistic regression in cross-sectional studies: an empirical comparison of models that directly estimate the prevalence ratio.

Barros AJ1, Hirakata VN. (link: https://www.ncbi.nlm.nih.gov/pubmed/14567763)

• The Burden and Determinants of Non Communicable Diseases Risk Factors in Nepal: Findings from a Nationwide STEPS Survey

Krishna Kumar Aryal ,Suresh Mehata ,Sushhama Neupane et.al (link: https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0134834#pone.0134834.ref019)

d. Multivariate of Clustering Risks should be on a separate table – preferably present – mean risk factors. Incidente ratios and robust Standard errors

Response: Thank you for suggestion. Table has been reformatted.

Discussion not acceptable in this current format.

Response: Discussion chapter has been reformatted

Submitted filename: PONE_reviewer two.doc

Click here for additional data file.

25 Nov 2019

PONE-D-19-15867R1

Socio-demographic correlates and clustering of Non-Communicable Diseases risk factors among reproductive aged women of Nepal: Results from Nepal Demographic Health Survey 2016

PLOS ONE

Dear Mr Bista,

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.

The reviewers have raised still some concerns on the revised manuscript. Kindly address all those issues raised by the reviewers.

We would appreciate receiving your revised manuscript by Jan 09 2020 11:59PM. When you are 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.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter.

To enhance the reproducibility of your results, we recommend that if applicable you deposit your laboratory protocols in protocols.io, where a protocol can be assigned its own identifier (DOI) such that it can be cited independently in the future. For instructions see: http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols

Please include the following items when submitting your revised manuscript:

A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). This letter should be uploaded as separate file and labeled 'Response to Reviewers'.

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Please note while forming your response, if your article is accepted, you may have the opportunity to make the peer review history publicly available. The record will include editor decision letters (with reviews) and your responses to reviewer comments. If eligible, we will contact you to opt in or out.

We look forward to receiving your revised manuscript.

Kind regards,

Kannan Navaneetham

Academic Editor

PLOS ONE

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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: All comments have been addressed

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: Partly

**********

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: No

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: No

Reviewer #2: No

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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: Manuscript Review 2

Title: Socio-demographic correlates and clustering of Non-Communicable Diseases risk factors among reproductive aged women of Nepal: Results from Nepal Demographic Health Survey 2016

Manuscript Number: PONE-D-19-15867R1

General Comments

The revised manuscript looks improved in many ways. The authors have addressed many comments which were raised in the previous review. There is general flow of ideas from the introduction to the conclusion section. Consequently this is a much improved version of the manuscript. Most of the sections are improved. However there are minor comments which authors need to address before the manuscript can be accepted for publication. Moreover, there is need for language editing.

Introduction section

Line 61-at the end of the reference and beginning of the sentence which starts with ‘Evidence show…..’ there is need for spacing

Line 64-The entire sentence need to be reconsidered, something is missing, either a conjunctive ‘and’ or a comma before 11.4% of

Line 65-The word ‘indicative’ should be replaced by ‘indication’

Line 70- The word ‘has’ needs to be replaced with ‘have’ since women is plural

Line 72-74-The sentence needs to be rephrased to read better. The word determinates is supposed to be determinants.

Methodology

For me this is section has been well revised and is well presented

Results

Tables look more organized now, and the section is easy to follow. Meanwhile there should be consistency in interpretation of results, for instance you cannot say slightly over one third of women reported multiple NCD risk factors, while only 6.3% reported a single NCD risk factor. These are two different ways of interpreting results in the same sentence and should be avoided. Choose one and stick to it for consistency.

For interpretation of results in table 3 and 4, the Adjusted Prevalence Ratios & Adjusted Risk Ratios are supposed to be in brackets to put emphasis on the interpretation. For instance, in lines 189-191 the sentence is ‘Compared to the women with no education, women who had pursued secondary level of education were (ARR: 0.87; 95% CI:0.77-0.98) times less likely to experience NCD risk factors’

The correct and the conventional way of writing this sentence is;

‘Compared to the women with no education, women who had pursued secondary level of education were less likely (ARR: 0.87; 95% CI:0.77-0.98) to experience NCD risk factors.’

Consider making the correction.

Discussion

This part is well written. However there are some minor comments noted.

Line 208- replace 3 fold with three-fold

Line 235-cf? Make a correction

References

No comments, they follow the journal style.

Reviewer #2: Socio-demographic correlates and clustering of Non-Communicable Diseases risk factors among reproductive aged women of Nepal: Results from Nepal Demographic Health Survey 2016 – Second Review

The manuscript is much improved as the authors have addressed many of the initial concerns. However, the authors still need to address a few more major concerns.

1. The CHOICE of the DATA utilized for their study. Why did the authors use the Nepal Demographic Health Survey 2016 which does not directly address NCD risk factors when Nepal has conducted the stepwise SURVEY which addresses? All the 8 NCD risk factors which enables a more robust exploration of NCD risk factors than the DHS data.

Researchers have investigated prevalence and factors of NCD in Nepal using the steps SURVEY.

i. Aryal KK, Mehata S, Neupane S, Vaidya A, Dhimal M, Dhakal P, et al. (2015) The Burden and Determinants of Non Communicable Diseases Risk Factors in Nepal: Findings from a Nationwide STEPS Survey. PLoS ONE 10(8): e0134834. https://doi.org/10.1371/journal.pone.0134834

ii. Bista B, Mehata S, Aryal KK, Thapa P, Pandey AR, Pandit A, et al. Socio-demographic Predictors 518 of Tobacco Use among Women of Nepal: Evidence from Non Communicable Disease Risk Factors STEPS 519 Survey Nepal 2013. Journal of Nepal Health Research Council. 2015;13(29):14-9. Epub 2015/09/29. 520 PubMed PMID: 26411707.

Even then this work does not lose its merit but the title should change evidence of clustering from this work may be misleading because of missing variables (3 out of 8). Hence whilst clustering may remain in the body of the work as one of the objectives of the study it should be removed from the title

iii. Olawuyi AT, Adeoye IA (2018) The prevalence and associated factors of noncommunicable disease risk factors among civil servants in Ibadan, Nigeria. PLoS ONE 13(9): e0203587.https://doi.org/10.1371/journal. pone.0203587

I suggest the new title should be simply “Socio-demographic correlates of selected Non-Communicable Diseases risk factors among reproductive aged women of Nepal: Results from Nepal Demographic Health Survey 2016”

However, there is need to justify additional evidence above that which has been provided by Aryal and his co-workers. In addition, authors need to emphasise the importance of NCD risk factors among women of reproductive age. Which may be an important contribution of their study.

2. The authors need to employ an English editor – The flow of the written is still poor. For instance, this section in the result could start with the mean age and standard deviation. The description of the table should flow sequentially

Just over half (53.95%) of the participants were d15-29 years. Largest proportions (36.62%) of the participants were from Janjati group (indigenous group). One thirds (33.34%) had no formal schooling while 76.655% of the participants were married. Most of the participants belonged to the Terai belt (49.89%) and rural areas (63.30%). Similarly, 22.43% and 20.92% of participants belonged to richer and the richest wealth quintile. Most of the participants were engaged in agriculture or were self-employed

3. There a need for a ROBUST description of the study area and setting.

The Provinces – their characteristic features, level of development including infrastructure, are rural or urban, level of westernization and epidemiologic/ nutritional transition going on. This will make interpretation and discussion of results more meaningful. This should apply to the ecological region and ethnic group. For example, it is not clear why all the other provinces (Provinces 1 – 5, Karnali etc should have a lower risk for smoking, overweight and hypertension compared to Province 1)

4. DISCUSSION still needs to be worked on

“Our study demonstrated that the proportion of tobacco use was nearly 3 fold higher in 30-40 years age group women which has also been observed in previous studies [23, 24].”

We need to know why tobacco use is higher among older women of reproductive age compared to younger women, what does this imply and what are your recommendations. Not sufficient to state that it has also been observed in previous studies [23, 24].”

5. NEED TO WRITE A STRONG LIMITATION SECTION – in the light of limited variables

6. OTHERS

a. Variable definitions

i. Is it overweight or overweight and obesity

ii. Occupational status . The categories not seem homogenous Agriculture does that mean self employed? What is services?

Generally, authors need to follow the systematic reporting of Plos one articles. There are several articles published on NCD risk factors

Ikeola Adeoye

**********

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: Dr Mpho Keetile

Reviewer #2: No

[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 be viewed.]

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Submitted filename: Manuscript Review 2.docx

Click here for additional data file.

Submitted filename: PONE_reviewer_Nepal 2nd.docx

Click here for additional data file.

22 Jan 2020

Reviewer 1:

General Comments

The revised manuscript looks improved in many ways. The authors have addressed many comments which were raised in the previous review. There is general flow of ideas from the introduction to the conclusion section. Consequently this is a much improved version of the manuscript. Most of the sections are improved. However there are minor comments which authors need to address before the manuscript can be accepted for publication. Moreover, there is need for language editing.

Response: English language has been further reviewed.

Introduction section

Line 61-at the end of the reference and beginning of the sentence which starts with ‘Evidence show…..’ there is need for spacing

Response: Thank you for your comments.It has been revised.

Line 64-The entire sentence need to be reconsidered, something is missing, either a conjunctive ‘and’ or a comma before 11.4% of

Response: Thank you for your comments.It has been revised.

Line 65-The word ‘indicative’ should be replaced by ‘indication’

Response: Thank you for your comments.It has been revised.

Line 70- The word ‘has’ needs to be replaced with ‘have’ since women is plural

Response: Thank you for your comments.It has been revised.

Line 72-74-The sentence needs to be rephrased to read better. The word determinates is supposed to be determinants.

Response: Thank you for your comments.It has been revised.

Methodology

For me this is section has been well revised and is well presented

Results

Tables look more organized now, and the section is easy to follow. Meanwhile there should be consistency in interpretation of results, for instance you cannot say slightly over one third of women reported multiple NCD risk factors, while only 6.3% reported a single NCD risk factor. These are two different ways of interpreting results in the same sentence and should be avoided. Choose one and stick to it for consistency.

For interpretation of results in table 3 and 4, the Adjusted Prevalence Ratios & Adjusted Risk Ratios are supposed to be in brackets to put emphasis on the interpretation. For instance, in lines 189-191 the sentence is ‘Compared to the women with no education, women who had pursued secondary level of education were (ARR: 0.87; 95% CI:0.77-0.98) times less likely to experience NCD risk factors’

The correct and the conventional way of writing this sentence is;

‘Compared to the women with no education, women who had pursued secondary level of education were less likely (ARR: 0.87; 95% CI:0.77-0.98) to experience NCD risk factors.’

Consider making the correction.

Response: Thank you for your comments. It has been revised.

Discussion

This part is well written. However there are some minor comments noted.

Line 208- replace 3 fold with three-fold

Line 235-cf? Make a correction

Response: Thank you for your comments.It has been revised.

References

No comments, they follow the journal style.

Overall response: Thank you for comments and suggestions. As per your expert feedback manuscript has been revised.

Reviewer 2:

1. The CHOICE of the DATA utilized for their study. Why did the authors use the Nepal Demographic Health Survey 2016 which does not directly address NCD risk factors when Nepal has conducted the stepwise SURVEY which addresses? All the 8 NCD risk factors which enables a more robust exploration of NCD risk factors than the DHS data.

Researchers have investigated prevalence and factors of NCD in Nepal using the steps SURVEY.

i. Aryal KK, Mehata S, Neupane S, Vaidya A, Dhimal M, Dhakal P, et al. (2015) The Burden and Determinants of Non Communicable Diseases Risk Factors in Nepal: Findings from a Nationwide STEPS Survey. PLoS ONE 10(8): e0134834. https://doi.org/10.1371/journal.pone.0134834

ii. Bista B, Mehata S, Aryal KK, Thapa P, Pandey AR, Pandit A, et al. Socio-demographic Predictors 518 of Tobacco Use among Women of Nepal: Evidence from Non Communicable Disease Risk Factors STEPS 519 Survey Nepal 2013. Journal of Nepal Health Research Council. 2015;13(29):14-9. Epub 2015/09/29. 520 PubMed PMID: 26411707.

Even then this work does not lose its merit but the title should change evidence of clustering from this work may be misleading because of missing variables (3 out of 8). Hence whilst clustering may remain in the body of the work as one of the objectives of the study it should be removed from the title.

iii. Olawuyi AT, Adeoye IA (2018) The prevalence and associated factors of noncommunicable disease risk factors among civil servants in Ibadan, Nigeria. PLoS ONE 13(9): e0203587.https://doi.org/10.1371/journal. pone.0203587

Response: Thank you for your suggestion. Regarding clustering study on STEPS survey 2013 data, that has been done by other authors.However, for women only clustering analysis was not done on STEPS survey 2013.Reviewer suggestion is highly appreciable on that regards but sample size(for 15-49 years) for that study is largely small than that of DHS data of 2016.So,we group of authors decided to work on DHS data. Thank you reviewer for your insight,we will definitely plan to work on recent data STEPS survey as a separate paper. In addition, Title has been revised on revised manuscript.

I suggest the new title should be simply “Socio-demographic correlates of selected Non-Communicable Diseases risk factors among reproductive aged women of Nepal: Results from Nepal Demographic Health Survey 2016”

However, there is need to justify additional evidence above that which has been provided by Aryal and his co-workers. In addition, authors need to emphasise the importance of NCD risk factors among women of reproductive age. Which may be an important contribution of their study.

2. The authors need to employ an English editor – The flow of the written is still poor. For instance, this section in the result could start with the mean age and standard deviation. The description of the table should flow sequentially

Just over half (53.95%) of the participants were d15-29 years. Largest proportions (36.62%) of the participants were from Janjati group (indigenous group). One thirds (33.34%) had no formal schooling while 76.655% of the participants were married. Most of the participants belonged to the Terai belt (49.89%) and rural areas (63.30%). Similarly, 22.43% and 20.92% of participants belonged to richer and the richest wealth quintile. Most of the participants were engaged in agriculture or were self-employed

3. There a need for a ROBUST description of the study area and setting.

The Provinces – their characteristic features, level of development including infrastructure, are rural or urban, level of westernization and epidemiologic/ nutritional transition going on. This will make interpretation and discussion of results more meaningful. This should apply to the ecological region and ethnic group. For example, it is not clear why all the other provinces (Provinces 1 – 5, Karnali etc should have a lower risk for smoking, overweight and hypertension compared to Province 1).

Response: Details about study settings is mentioned on full report and reference has been cited in manuscript. So, we have not included extra details on article to reduce bulkiness of manuscript. However, as per reviwer suggestions we have included province related information wherever necessary.

4. DISCUSSION still needs to be worked on

“Our study demonstrated that the proportion of tobacco use was nearly 3 fold higher in 30-40 years age group women which has also been observed in previous studies [23, 24].”

We need to know why tobacco use is higher among older women of reproductive age compared to younger women, what does this imply and what are your recommendations. Not sufficient to state that it has also been observed in previous studies [23, 24].”

Response: Thank you. As per suggestions discussion has been revised wherever necessary

5. NEED TO WRITE A STRONG LIMITATION SECTION – in the light of limited variables

Response: Thank you. Limitation has been further stated as per suggestions.

6. OTHERS

a. Variable definitions

i. Is it overweight or overweight and obesity

Response: Here in manuscript the overweight includes all those participintants whose BMI is greater>24.9 kg/m2.We revised terminology as per reviewer’s suggestions.Thank you.

ii. Occupational status . The categories not seem homogenous Agriculture does that mean self employed? What is services?

Response: In context of Nepal, majority of agriculture activities are not with motive of business motive.So, this was considered as self-employed and merged with self-employed.

Generally, authors need to follow the systematic reporting of Plos one articles. There are several articles published on NCD risk factors

Submitted filename: Response to reviewers 2 _rev.docx

Click here for additional data file.

24 Feb 2020

Prevalence and determinants of non-communicable diseases risk factors among reproductive aged women of Nepal: Results from Nepal Demographic Health Survey 2016

PONE-D-19-15867R2

Dear Dr. Bista,

We are pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it complies with all outstanding technical requirements.

Within one week, you will receive an e-mail containing information on the amendments required prior to publication. When all required modifications have been addressed, you will receive a formal acceptance letter and your manuscript will proceed to our production department and be scheduled for publication.

Shortly after the formal acceptance letter is sent, an invoice for payment will follow. To ensure an efficient production and billing process, please log into Editorial Manager at https://www.editorialmanager.com/pone/, click the "Update My Information" link at the top of the page, and update your user information. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org.

If your institution or institutions have a press office, please notify them about your upcoming paper to enable them to help maximize its impact. If they will be preparing press materials for this manuscript, you must inform our press team as soon as possible and 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.

With kind regards,

Kannan Navaneetham

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

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: All comments have been addressed

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: No

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: No

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: The manuscript has been improved and is legible. However, there is need for language editing, and correction of typographical or grammatical errors before publishing the manuscript.

Reviewer #2: I authors have done a lot to address all the issues and the concerns that were raised. Theirs will be one of the evidence provided from the demographic and health surveys which is widely available in most low and middle income countries.

**********

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: Dr Mpho Keetile

Reviewer #2: No

3 Mar 2020

PONE-D-19-15867R2

Prevalence and determinants of non-communicable diseases risk factors among reproductive aged women of Nepal: Results from Nepal Demographic Health Survey 2016

Dear Dr. Bista:

I am pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

If your institution or institutions have a press office, please notify them about your upcoming paper at this point, to enable them to help maximize its impact. If they will be preparing press materials for this manuscript, please inform our press team within the next 48 hours. 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.

For any other questions or concerns, please email plosone@plos.org.

Thank you for submitting your work to PLOS ONE.

With kind regards,

PLOS ONE Editorial Office Staff

on behalf of

Professor Kannan Navaneetham

Academic Editor

PLOS ONE