Micronutrient intake status and associated factors among children aged 6-23 months in the emerging regions of Ethiopia: A multilevel analysis of the 2016 Ethiopia demographic and health survey.

BACKGROUND: Micronutrient (MN) deficiency among children is recognised as a major public health problem in Ethiopia. The scarcity of MNs in Ethiopia, particularly in pastoral communities, might be severe due to poor diets mitigated by poor healthcare access, drought, and poverty. To reduce MNs deficiency, foods rich in vitamin A (VA) and iron were promoted and programs like multiple micronutrient powder (MNP), iron and vitamin A supplements (VAS) and or deworming have been implemented. Nationally for children aged 6-23 months, consumption of four or more food groups from diet rich in iron and VA within the previous 24 hours, MNP and iron supplementation within seven days, and VAS and >75% of deworming within the last 6 months is recommend; however, empirical evidence is scarce. Therefore, this study aimed to assess the recommended MN intake status of children aged 6-23 months in the emerging regions of Ethiopia.
METHODS: Data from the Ethiopia Demographic and Health Survey 2016 were used. A two-stage stratified sampling technique was used to identify 1009 children aged 6-23 months. MN intake status was assessed using six options: food rich in VA or iron consumed within the previous 24 hours, MNP or iron supplementation with the previous seven days, VAS or deworming within six months. A multilevel mixed-effect logistic regression analysis was computed, and a p-value of < 0.05 and Adjusted Odds Ratio (AOR) with 95% Confidence Interval (CI) were used to identify the individual and community-level factors.
RESULTS: In this analysis, 37.3% (95% CI: 34.3-40.3) of children aged 6-23 months had not received any to the recommended MNs sources. The recommended MNs resulted; VAS (47.2%), iron supplementation (6.0%), diet rich in VA (27.7%), diet rich in iron (15.6%), MNP (7.5%), and deworming (7.1%). Antenatal care visit (AOR: 1.9, 95% CI: 1.4-2.8), work in the agriculture (AOR: 2.2, 95% CI: 1.3-3.8) and children aged 13 to 23 months (AOR: 1.7, 95% CI: 1.2-2.4) were the individual-level factors and also Benishangul (AOR: 2.2, 95% CI: 1.3-4.9) and Gambella regions (AOR: 1.9, 95% CI: 1.0-3.4) were the community-level factors that increased micronutrient intake whereas residence in rural (AOR: 0.4, 95% CI: 0.1-0.9) was the community-level factors that decrease micronutrient intake.
CONCLUSIONS: Micronutrient intake among children aged 6-23 months in the pastoral community was low when compared to the national recommendation. After adjusting for individual and community level factors, women's occupational status, child's age, antenatal visits for recent pregnancy, residence and region were significantly associated with the MN intake status among children aged 6-23 months.

Introduction

Micronutrient (MN) deficiency among children is recognised as a global public health problem, and it is worse in low- and middle-income countries (LMICs), particularly in Ethiopia [1-3].

The essential MNs needed for life include iron, zinc, calcium, iodine, manganese, chromium, copper, fluoride, and vitamins [4,5]. Although MNs are only needed in small quantities, their absence from diet negatively affects children’s survival and development. Furthermore, MN deficiency contribute to debilitating consequences, like stunting, wasting, weak immunity, and delay in cognitive development [6-10]. Notably, MNs are critical during the first 1000 days of a child’s life; adequate nutrition during this period promotes healthy growth and development, but less attention has been given to MN [11,12].

According to the United Nations Children’s Fund 2019 report, around 340 million children worldwide suffered from hidden hunger caused by MN deficiencies [13]. The problem is much higher in LMICs, and few empirical studies showed that in 2018, only 29% of children aged 6–23 months were fed the minimum diversified diet (MDD) in Ethiopia [14]. ‘The MDD score for children 6–23 months old is a population-level indicator designed by the World Health Organization to assess diet diversity as part of infant and young child feeding practices among children 6–23 months old’. Accordingly, the national recommendation is that consumption of four or more food groups from the seven food groups, namely: grains, roots and tubers; legumes and nuts; dairy products; flesh foods (meat, fish, poultry and organ meats); eggs; vitamin A (VA) rich fruits and vegetables; other fruits and vegetables within the previous 24 hours [15].

Similarly, the deficiency of crucial MN are among the significant public health problems in Ethiopia. These deficiencies result from diets with limited diversity, minimal bioavailability, frequent meal skipping, limited access to micronutrient-rich and fortified foods, and low vegetable and fruit intake [16-18]. To prevent MN deficiencies among children in Ethiopia, the national nutritional supplementation program has been provided in the form of food and supplementation. The recommended MNs for children older than six months include foods rich in VA, foods rich in iron, multiple micronutrient powder, iron and vitamin A supplements (VAS) and or deworming (children older than 12 months) [19-21]. VAS and deworming have been provided for children aged 6 to 59 months semi-annually as a national nutrition program. Nationally for children aged 6–23 months, consumption of four or more food groups from diet rich in iron and VA within the previous 24 hours, MNP and iron supplementation within seven days, and VAS and >75% of deworming within the last 6 months is recommend. Interventions to improve maternal nutrition include multiple micronutrient supplements, food fortification, supplementary food, nutrition education, and counselling, majorly in the community-based nutrition program in Ethiopia [22].

According to the Ethiopia Demographic and Health Survey (EDHS) 2016 report, only 14% of children 6–23 months were received MDD [23]. In addition, the Ethiopian national nutritional supplementation survey (2016) indicated that VAS coverage among children was 63%, which is lower than the national target (more than 90%) [24] and the national prevalence rate of subclinical VA deficiency (serum retinol < 0.7 μmol/L) was severe (37.7%) [25,26].

MN intake is associated with various factors at individual and community levels, including mothers’ sociodemographics and child characteristics, dietary habits, community-level lifestyle, and place of residence [27-29]. In addition to the above factors, the use of maternal healthcare services, such as antenatal care (ANC), institutional delivery and postnatal care (PNC), are also associated with the MN intake status of children [30,31].

Although there is documented evidence of insufficient MN intake for agrarian communities and urban dwellers in Ethiopia [14,32], but there is little evidence on MN intake among children aged 6–23 months in emerging regions (Afar, Somali, Benishangul, and Gambela) of Ethiopia where pastoralist communities, with poor cultivation of fruits and vegetables, mainly reside [33]. Additionally, these regions have been identified as the hotspots in the country with high food insecurity, high child malnutrition rates, and recurrent droughts [34,35].

These areas have limited access to health facilities, poor infrastructure, and inaccessible health services [36,37]. However, studies that show the individual and community-level factors associated with MN intake among children are rare. Thus, this study aimed to assess the MN intake status and related factors among children aged 6–23 months in the emerging regions of Ethiopia using the 2016 EDHS data. The findings could give important insights to develop contextual strategies for the mitigation of the problems.

Materials and methods

Study settings and data source

The study used the EDHS 2016 data, a nationally representative household survey data collected every five years. It has been implemented by the Central Statistical Agency (CSA) [23] with the primary objective of providing up-to-date estimates of key demographic and health indicators. Administratively, Ethiopia is divided into nine regions (Tigray, Afar, Amhara, Oromia, Benishangul-Gumuz, Gambela, South Nation Nationalities and Peoples’ Region (SNNPR), Harari and Somali) and two administrative cities (Addis Ababa and Dire-Dawa) (Fig 1). These regions are again categorised as developed and emerging regions. The emerging regions are Afar, Somali, Benishangul, and Gambela, where scattered pastoralists predominantly live. Inadequate infrastructure, inaccessibility of health services, drought, poverty and absence of clear and detailed regulations are the common characteristics in emerging regions [36,37]. The developed regions are Amhara, Oromia, Tigray, SNNPR and Harari regions and the city administrations characterised by a relatively denser population and better infrastructure, and access to health and education services.

Fig 1

Map of the study area (Source, CSA:2013).

Sampling procedures

The sampling frame for the 2016 EDHS used the 2007 Ethiopian population and housing census, which was conducted by the CSA of Ethiopia. The census used a complete list of 84,915 enumeration areas (EAs), which contains the location, type of residence, and the estimated number of residential households. The 2016 EDHS sample was stratified in two stages, and samples of EAs were selected independently from each stratum. The regions were stratified into urban and rural areas. At each lower administrative level, implicit stratification and proportional allocation were achieved within each sampling stratum before sample selection at different levels.

In the first stage, 645 EAs were selected with probability proportional to the EA size, and each sampling stratum was selected from the given samples. The total residential households in the EA were the EA size, and a household listing operation was implemented. Then, the resulting lists of households were used as the sampling frame for selecting households in the second stage.

Twenty-eight households from each cluster were selected with an equal probability in the second stage, a systematic selection from the newly created household listing. The survey interviewer interviewed only pre-selected households. No replacements or changes of the pre-selected households were allowed in the implementing stages to prevent bias. In this study, the 2016 EDHS childhood datasets of the four emerging regional states: Afar, Benishangul, Gambella and Somali, were used for analysis.

All women aged 15–49 years who are the usual members of the selected households were eligible for the survey. Children aged 6–23 months were the source population and included 1009 mothers/caregivers and their recent children aged 6–23 months in the analysis. In contrast, the second and third child within the last five years (for those who have more than a child), children living with other than their mothers/caregivers were excluded from the analysis (Fig 2). For mothers/caregivers with twins, only one was selected by convenience. Potential individual and community level independent variables were also selected, and further analysis was done.

Fig 2

Sample study selection of children age 6–23 months in emerging regions, EDHS 2016.

Measurements of variables

The dependent variable of the study was MN intake status among children aged 6–23 months, which was determined by respondents’ reports and assessment of intake status. So, there were six options: food rich in VA or iron in the last 24 hours, MNP or iron supplement consumed within the previous seven days, VAS or deworming within the previous six months [19-21,38]. Accordingly, if the respondent reported that the child had eaten’ at least one of the minimum recommended MNs, we considered it "Yes"; if the children received none of the minimum recommended MNs, it was considered as "No".

Foods rich in VA were measured by the seven food groups’ consumption within the preceding 24 hours. These food groups were I. Eggs, ii. Meat (beef, pork, lamb, chicken), iii. pumpkin, carrots, and squash, iv. any dark green leafy vegetables, v. mangoes, papayas, and others with VA fruits, vi. Liver, heart, and other organs and vii. Fish or shellfish. Accordingly, if the respondent reported that the child had eaten’ at least one of these, we considered “yes”; otherwise “no” VA rich food.

Foods rich in iron were measured by the four iron-rich food groups’ consumption within the past 24 hours. These groups were i. eggs, ii. meat (beef, pork, lamb, chicken), iii. Liver, heart, and other organs, and iv. Fish or shellfish. Thus, if the respondent reported that the child had eaten’ at least one of these, we considered “yes”; otherwise “no” iron-rich food.

Multiple MN powders were assessed by asking the respondents whether their child had received micronutrient powders in the previous seven days.

Iron supplementation was assessed by asking the respondents whether their child had iron supplementation defined as iron pills, sprinkles with iron, or iron syrup in the previous seven days.

VAS and deworming were assessed for those 6–23 months of children whether they received for the last six months or not by reviewing the integrated child health card, which consists of immunisation and growth monitoring history and also from the mother’s verbal response.

The obstetric characteristics of women included current pregnancy status and use of maternal health services (ANC, institutional delivery and PNC). The child characteristics include birth weight, and current age. Birth weight was categorised as small, average or large.

The household wealth index was calculated as an index based on consumer goods such as television, bicycle, or car. Household characteristics such as the material used for floor and roof and toilet facilities were also considered in calculating the household wealth index. The household wealth index was computed using principal component analysis and ranked into poor, middle, and rich. Simultaneously, the community-level variables were residence, region, community-level wealth quantile, community-level media exposure, and distance to the nearest health facility.

Community-level wealth quantile was assessed using the asset index based on data from the entire country sample on separate scores prepared for rural and urban households, and combined to produce an index for all households as the community level and ranked into five (poorest, poorer, middle, richer, and richest). In other words, the community level wealth quantile was used to measure the community level poverty and it is a relative measure of how wealth is distributed within the population from the quantiles were calculated.

Community media exposure was assessed as “yes” if they have access to all three media (newsletter, radio, and television) at least once a week, otherwise “no” if they did not have any media exposure.

Distance to the health facility was assessed by the question “distance to the nearest health facility is a problem?” and the responses were categorised as “big problem” or “not a problem” [39].

Data processing and statistical analysis

The data were cleaned, re-coded and analysed using STATA (StataCorp, College Station, TX) version 14. Descriptive statistics were presented using tables and narration to describe the magnitude of MN intake status by sociodemographic, maternal obstetric and child characteristics.

A multilevel analysis was conducted after checking the eligibility. The model eligibility was assessed by calculating the Intra-class Correlation Coefficient (ICC) and a model with ICC greater than 10% for multilevel analysis. In this study, the ICC was 27.3%. Since the data were hierarchical (individuals were nested within communities), a two-level mixed-effects logistic regression model was fitted to estimate both the individual and community level variables (fixed and random effect) on MN intake status, and the log of the probability of MN intake was modelled using the formula as follows [40]: Where i is an individual level unit and j is a community-level unit; X and Z refer to individual and community-level variables, respectively; πij is the probability of MN intake for the ith child in the jth community; the β’s are the fixed coefficients. Whereas β0 is the intercept; the effect on the probability of MN intake in the absence of influence of predictors, and uj showed the community’s effect (random effect) on MN intake for the jth community and eij showed random errors at the individual levels. By assuming each community had different intercepts (β0 + Uj) and fixed coefficient (β1,2), the clustered data nature and the within and between community variations were considered.

Bivariable and multivariable analyses were computed. In the bivariable logistic regression analysis, a p-value of less than 0.2 was used to fit three models (models for the individual, community, and individual and community levels). Then, in the final model (fixed effect), a p-value of less than 0.05 and an Adjusted Odds Ratio (AOR) with a 95% confidence interval (CI) were used to estimate the association of individual and community level factors with MN intake status.

The measures of variation (random-effects) between clusters were reported using ICC and proportional change in variance (PCV). The ICC refers to the ratio of cluster variance to total variance, and it tells us the proportion of the total variance in the outcome variable that is accounted at the cluster level. The loglikelihood test was used to estimate the goodness of fit of the final adjusted model compared to the preceding models. A model with the smallest value of loglikelihood is better; accordingly, model three (a model for both individual and community-level variables) had the lowest value.

Ethical considerations

The ethical approval and permission to access the data were obtained from the MEASURE DHS (available from https://www.dhsprogram.com/Data/: accessed on April 06, 2020) after a brief study concept was submitted.

Results

Sociodemographic and economic characteristics of participants

Table 1 shows the sociodemographic and economic characteristics of the study participants. A total of 1009 mothers/caregivers with children aged 6–23 months were included in the final analysis. The mothers’ mean age was 27.5 (SD ± 6.3) years; the majority (72.4%) of the households were in the poor wealth index; the mean family size was 5.9 (SD± 2.3). Religious preference for 71.1% of the mothers was Muslim.

Table 1

Sociodemographic and economic characteristics of study participants in emerging regions of Ethiopia, 2016 (n = 1009).

Variables	Category	Frequency (n)	Percent (%)
Age of mothers/caregivers in years	15–24	341	33.8
	25–34	497	49.3
	>=35	171	16.9
Religion	Muslim	717	71.1
	Protestant	173	17.1
	Orthodox	85	8.4
	Others*	34	3.4
Sex of household head	Male	674	66.8
	Female	335	33.2
Household wealth index	Poor	730	72.4
	Middle	78	7.7
	Rich	201	19.9
Current marital status	Married	961	95.2
	Unmarried	48	4.8
Educational status of mothers/caregiver’s	No education	715	70.9
	Primary education	199	19.7
	Secondary education	67	6.6
	Higher	28	2.8
Educational status of husband’s/partner’s (n = 961)	No education	570	59.3
	Primary education	197	20.5
	Secondary education	104	10.8
	Higher	90	9.4
Mother’s/caregiver’s occupation	No work	671	66.5
	Professional worker	80	7.9
	Agricultural worker	189	18.7
	Others**	69	6.8
Husband’s/partner’s occupation (n = 961)	No work	139	14.5
	Professional worker	175	18.2
	Agricultural worker	448	46.6
	Others**	199	20.7

*Catholic, traditional, Joba.

**Daily labor, merchant.

Obstetric characteristics of mothers/caregivers

The obstetric characteristics of mothers/caregivers are presented in Table 2. Of the total women, 56.4% of women had ANC; 26.2% delivered at health facilities, and 7.2% of them had PNC checks within two months after delivery.

Table 2

Obstetric characteristics of participants in the emerging regions of Ethiopia, 2016 (n = 1009).

Variables	Category	Frequency (n)	Percent (%)
ANC visit	Yes	569	56.4
	No	440	43.6
Desire for more children	Wants	798	79.1
	Undecided	43	4.3
	Wants no more	168	16.6
Place of delivery	Home	745	73.8
	Health facility	264	26.2
PNC check up	Yes	73	7.2
	No	936	92.8
Current pregnancy status	Pregnant	90	8.9
	Non-pregnant	919	91.1

ANC: Antenatal care.

PNC: Postnatal care.

Child characteristics and common childhood illness

Table 3 shows the child characteristics and common childhood illnesses. Of the total children, 42.0% of them had average birth weight, and 15.9% had diarrhoea within the last two weeks.

Table 3

Child characteristics and common childhood illness among children aged 6–23 months in the emerging regions of Ethiopia, 2016 (n = 1009).

Variables	Category	Frequency (n)	Percent (%)
Current age of the child (months)	6–12	462	45.8
	13–23	547	54.2
Child’s birth weight	Large	269	26.7
	Average	424	42.0
	Small	316	31.3
Had diarrhoea*	Yes	160	15.9
	No	849	84.1
Had cough*	Yes	137	13.6
	No	872	86.4

*Diarrhoea and cough were assessed for two weeks preceding the survey.

Community-level variables

The majority (83.9%) of the participants were rural dwellers; 63.1% are in the poorest wealth quantile (Table 4).

Table 4

Community-level variables in the emerging regions of Ethiopia, EDHS 2016 (n = 1009).

Variables	Category	Frequency (n)	Percent (%)
Residence	Urban	163	16.1
	Rural	846	83.9
Region	Afar	254	25.2
	Somali	346	34.3
	Benishangul	224	22.2
	Gambela	185	18.3
Community level wealth quantile	Poorest	637	63.1
	Poorer	162	16.1
	Middle	94	9.3
	Richer	74	7.3
	Richest	42	4.2
Community level media exposure	Yes	50	5.0
	No	959	95.0

Micronutrient intake status

Overall, 37.3% (95% CI: 34.3–40.3) of children aged 6–23 months had not received any to the recommended MNs sources. Only 27.8% (95% CI: 25.0–30.5) of the children consumed foods rich in VA within the previous 24 hours and 15.6% (95% CI: 13.3–17.8) consumed foods rich in iron within the previous 24 hours; 7.5% (95% CI: 5.9–9.2) received multiple MNP within the last seven days; 6.0% (95% CI: 4.5–7.4) received iron supplements, and 47% (95% CI: 44.1–50.3) of the children received VAS within the previous six months (Table 5).

Table 5

Micronutrient intake status among children aged 6–23 months in the emerging regions of Ethiopia, 2016 (n = 1009).

Food groups and supplementations	Contains/measurements	Received
		n	% (95% CI)
Consumed foods rich in VA within 24 hours	Eggs	85	8.4 (6.8–10.3)
	Meat (beef, pork, lamb, chicken, etc)	52	5.2 (3.9–6.7)
	Pumpkin, carrots, and squash	111	11.0 (9.2–13.0)
	Any dark green leafy vegetables	91	9.0 (7.4–10.9)
	Mangoes, papayas, and others with VA fruits	133	13.2 (11.2–15.4)
	Liver, heart, and other organs	32	3.2 (2.2–4.4)
	Fish or shellfish.	45	4.5 (3.3–5.9)
Overall VA rich foods consumptions		280	27.7 (25.0–30.5)
Consumed foods rich in iron at any time in 24 hours	Eggs	85	8.4 (6.8–10.3)
	Meat (beef, pork, lamb, chicken)	52	5.2 (3.9–6.7)
	Liver, heart, and other organs	32	3.2 (2.2–4.4)
	Fish or shellfish.	45	4.5 (3.3–5.9)
Overall iron rich food consumption		157	15.6 (13.3–17.8)
Multiple micronutrient powder within seven days		76	7.5 (6.1–9.3)
Iron supplements within seven days		60	6.0 (4.6–7.6)
VAS within six months		476	47.2 (44.1–50.3)
Deworming medication in the six months (n = 547)		46	8.4 (7.7–8.9)
Overall, received at least one of the recommended MNs		633	62.7 (59.7–65.7)

MNs: Micronutrients.

VA: Vitamin A.

VAS: Vitamin A Supplements.

Random effects (measures of variation)

There was a significant variation in the intake of MNs among children aged 6–23 months across the communities (clusters). The intra-cluster correlation coefficient (ICC) in the null model (model 0) for MN intake was 0.273. In other words, 27.3% of the variation in MN intake among children aged 6–23 months is due to the differences between regions/clusters (between-cluster variation) (Table 6).

Table 6

Results from a random intercept model (a measure of variation) for MN intake among children aged 6–23 months at cluster level by multilevel logistic regression analysis, EDHS 2016.

Measure of variations	Model 0 (null model)	Model 1	Model 2	Model 3 (full model)
Variance	3.35	1.49	1.61	1.43
Explained variation (PCV) (%)	Ref.	55	52	57
Model fitness
Deviance (-2*log likelihood)	1271.9	1154.7	1195.0	1135.4
AIC	1275.9	1200.4	1214.5	1193.8

AIC: Akaike’s Information Criterion.

ICC: Intra-class Correlation Coefficient.

PCV: Proportional Change in Variance.

Model 0: Without independent variables (null model).

Model 1: Only individual-level variables.

Model 2: Only community-level variables.

Model 3: Individual and community-level variables (full model).

Individual and community-level factors of micronutrient intake status (fixed effects)

In the final model (model 3), after adjusting for individual and community level factors, women’s occupational status, child’s age, ANC for current pregnancy, residence and region were significantly associated with the MN intake status among children aged 6–23 months. But, mothers’ educational status, being head of household, mothers’ occupation, household wealth index, place of delivery, PNC visit, desire more child, child currently breastfeed, currently pregnant mother, diarrhoea and cough in the last two weeks, community level poverty, and community level media exposure were not significant with the MN intake among children aged 6–23 months.

Accordingly, the odds of recommended MN intake among children whose mothers/caregivers with an agricultural occupation were 2.2 times higher than those whose mothers/caregivers with no work (AOR: 2.2, 95% CI: 1.3–3.8). Children born from mothers who had ANC visits for their recent pregnancy were had 1.9 times more odds to receive any one of the six recommended MNs than those who had no ANC visits (AOR: 1.9, 95% CI:1.4–2.8). Those children aged 13 to 23 months were had 1.7 times more odds to receive the recommended MN compared to those aged 6 to 12 months (AOR: 1.7, 95% CI: 1.2–2.4). Those children who reside in the rural communities were 60% lower to receive any MNs than urban residents (AOR: 0.4, 95% CI: 0.1–0.9). The odds of taking any one of the MNs among children who live in the Benishangul and Gambella region were 2.5 (AOR: 2.5, 95% CI: 1.3–4.9) and 1.9 (AOR: 1.9, 95% CI: 1.0–3.4) times higher than those children who live in the Afar region, respectively (Table 7).

Table 7

Multilevel mixed effect logistic regression analysis of factors associated with MN intake status among children aged 6–23 months in the emerging regions of Ethiopia, EDHS 2016 (n = 1009).

Variables	Received at least one of the recommended MNs		COR (95%CI)	Model 1 AOR (95% CI)	Model 2 AOR (95%CI)	Model 3 AOR (95%CI)
	Yes n (%)	No n (%)
Individual-level characteristics
Mothers’ occupation
No work	371 (55.3)	300 (44.7)	1	1		1
Professional	57 (71.3)	23 (28.7)	1.8 (0.9–3.2)	1.4 (0.7–2.5)		1.4 (0.8–2.5)
Agricultural	154 (81.5)	35 (18.5)	3.3 (2.1–5.4)	3.0 (1.9–4.9)		2.2 (1.3–3.8) *
Others	51 (73.9)	18 (26.1)	2.0 (1.1–3.9)	1.5 (0.8–2.9)		1.3 (0.7–2.6)
ANC visit
No	214 (48.6)	226 (51.4)	1	1		1
Yes	419 (73.6)	150 (26.3)	2.8 (2.0–3.8)	2.0 (1.4–2.8)		1.9 (1.4–2.8) *
Age of child in months
6–12	259 (56.1)	203 (43.9)	1	1		1
13–23	374 (68.4)	173 (31.6)	1.7 (1.3–2.4)	1.8 (1.3–2.5)		1.7 (1.2–2.4) *
Community-level characteristics
Residence
Urban	126 (77.3)	37 (22.7)	1		1	1
Rural	507 (60.0)	339 (40.0)	0.4 (0.2–0.8)		0.4 (0.2–0.7)	0.4 (0.1–0.9) *
Region
Afar	127 (50.0)	127 (50.0)	1		1	1
Somali	182 (52.6)	164 (47.4)	1.1 (0.7–1.8)		1.0 (0.6–1.6)	1.1 (0.7–1.76)
Benishangul	187 (83.4)	37 (16.6)	6.4 (3.5–11.7)		5.3 (2.9–9.7)	2.5 (1.3–4.9) *
Gambella	137 (74.0)	48 (26.0)	3.81 (2.1–6.9)		2.9 (1.6–5.0)	1.9 (1.0–3.4) *

*Statistically significant at p-value <0.05 at model 3.

ANC: Antenatal Care.

AOR: Adjusted Odds Ratio.

COR: Crude Odds Ratio.

Discussion

The study showed that 37.3% of children aged 6–23 months had not received any to the recommended MNs sources in the emerging regions of Ethiopia. After adjusting for individual and community level factors, women’s occupational status, the child’s age, antenatal visits for current pregnancy, residence and region were significantly associated with the MN intake status among children aged 6–23 months. In this study, 28.0% and 15.6% of children had consumed foods rich in VA and iron, respectively. The EDHS 2016 showed that consumption of foods rich in VA and iron was 38.0% and 22.0%; correspondingly, the lowest intake was observed in Afar [23], comparable with the current finding. Almost half of the children (47.2%) got VAS and as few as 6.0% of them got iron supplements. The previous EDHS (2011) finding showed that VAS in the four regions was 43.2%, which is lower than our findings [35].

This study identified that MN intake among children from mothers who had no formal/paid jobs was lower than children whose mothers had work. Mothers who work in agriculture might have better access to diversified agricultural and animal products rich sources of MNs. Moreover, participating in work may expose mothers to peers and friends who can serve as sources of information related to MN intake and its benefits. This study also showed that agrarian dominants were more likely to consume diversified food, which can be used as a proxy for adequate MN density of foods [41]. Previous studies in Ethiopia and Nigeria are also consistent with this study [35,42].

The odds of MN intake for children aged 13–23 were higher than those aged between 6 and 12 months. This could be explained by poor complementary feeding practices that should be introduced at six months of age, especially in the rural population and emerging regions. Also, older age groups could have better dietary diversity as they can eat family meals for themselves. In EDHS 2016, children above 12 months old were more likely to obtain diversified food [41,43]. The late introduction of complementary feeding might have resulted in consuming a limited variety of food, such as only milk or cereal products. Moreover, mothers’ perceptions and traditional beliefs might contribute to low consumption of diversified food in those children (6–12 months).

In this study, higher odds of MN intake were observed among children whose mothers had ANC follow-ups compared to those whose mothers did not have ANC follow-ups. This finding was in line with those of previous studies conducted in Ethiopia [35]. The possible explanation might be that mothers who had ANC follow-up may have a chance to get information, education, knowledge, and counselling services from the health professionals. Caregivers may have learned or acquired knowledge of iron supplements during their ANC follow-up. Another explanation might be that mothers with follow-up live nearer to health facilities have more time/money available to attend ANC. Moreover, a systematic review and meta-analysis of dietary diversity feeding practice done in Ethiopia suggests that children whose mothers have ANC follow-up have a higher probability than their counterparts to eat diversified food [44].

The odds of MN intake among children who reside in rural communities were lower compared to their counterparts. This is supported by a systematic study in Ethiopia, which reported that urban residents had higher odds of MN intake than rural residents [44]. However, a few studies’ findings [45-47] contradict the current study. The potential explanation might be food fortification and supplementation focused more on rural than urban through community-based maternal and child health outreach programs.

Our finding showed that MN intake among children living in Benishangul and Gambella regions was higher than those who live in the Afar region. This can be explained by the fact that, compared to the two regions, the Afar and Somalia regions’ economic activities are mostly dominated by cattle breeding and pastoral lifestyles, and agriculture is common in Benishangul and Gambella. Besides, since the latter two regions have dense forests and water reservoirs, caregivers could get wild fruit and fish, which are good sources of MNs. Previous studies showed that VA rich foods were scarce in the pastoral community, and meat and egg consumption were low [48]. Natural forests and semi-natural forests were positively associated with many nutritionally important food groups [49]. A study from the recent EDHS (2016) showed that the agrarian community children were more likely to consume diversified food than the pastoral community.

The study’s main strengths are its representativeness, large sample size, and the availability of individual and community-level factors. This study used a multilevel-modelling technique to identify a more valid result that takes the survey data’s hierarchical nature into account. Furthermore, the DHS methodology allows for comparison with other settings. The mothers might have experienced recall bias, particularly regarding VAS and deworming for their child in the last six months before the survey, for instance.

Conclusions

The overall intake of MNs in this study was below the national recommendation. Mothers’ occupation, age of a child, recent ANC, residence, and region were significantly associated with the MN intake status. Improving ANC, promoting affordable and available MN-rich foods through improved/adaptive agricultural practices, deworming, MNPs, Iron and VAS are essential for increasing MN intake among children in Ethiopia.

15 Jun 2020

PONE-D-20-13718

Antenatal care visit increases micronutrient intake among children aged 6-23 months in the emerging regions of Ethiopia: a multilevel analysis of the 2016 Ethiopian demographic and health survey

PLOS ONE

Dear Dr. Tsegaye Gebremedhin,

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Reviewer #2: Partly

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Reviewer #2: Yes

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Reviewer #1: Yes

Reviewer #2: Yes

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5. 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: 1. I do not find there to be a strong rationale in the paper for why only data from four regions is analysed, when (presumably) the EDHS has data available from other regions as well.

2. Dependent variable. The individual questions are well explained but I do not fully understand how you combined these into the outcome variable. In the paper you refer both to micronutrient "intake status", which could be categorical, but also "level of intake" which sounds continuous; however my understanding is your outcome variable is binary, in which case "minimum intake" or similar would be most appropriate. Furthermore, was a positive answer to any of the six questions sufficient for the outcome to be coded as a "yes"? On a conceptual level, I find it difficult to understand why this makes sense if the child has received deworming medication but answers to the five other questions are negative.

3. Sampling procedures. Please use the term "community" in this section, since this is used frequently elsewhere in the paper. Is EA the community level?

4. Rows 123-125: Please clarify whether 1009 was the total number of eligible respondents available in the EDHS (from the four regions), or whether you have made some selection.

5. The description of multilevel modelling is very nice and while I am not overly familiar I believe there is a mistake on row 200, where the reference should be to (beta0+Uj) and beta2.

6. The large number of variables describing obstetric history is surprising, given the outcome variable. No rationale is provided in the paper either, and very few end up being included in the final model.

7. Discussion. You mention there is a national target, however, I cannot find a mention of what the target actual is/was.

8. Strengths and weaknesses. Given the focus on four regions, I am not convinced by your argument that the results are nationally representative, nor that the use of standardised DHS questions makes findings generalisable to other settings. Instead, it would be relevant to discuss strengths and weaknesses of using EDHS as a data source, compared to alternatives e.g. cross-sectional survey focused on nutrition, to answer the research question.

9. Conclusion. You recommend specifically continued investment in scaling up vitamin A supplementation, but I cannot find any support in your results to suggest that this would be more important a focus than say iron supplements.

10. Data availability. This needs to be revised to refer readers to Measure DHS.

11. There are minor spelling mistakes namely "ricked" (row 60), "antennal" (row 305), "vibrations" (Table 5). In references, WHO shows up as Organization WH.

Reviewer #2: • Line 166-167: Can you clearly state whether Vitamin A uptake and ANC visits was based on mother’s recall, some form of Health documents (like child health card) or both. What about distance to the health facility? This is an ideal variable when it comes to mother’s visits to the clinics. I advise you adequately described, analyzed and discussed if the data exist

• Table 4: Please include confidence intervals for the coverages

• The sample size is not clear. Can you please clarify whether 1009 was the total number of eligible respondents available from the four regions? Also you have used same denominators for mothers and children sample characteristics. It is possible that a mother was interviewed for more than one child. Can you please clarify here

• Discussion: You have only stated the national target but have not provided or given a reference for that.

• There are a few typos and grammatical error. Please get a native English speaker to review and help correct some of the minor mistakes.

• Strengths and weaknesses: I find it problematic that you have not used the 6 months recall for Vitamin A. I assume the EDHS used the 6 months recall and so I do not think your argument that the results can be compared to national estimates is right especially given the fact that there is some recall bias here.

• Please provide p values for comparism where there are significant differences.

• Conclusion: What is the national vitamin A coverage and how does it compare to the findings here? Also worth citing the national Vitamin A deficiency status from a most recent micronutrient survey. Then you need to make this comparism clear before you can recommend continued investment in scaling up vitamin A supplementation. I also think promoting Vitamin A rich foods is a good strategy worth promoting but that will depend on the status of vitamin A in the country.

**********

6. 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.

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Reviewer #1: Yes: Anni-Maria Pulkki-Brännström

Reviewer #2: Yes: Habib Issa Kamara

[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.]

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1 Aug 2020

Dear Editor,

Greetings!

Firstly, we would like to appreciate and thank the academic editor and reviewers for investing their time and energy to review and make comments. It is with great pleasure to receive the invaluable and constructive comments which improves our manuscript. We accepted and tried to incorporate all of the comments provided. Moreover, the manuscript has been revised by English language expert and grammar and spellings have been improved throughout the manuscript, and we made rewording and rephrasing some parts of the paragraphs of the paper accordingly. The responses to the editor and reviewers' comments are provided here below; please see the responses.

Journal requirements:

1-When submitting your revision, we need you to address these additional requirements:

Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at http://www.plosone.org/attachments/PLOSOne_formatting_sample_main_body.pdf and http://www.plosone.org/attachments/PLOSOne_formatting_sample_title_authors_affiliations.pdf

Authors' response: Thank you so much for your comments. The comment is accepted and corrected in the style of the PLOS ONE journal. Please refer to the clean version of the revised manuscript.

2- Please modify the title to ensure that it is meeting PLOS’ guidelines (https://journals.plos.org/plosone/s/submission-guidelines#loc-title) . In particular, the title should be "specific, descriptive, concise, and comprehensible to readers outside the field" and in this case we have concerns that the title contains a causal statement not completely supported by the study

Authors' response: Again, thank you very much for your very kindly and careful review. We had gone throughout the linked document and we have modified the title “Micronutrient intake status and associated factors among children aged 6-23 months in the emerging regions of Ethiopia: a multilevel analysis of the 2016 Ethiopian demographic and health survey” to be more specific, descriptive, concise and comprehensive with the findings. Please see the first page of the clean version of the revised manuscript.

Reviewer #1:

1. I do not find there to be a strong rationale in the paper for why only data from four regions is analysed, when (presumably) the EDHS has data available from other regions as well.

Authors’ response: Dear reviewer, thank you for your constructive comments. We revised the introduction and set out the rationale of the study as per the comments provided; please see the clean version of the revised manuscript on page 5, lines 72-81.

2. Dependent variable. The individual questions are well explained but I do not fully understand how you combined these into the outcome variable. In the paper you refer both to micronutrient "intake status", which could be categorical, but also "level of intake" which sounds continuous; however, my understanding is your outcome variable is binary, in which case "minimum intake" or similar would be most appropriate. Furthermore, was a positive answer to any of the six questions sufficient for the outcome to be coded as a "yes"? On a conceptual level, I find it difficult to understand why this makes sense if the child has received deworming medication but answers to the five other questions are negative.

Authors’ response: Dear reviewer, thank you very much for your comments and insights. The dependent variable of the study was categorical; It was dichotomized in yes and no category. when one chid got at least one of the minimum recommended micronutrients, they were considered us “got the recommended micronutrient”; otherwise it was considered as that “the recommended micronutrient is not received”. We used the classification according to the national micronutrient recommendations, and if the child received at least one of the minimum recommended micronutrients, the national recommendation stated that they were considered “received”; otherwise “not received”. Such recommendation might not give confidence to say the micronutrient intake status is sufficient, so, this might be one of the limitations of the study mentioned on the strength and limitation section (page 26, lines 404-406).

Furthermore, for the deworming medication, it was not considered the medication prescribed for treatment of disease/illness; rather the national micronutrient recommendation has included it, for any heathy child, it should be supplement alongside with the vitamin A and others. So, we have included the deworming medication which was provided as a supplement rather than for those prescribed for the treatment of illness/disease. Please refer to the variables' measurement section in the clean version of the revised manuscript on pages 8-11, lines 132-183.

3. Sampling procedures. Please use the term "community" in this section, since this is used frequently elsewhere in the paper. Is EA the community level?

Authors’ response: Dear reviewer, thank you for your concerns. In the EDHS, enumeration areas were the clusters with a specified household numbers; thus, instead of clusters we used as EA. Furthermore, EA are not the community level rather they are clusters created in the Ethiopian demographic and health survey for sampling purposes. So, we kindly invite you to see the sampling procedures as per those perspectives, on pages 6-7, lines 95-116 in the revised manuscript.

4. Rows 123-125: Please clarify whether 1009 was the total number of eligible respondents available in the EDHS (from the four regions), or whether you have made some selection.

Authors response: Dear reviewer, we are thankful for your positive comments to improve the manuscript. In the first step, a total of 1130 participants from the four regions were available as a source. Then, using a selection criterion; alive, first index to birth history and live with their mothers’/caregivers, we have included a total of 1009 eligible children with their mothers/caregivers in the final analysis. we put this in figure 1; please see the clean version of the revised manuscript on page 7, lines 117-124.

5. The description of multilevel modelling is very nice and while I am not overly familiar, I believe there is a mistake on row 200, where the reference should be to (beta0+Uj) and beta2.

Authors response: Dear reviewer, we are very much thankful for your observation and comments. We have addressed the issue; please see the clean version of the revised manuscript on page 11, line 203.

6. The large number of variables describing obstetric history is surprising, given the outcome variable. No rationale is provided in the paper either, and very few end up being included in the final model.

Authors response: Dear reviewer, thank you for your critical insights and suggestions. In our assumptions, the micronutrient intake status of children can be affected by the maternal obstetric history as we tried to show in the introduction section (page 5, lines 69-71). Moreover, we have revised the obstetric history in the result section and removed few irrelevant variables form the descriptive; please see the clean version of the revised manuscript on page 13, lines 237-243.

7. Discussion. You mention there is a national target, however, I cannot find a mention of what the target actual is/was.

Authors response: Thank you for your comments. We mentioned the national targets; please see the clean version on page 23, line 345 of the revised manuscript. Besides, we included that in the introduction section (page 5, lines 65-66).

8. Strengths and weaknesses. Given the focus on four regions, I am not convinced by your argument that the results are nationally representative, nor that the use of standardised DHS questions makes findings generalisable to other settings. Instead, it would be relevant to discuss strengths and weaknesses of using EDHS as a data source, compared to alternatives e.g. cross-sectional survey focused on nutrition, to answer the research question.

Authors response: Dear reviewer, thank you for your detailed evaluation. We have addressed the issue; please see the clean version of the manuscript on page 26, lines 396-410.

9. Conclusion. You recommend specifically continued investment in scaling up vitamin A supplementation, but I cannot find any support in your results to suggest that this would be more important a focus than say iron supplements.

Authors response: Dear reviewer, thank you so much. We have revised the conclusion section and the problem has been addressed; please see the clean version of the revised manuscript on pages 26-27, lines 412-421.

10. Data availability. This needs to be revised to refer readers to Measure DHS.

Authors response: Thank you for your comments. We have addressed the issue.

11. There are minor spelling mistakes namely "ricked" (row 60), "antennal" (row 305), "vibrations" (Table 5). In references, WHO shows up as Organization WH.

Authors response: Dear reviewer, thank you for your insights, we have addressed the issue throughout the manuscript please see the clean version of the revised manuscript.

Reviewer #2:

1. Line 166-167: Can you clearly state whether Vitamin A uptake and ANC visits was based on mother’s recall, some form of Health documents (like child health card) or both. What about distance to the health facility? This is an ideal variable when it comes to mother’s visits to the clinics. I advise you adequately described, analyzed and discussed if the data exist

Authors response: Dear reviewer, thank you very much for your constructive comments. We have addressed the issue; please see the measurement of variables section, particularly on page 9-10, lines 159-183.

2. Table 4: Please include confidence intervals for the coverages

Authors response: Dear reviewer, thank you for your comments. We have included the confidence intervals; please see the clean version of the revised manuscript on page 15-16, lines 260-271.

3. The sample size is not clear. Can you please clarify whether 1009 was the total number of eligible respondents available from the four regions? Also, you have used same denominators for mothers and children sample characteristics. It is possible that a mother was interviewed for more than one child. Can you please clarify here

Authors response: Again, thank you very much for your very kindly and careful review. We described the EDHS sample selection in text, and presented it in figure as well. Please see the clean version of the revised manuscript on page 7, lines 117-124, and also presented in figure 1.

4. Discussion: You have only stated the national target but have not provided or given a reference for that.

Authors response: Dear reviewer, thank you for your insights. We have addressed the issue; please see the clean version of the revised manuscript on page 23, line 345.

5• There are a few typos and grammatical error. Please get a native English speaker to review and help correct some of the minor mistakes.

Authors response: Dear reviewer, thank you so much for your comments and suggestions. The manuscript has been revised by English language expert and grammar and spellings have been improved throughout the manuscript, and we made rewording and rephrasing some parts of the paragraphs of the paper accordingly; please see the clean version of the revised manuscript once again.

6. Strengths and weaknesses: I find it problematic that you have not used the 6 months recall for Vitamin A. I assume the EDHS used the 6 months recall and so I do not think your argument that the results can be compared to national estimates is right especially given the fact that there is some recall bias here.

Authors response: Dear reviewer, thank you for your valuable comments. We have revised the strength and weaknesses of our study; please see the clean version of the revised manuscript on page 26, lines 396-410.

7. Please provide p values for comparism where there are significant differences.

Authors response: Dear reviewer, thank you for your comments and the comment is admitted. We have used the confidence interval and also the p values for the comparison, but to be consistent in writing/editing of the manuscript we did not mentioned it. So, kindly request you to consider it.

8. Conclusion: What is the national vitamin A coverage and how does it compare to the findings here? Also, worth citing the national Vitamin A deficiency status from a most recent micronutrient survey. Then you need to make this comparism clear before you can recommend continued investment in scaling up vitamin A supplementation. I also think promoting Vitamin A rich foods is a good strategy worth promoting but that will depend on the status of vitamin A in the country.

Authors response: Dear reviewer, we are very thankful for your comments and suggestions. We have addressed it as per the comments; please see the clean version of the revised manuscript on pages 26-27, lines 412-421.

Submitted filename: Point-by-point response to reviewers comments.docx

Click here for additional data file.

26 Aug 2020

PONE-D-20-13718R1

Micronutrient intake status and associated factors among children aged 6-23 months in the emerging regions of Ethiopia: a multilevel analysis of the 2016 Ethiopian demographic and health survey

PLOS ONE

Dear Tsegaye Gebremedhin,

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.

Please submit your revised manuscript by September 25th. 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.

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). You should upload this letter as a separate file labeled 'Response to Reviewers'.

A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.

An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

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

We look forward to receiving your revised manuscript.

Kind regards,

Mary Hamer Hodges, MBBS MRCP DSc

Academic Editor

PLOS ONE

Additional Editor Comments (if provided):

I should double check that you are entitled to provide the dataset as supporting information file by contacting Measure DHS.

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

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: (No Response)

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: Yes

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: 1) I am surprised that a data file is provided as supporting information because as the authors correctly report, the data can be very easily accessed through contacting MeasureDHS. I would recommend the authors double check that they are entitled to provide the dataset as supporting information file.

Otherwise, I only have two minor concerns that relate to ambiguities remaining after the authors' otherwise satisfactory responses (to my previous comments nr 2 and 4):

2) References to “received the recommended micronutrients” can be misunderstood to mean adequate intake. Please consistently refer to “received at least one of the recommended micronutrients” to ensure no reader is mislead about your outcome variable. For example: in the results section of the Abstract, in the column heading in Table 6, and the first sentence of the Discussion.

3) Regarding the exclusion criteria, please rephrase “index to birth history” in Figure 1 and on row 120, because the meaning is difficult to understand.

Reviewer #2: In the results section you stated children born of mothers who had ANC visits for their recent pregnancy were 1.95 times more likely to receive micronutrients. This may be related to knowledge gained from health talks during ANC visits. It would be prudent to proffer reasons for these differences.

Also proffer reasons in the discussion section for why more mother tend to do complementary feeding for children ages 13-23 compared to 6-12months.

I think it would be worth knowing why more mother preferred to give birth at compared to health facility. Is this because of distance to health facility, costs or they trust the traditional birth attendance more than they do health workers?

**********

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: A-M Pulkki-Brannstrom

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.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

29 Sep 2020

Response to reviewers’

To: PLOS ONE Journal Editorial Office

Manuscript title: “Micronutrient intake status and associated factors among children aged 6-23 months in the emerging regions of Ethiopia: a multilevel analysis of the 2016 Ethiopian demographic and health survey” [Manuscript ID: PONE-D-20-13718].

Subject: Submission of a revised manuscript for publication

Dear Editor,

Greetings!

We appreciate and acknowledge the academic editor and reviewers for investing their time and energy to review and make comments on our manuscript once again. It is with great pleasure to receive the invaluable and constructive comments for our manuscript.

We accepted and tried to incorporate all of the comments provided. Moreover, the manuscript has been revised by English language expert and grammar and spellings have been improved throughout the manuscript. Thus, the comments are attached here below with their point-by-point responses. In addition, the detailed changes made are highlighted in the “revised manuscript with track changes” to easily identify the changes/improvements and also the clean copy of the revised manuscript is prepared.

Finally, we kindly request you to review our revised manuscript.

RESPONSE TO EDITOR’S COMMENTS

Academic editor (Mary Hamer Hodges, MBBS MRCP DSc)

#1. I should double check that you are entitled to provide the dataset as supporting information file by contacting Measure DHS.

Authors’ response: Dear editor, thank you for your important comment. We have double checked the authorization letter, and unfortunately, we were prohibited to share the data set, “The data must not be passed on to other researchers without the written consent of DHS”. So, we would like to say sorry for the previous data set attachment as a supplementary information and we have removed the data set from the manuscript tracking system. Finally, we kindly request the journal office to remove the data set from the public repository if it’s deposited.

Response to Reviewers

Reviewer #1 (Anni-Maria Pulkki-Brannstrom):

1. I am surprised that a data file is provided as supporting information because as the authors correctly report, the data can be very easily accessed through contacting Measure DHS. I would recommend the authors double check that they are entitled to provide the dataset as supporting information file.

Authors’ response: Dear reviewer, we are very much thankful for your critical insights. We have checked the authorization letter; unfortunately, we were prohibited to share the data set, “The data must not be passed on to other researchers without the written consent of DHS”. So, we have removed the data from the supporting information and we hope you will definitely understand for the mistaken done in our previous submission regarding to the data file. Finally, we kindly request the journal editorial office to remove the data set from the supplementary files.

2. References to “received the recommended micronutrients” can be misunderstood to mean adequate intake. Please consistently refer to “received at least one of the recommended micronutrients” to ensure no reader is misled about your outcome variable. For example: in the results section of the Abstract, in the column heading in Table 6, and the first sentence of the discussion.

Authors’ response: Dear reviewer, thank you for your comment. We have amended the term of outcome variable “received the recommended micronutrients” in to “received at least one of the recommended micronutrients” in the results section of the Abstract, in the column heading in Table 6, and the first sentence of the discussion. Kindly see the clean version of the revised manuscript on page 2 lines 24-25, Table 6 column heading on page 20 and in the discussion page 23 lines 322-323.

3. Regarding the exclusion criteria, please rephrase “index to birth history” in Figure 1 and on row 120, because the meaning is difficult to understand.

Authors’ response: Dear reviewer, thank you so much for your comments. We have addressed the issue as per the comments, kindly see the clean version of the revised manuscript on page 7, lines 119-120.

Reviewer #2:

1. In the results section you stated children born of mothers who had ANC visits for their recent pregnancy were 1.95 times more likely to receive micronutrients. This may be related to knowledge gained from health talks during ANC visits. It would be prudent to proffer reasons for these differences.

Authors’ response: Dear reviewer, thank you very much for your comment. We have mentioned that information and knowledge gained from health talks during ANC visits could be the possible explanations of micronutrient intake status difference. Kindly see the clean version of the revised manuscript on page 25, lines 373-376.

2. Also proffer reasons in the discussion section for why more mother tend to do complementary feeding for children ages 13-23 compared to 6-12months.

Authors’ response: Dear reviewer, thank you for your comments; we have included the possible explanation. We tried to discuss the difference in feeding practice by stating the contributor factors of low feeding among children 6-12 months. Please see the clean version of the revised manuscript on page 24, lines 363-366.

3. I think it would be worth knowing why more mother preferred to give birth at compared to health facility. Is this because of distance to health facility, costs or they trust the traditional birth attendance more than they do health workers?

Authors’ response: Dear reviewer, thank you very much for your insight. A plenty of studies identified that distance to health facility, mothers’ low awareness about institutional delivery and others cultural and social factors were the high contributor for having a significant number of home delivery in Ethiopia. These factors were contributed not only for low institutional delivery services utilization and or coverage, but also for other maternal and neonatal health services uptake like postnatal services.

20 Nov 2020

PONE-D-20-13718R2

Micronutrient intake status and associated factors among children aged 6-23 months in the emerging regions of Ethiopia: a multilevel analysis of the 2016 Ethiopian demographic and health survey

PLOS ONE

Dear Dr. Tsegaye Gebremedhin,

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 definition of to recommended MN interventions needs to be clearly introduced

Why have you included de-worming?

The discussion needs to be better oragnized to address first the findings and then comparisons with other manuscripts on MNs.

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

Please submit your revised manuscript by 19th December. 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.

Please include the following items when submitting your revised manuscript:

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An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

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

We look forward to receiving your revised manuscript.

Kind regards,

Mary Hamer Hodges, MBBS MRCP DSc

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: 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?

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: (No Response)

Reviewer #2: Yes

Reviewer #3: Yes

**********

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

Reviewer #1: (No Response)

Reviewer #2: Yes

Reviewer #3: 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 Response)

Reviewer #2: No

Reviewer #3: 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 Response)

Reviewer #2: No

Reviewer #3: 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: (No Response)

Reviewer #2: My previous comments have all been addressed. I think there are a few areas with grammatical and typo errors especially in the discussion which needs attention. I advise the authors to find another native/fluent English language speaker to review this thoroughly.

In the discussion, please provide adequate references where comparism is made to other studies.

Reviewer #3: Comments

L 2: It is unclear what “emerging” means in this context. Please provide an explanation when this word is first introduced.

ABSTRACT

L13: Scarcity of MN is due to poor diets rather than poor health care access, health care access helps mitigate the impact of these poor diets but are not the fundamental cause.

L15: children 6-23 months include “and their associated factors”. Which MN? it is essential you specify what you are measuring is it Vitamin A supplementation or something else: MNPs, 24 dietary recall?

L 25: this is too generic, need to specify which ‘recommended micronutrient supplements’. If more than just VAS, what else?

L 30: Again, still unclear whether you are describing VAS or MNPs or 24 hour dietary recall.

L31: i suggest "study population in this area", rather than "study area"

L33: i suggest putting a full stop (.) after ‘community level’

L35: This final sentence is a recommendation, please conclude your findings rather than just saying they were low in the previous sentence.

INTRODUCTION

L45: I suggest “micronutrients are”

L50: I suggest “growth” instead of grow

L55: please define Minimal Diversified Diets (MDD)

L66: You need to explain more about VAD, is the 14% corrected for inflammation? If so which methods of correction was used. 14% prevalence is considered ‘moderate VAD’

L74: What is the definition of “emerging regions”. where are they on a map? Please provide a map.

L77: 'onset of' is superfluous

L81: “therefore” is unnecessary

L83: 'Moreover' is unnecessary

L84: I suggest “problems”

STUDY SETTINGS AND DATA SOURCES

L92: Why are they called 'emerging'. Please explain.

SAMPLING PROCEDURES

L108: I presume you mean 'one' segment rather than 'only a'.

L110: 'A fixed number of' is redundant. The sentence can start with 'twenty-eight'

L112: What do the enumerators do if no-one was at home to be interviewed? or no children 6-23 within the household.

L117: Why female survey, were females the only targeted audience?

L118: Please be consistent with the use of mothers/caregivers

L119: The meaning of this sentence is unclear.

L121: How was that one child of twins selected? By ballot?

L122: ‘extracted’ is an odd way of expressing this

MEASUREMENTS OF VARIABLES

L130: Again, the reader can’t follow the augment clearly as you haven't defined what MNs and which preparations and recommended timeframes at the beginning

L131: add “/caregivers”

L137: Please clearly explain in background why deworming medication was included in this analysis MNs

L138: is this referring to any one of the recommended micronutrients, two or three?

L159: Do the national programs start providing deworming medication at 6 months of age rather than more normally from 12 months of age. What was the deworming medication?

L160: How reliable is the child health card as a source of information rather than the verbal history form the caregiver.

L164: Do you mean obstetric or history and/or parity and/or ante-natal care?

L168: These indicators measured to reach your definition of wealth need to be described.

L169: Are these ranks comparable to international definitions or just in relation to the cohort under investigation. Are you really comparing very poor, poor, less poor?

L170-1: This sentence is unclear.

DATA PROCESSING AND STATISTICAL ANALYSIS

L185: Again, do you mean parity/access to ANC?

RESULTS

L223: Again, were ALL the participants mothers of these children or were some caregivers?

OBSTETRIC HISTORY OF PARTICIPANT

L236: please define the term “multipara”

L237: acronym ANC not yet introduced and must be spelt in fill the first time it is used

L239: acronym PNC not yet introduced and must be spelt in fill the first time it is used

L241: Grand multipara must first be defined as mentioned above

CHILD CHARACTERISTICS AND COMMON CHILDHOOD ILLNESSES

L245: No definitions of average birth weight provided

L247: “were weighted” should be changed to 'were weighed'

L247: please insert % after these figures

L248: I presume you mean had 'either' rather than 'and'

L251: I suggest adding “within last 2 weeks” for diarrhoea, cough and fever which is I believe the timeframe under consideration

COMMUNITY LEVEL POVERTY, MEDIA EXPOSURE AND ACCESS TO HEALTH FACILITY

L254: ‘had had’ not ‘has’

L256: do you mean ‘was’ or ‘was not’

MICRONUTRIENT INTAKE AMONG CHILDREN 6-59 MONTH

L258: I don't think you adequately described your definition of minimum recommended in background or methods.

DISCUSSION

I think this section need to be carefully rewritten to ensure it relates to the findings in a systematic manner.

L361: discuss the association to “care” in these regions. like active response feeding for this age group since they are young compare to the older age group, who might be considered “can eat for themselves” in a family meal!!

CONCLUSIONS

L418-onwards are recommendations rather than conclusions based upon findings

REFERENCES

Placed ensure you comply with instructions to authors.

**********

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: Anni-Maria Pulkki-Brännström

Reviewer #2: Yes: Habib Issa Kamara

Reviewer #3: 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.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

Submitted filename: mcn13041 MB Final.pdf

Click here for additional data file.

Submitted filename: Reviewer comments MB final.docx

Click here for additional data file.

22 Dec 2020

Dear Sir/ Madam,

We appreciate and thank to the academic editor and reviewers for reviewing our manuscript for improvements. It is with great pleasure to receive the invaluable and constructive comments.

We have incorporated all the comments and made necessary edition and corrections. All the comments with their point-by-point responses are included in the response to reviewers and we hope now we have addressed all the concerns. Therefore, we are kindly requesting you to review our revised manuscript.

Submitted filename: Response to reviewers.doc

Click here for additional data file.

12 Feb 2021

PONE-D-20-13718R3

Micronutrient intake status and associated factors among children aged 6-23 months in the emerging regions of Ethiopia: a multilevel analysis of the 2016 Ethiopian demographic and health survey

PLOS ONE

Dear Dr. %Tsegaye Gebremedhin%,

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

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

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

This manuscript is improving but would be benefit from another thorough review with a fluent English speaker with a background in public health. I have uploaded many comments

Be concise, to not repeat all finding in the text where they are clearly visible in the tables and are of no further importance to the discussion.

Define minimum MN recommendations in the Abstract and again in Methods

Provide the multivariant findings in Abstract-Results

In discussion focus on the multivarient findings and their interpretation

Select the best references

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

Please submit your revised manuscript by %12 April 2021%. 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.

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). You should upload this letter as a separate file labeled 'Response to Reviewers'.

A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.

An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

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

We look forward to receiving your revised manuscript.

Kind regards,

Mary Hamer Hodges, MBBS MRCP DSc

Academic Editor

PLOS ONE

Additional Editor Comments (if provided):

This manuscript is improving with each revision. However it still needs substantial modifications before it is ready for publication in PLOSONE. I have made many detailed observations but the general messages are:

You have not clearly defined what the minimum recommendation of MNs intake is. Is it all 6 options, one of the six options or 3 of the six or something else?

In results be far more concise and after describing the cohort provide the coverage of all 6 of these MN options and refer the reader to the Tables for the other details unless there is something you especially want to draw their attention to and will be discussing later.

In discussion summarize the findings concisely before comparing with 1) other studies in Ethiopia and then 2) other studies in SSA.

You have far too many references for a study of this nature. I recommend to reduce to a maximum of 40 by picking only the best of the rest (most recent, most robust)

Focus on the mutlivariate analysis one at a time with your interpreation of their meaning. For example the most interesting observation was ANC (prenatal care) or distance to health centers.

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

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 #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?

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 #2: Yes

Reviewer #3: Yes

**********

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

Reviewer #2: Yes

Reviewer #3: 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 #2: Yes

Reviewer #3: 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 #2: No

Reviewer #3: 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 #2: Abstract- The author has not been too clear with his conclusion. He says ‘The micronutrient intake status in the study population in this area was low compared to the national recommendation. Promoting vitamin, A and iron-rich foods and micronutrient powders are better for micronutrient enrichments. Strengthen supplementations 35 and deworming alongside the community-based maternal and child health services would 36 improve micronutrient intake among children. There are a couple of typos here and grammatical errors that need to be addressed to make the conclusion concise. The author could try and rephrase the conclusion to read: The status of micronutrient intake among the study population was low when compared to the national recommended threshold. Strengthening supplementation and deworming in addition to maternal and child health services would improve micronutrient intake among children

Line 141-142: In the sampling procedure, the author has not explained why mothers with twins were only interviewed for one child. The author could consider explaining this sampling method for easy comprehension of sampling at the household for readers.

Line 285-286: This sentence does not read well. The author could rephrase the sentence to read- Of those who took the recommended micronutrient, only 12.9% had received three or more types of micronutrients

Line 293-294: There are a few typos in this sentence: “Around 47% (95% CI: 44.1-50.3) of the children 293 received vitamin A supplements in the six months preceding the interview. Besides, 8.4% (95% 294 CI: 5.5-8.7) of the children aged 12 to 23 months of were received deworming medication in the six months preceding the interview (Table 4).” The author could rewrite to make it easier for readers to understand what he is trying to say.

Line 361-362: Vitamin A supplement in Nigeria was 45% which is comparable with the current finding [53]. However, our study differs from the finding in India (30.4%) [54]. I suggest the author sticks with studies whose results are comparable to this study. Only compare finding in Nigeria to this and take out the study in India.

Line 363: This study's result is much lower than that of the national target of over 90% [55]. The way this sentence is written is not grammatically sound. The author could consider re-writing to read: “Results from this study shows much lower micro nutrients uptake compared to the national target of over 90%

Line 372, 388-391, 398-399 either are not writing in proper English or are not clear. The author need to rewrite again to make them readable and clear to the reader. I have made some suggestions here. Instead of saying micronutrient intake among children whose mothers worked in agriculture was higher than children whose mothers did not have work; Rephrase sentence to read – Mothers who were housewives or who had no formal/paid jobs

Replace Also, even if vitamin A supplement is effective for 6-11 months, especially when used with the vaccine against measles…. With when administered with measles vaccines

Instead of saying Furthermore, they might learn about the value of iron intake that supplements, the author could re-write sentence to read: caregivers may have learned or acquired knowledge of iron supplements during their ANC follow-up.

Line 412-413: Again, instead of saying” Besides, since the latter two regions have dense forests and water reservoirs, they could get wild fruit and fish, which are good micronutrients” the author should rephrase as “Besides, since the latter two regions have dense forests and water reservoirs, caregivers could get wild fruit and fish, which are good sources of micronutrients”

I recommend the author to read the whole manuscript again and ensure consistency in presenting results. Adjust all percentages to 1 decimal point.

Once more I suggest the author gets a native English speaker, to proof read the manuscript and ensure it is written in clear, simple English language.

Reviewer #3: Abstract

L14:I suggest you add "include" before the word food

Conclusion

L 33: What is the national recommended threshold?

L 34: Supplementation of what?

Introduction

L 75: This target should be sighted in the abstract above, L33, of my previous comment

Measurement of Variables

L 174 : Were the mothers shown a sample of the sachet during the interview?

L 182: I suggest including the word "health" before the word "card"

Micronutrient intake status among children aged 6-23 months

L 294: I suggest deleting "of were"

**********

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 #2: Yes: Habib Issa Kamara

Reviewer #3: 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.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

Submitted filename: PONE-D-20-13718 R3.docx

Click here for additional data file.

23 Mar 2021

Dear Editor and Reviewers,

We are very much thankful for your constructive comments and suggestions, which are really useful for the improvement of our manuscript. We have addressed all your concerns and the responses are included in the 'Response to Reviewers point-by-point' and clean version of the revised manuscript and submitted for your revision.

Thank you in advance!

Submitted filename: Response to reviewers.doc

Click here for additional data file.

26 Apr 2021

PONE-D-20-13718R4

Micronutrient intake status and associated factors among children aged 6-23 months in the emerging regions of Ethiopia: a multilevel analysis of the 2016 Ethiopian demographic and health survey

PLOS ONE

Dear Dr. %Tsegaye Gebremedhin%,

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

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

ACADEMIC EDITOR:

Please pay careful attention to the reviewers comments on language and use to abreviations and references

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

Please submit your revised manuscript by Jun 10 2021 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.

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). You should upload this letter as a separate file labeled 'Response to Reviewers'.

A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.

An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols. Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols.

We look forward to receiving your revised manuscript.

Kind regards,

Mary Hamer Hodges, MBBS MRCP DSc

Academic Editor

PLOS ONE

Journal Requirements:

Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

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 #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 #2: Partly

**********

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?

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Reviewer #2: Yes

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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 #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 #2: Abtract, conclusion

L35: Although you have now clearly defined the sources of MN you have not defined the national recommendations. is it that all individuals should have all of these interventions?

Introduction

L42:Include (there are others)

L48: The last part of this sentence needs amending

L50: Instead of saying vitamins and minerals why not stay with MN?

L51: At the beginning of this sentence it would be good to state which year(s) you are referring to.

L72: Please state whether this was corrected for inflammation and if so by which method. L75: Rather than 'on top of' I suggest 'in addition to'

L89: Problem (no s)

L131: 'Those second' do you mean 'those years old and older'?

L133: For mother /caregivers with twins only one was selected by convenience

L183: You mean 9 instead of an television?

L240: Having defined grand multi para please use it here, unless there was a discrepancy between giving birth and living children.

L247: I recommend reducing this text further by referring the reader to the table. Only points of interest in the final analysis need a mention which does not include average birth weight and diarrhoea. However, the final analysis does include mothers occupation etc.

L251: In the text you are using the word weight and here you are referring to size. Please clarify again as earlier you actually specified weight in kg whereas previously, I thought this was a subjective assessment by the mother/caregiver.

L259: Rather than 'Moreover' use 'Only'

L261: Better to continue the sentence rather than break it with 'additionally'

L286: Rather than antenatal visit stay with ANC

L300: I believe the manuscript would make a bigger impact if you limit this table to only those findings of statistical significance. The text could then simply stat that the other characteristics were not significant.

Discussion

L312: I see you have dropped the child’s weight now but there is still confusion over whether you were recording weight or size. Add had consumed

L313: Do you mean or iron? No need for the word 'reports'

L315: No need to start this sentence with 'besides'

L316: Got, not get.

L318: Current result? are you comparing EDHS 2011 with 2016 or with this analysis?

L322: Use MN

L326: Rather than 'the current finding' I suggest 'this study'

L329: No need for 'in Ethiopia'

L331: The sentence starting on L331-332 seems redundant although the citations might be useful

L332: Again, starting the sentence with 'on the other way' is redundant.

L334: What do you mean by low ability?

L338: The sentence starting on L336-339 does not make sense. Why would children not be eligible for VAS

L344: Another explanation might be that mothers with follow-up live nearer to health facilities of have more time/money available to attend ANC.

L347: Same comment as above

L351: A few

Strength and limitations of the study

L368: No need to expand this sentence. You can stop after factors.

L369: No need to start the sentence with 'besides'

L372: The last sentence in this para can be simplified to 'the DHS methodology allows for comparison with other settings'.

L373: This sentence is redundant as it is neither a strength not a weakness.

L375: This second sentence can be removed as you are not assessing adequacy only the MN intake of MN recommendations.

L376: No need to start with 'furthermore'

L377: Here you are using VAS but not in previous sections. Once an abbreviation has been introduced please ALWAYS use it.

L378: I don't feel the last sentence is required.

Conclusion

L381: Conclusion should be only 2-3 sentences just starting the essential facts not going over the details again. Some of what you say here could be in the discussion (but not all)

References

L4023: Please review these citations and ensure only those of importance are used and that none are used twice.

**********

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Reviewer #2: Yes: Habib Issa Kamara

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11 Jul 2021

Dear editor and reviewer,

Thank you for your valuable comments, suggestions and insights which really improved our manuscript. All the responses are included in the "Response to reviewers' file.

Submitted filename: Response to reviewers comments.doc

Click here for additional data file.

18 Aug 2021

PONE-D-20-13718R5

Micronutrient intake status and associated factors among children aged 6-23 months in the emerging regions of Ethiopia: a multilevel analysis of the 2016 Ethiopia demographic and health survey

PLOS ONE

Dear Dr. %Tsegaye Gebremedhin%,

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.

Please address the comments on wealth and birth weight/size and consider deleting Table 3 and just making a statement that none of those factors were found to be of significance with regard to MN intake.

Please submit your revised manuscript by %17th September 2021%. 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,

Mary Hamer Hodges, MBBS MRCP DSc

Academic Editor

PLOS ONE

Journal Requirements:

Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

Additional Editor Comments (if provided):

You have made some improvements but there is still too much information being presented in Tables 2 and 3 that have no relevance to your final analysis. Confusion over how you have defined wealth status/index. quintile/quantile and birth weight/size remain. If data in tables 2 and 3 have been analyzed and found 'Not Significant' I suggest to reduce the amount of data being presented to the reader so that attention can be drawn to important findings: mothers occupation, ANC visits, child's age, residence and region.

Please define what the governments recommendations for minimum dietary diversity are in terms of food groups consumed within last 24 hours. Below I have drawn attention to some minor typos and presentation issues

L 14: rather than ‘prevent’ I believe these recommendations/interventions help to ‘reduce’.

L 14: I think this sentence need to be modified as diets have been ‘promoted’ and programs for the distribution MNPs or others supplements for iron and VA and deworming ‘have been implemented’.

Methods

L 21: ‘consumed within the previous’ 24 hours

L 22: ‘supplementation with the previous’ seven days

Result

L 31: This sentence seems unfinished. Are these factors that increase MN uptake or decrease MN intake, or mixed some increased and some decreased? Same comment for last sentence.

Conclusions L 35: recommendation’s’. it is still not clear what the Government recommendations are whether it is a diet with VA or iron rich foods plus VAS or iron supplementation or MNPs. I suspect you are trying to say diet rich (in VAS or iron) or VA or Iron supplementation or MNPs but it is still not clarified in Background.

Introduction

L 45: May lead would be better replaced by 'contribute to'

L 64: 6-59 months semi-annually in a (no need for ‘by’)

L 65: Which ones? Iron folic acid (IFA) or multiple micronutrient supplements (MMS)?

L 69: Were receiving ‘a diet of minimal dietary diversity’ Please don’t use an abbreviation such as MDD without first introducing it. What does the government recommend for MDD? Three or more of the food groups as elaborated further in Results? Please specify.

L 82: Hotspot’s’ (pleural)

L 85: I think the last section of this sentence ‘that exacerbate MN deficiency’ could be deleted. These factors to not exacerbate MN deficiency they limit the ability to address the issue through interventions.

L 88: Finding’s’

L 89: Problem’s’

Study setting and data source

L 104: ‘and access to health and education services’

Measurements of variables

L 143: ‘consumed within the previous seven days’

L 144: ‘the previous’ six months

L 170: reviewers have asked previously how birth weight/size was assessed. Was it mothers recall of size or an actual weight taken at birth and recorded in a child health card? If it was mothers recall them please use large, average or small as reported in table 3.

L 171: Where did you get this classification? 4kgs seem excessive. please double check and provide a reference. As the results of this weight/size was not fund to be of any significance it might be best to omit it altogether to avoid these critisims.

L 172: This section lines 172-187 is unclear. Sometime you use quintile, sometimes quantile and sometimes index. On line 175 you have 3 subdivisions and on line 181 you have 5 (usual for quintiles). please clarify.

L 174: Quintile or index?

Result

L 231: What do to mean here wealth quintiles?

L 241: Why have you written this in words rather than given the actual figure 56.4%?

L 245 Table 2: What is the merit or presenting this data as it is not used in the further analysis or found significant. What is the merit of presenting all this date? It is not used or found significant in the analysis

What is the merit of presenting this data if it was not further analysis or found significant? A reader interested in these figures can find them in the EDHS. Only data that directed the reader to your important findings really deserves attention.

L 252: The merit of Table 3 is questionable. None of these factors were associated with MN intake.

L 253: Date that was not found to be of significance in the analysis could be removed from these tables to draw attention to elements there are of significance.

If the birth interval or birth order had no significant association with MN intake what is the merit of presenting the date?

what is the merit of the current child weight being presented if it is not related to the child age (W/A) or height (WH)? If you are not using this data in the analysis, please delete both these rows.

These last 3 section on diarhoea, cough and fever get not further mention in the analysis. If they were not significantly assassinated with MN intake, please delete these 6 rows and jut make a statement that there was not associated with MN intake.

Community level variables

L 256: Past tense 'were'

L 257: Now you are using status as opposed to index, quintile/quantile.

L 259: Quantile needs a better explanation in methods

Individual and community level factor of micronutrient intake status (fixed effects)

L 293: Here you could list all the factors that were not significant.

L 301: Versus urban residents

Discussion

L 316-322 you are inconsistent with the use of decimal places sometime non and sometimes 2. For example: 38% and 43.17%. This is distracting for the reader.

L 323: The term 'housewives' has not previously been used.

L 347: Citing the author is not the PLOS ONE format for referencing

Strength and limitation of the study

L 367: It is normal practice to just draw attention to the study limitations as the last paragraph in discussion (without a sub-heading)

Conclusion

L 375: You have not clearly defined the national dietary recommendations (number of food groups to be consumed in previous 24 hours). For deworming it might be >75% in the last 6 months. But what about the other options?

L 377: This second sentence is not based upon findings.

L 379-381: We have only cited deworming and MNPs. What about iron and VAS?

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Reviewers' comments:

[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.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

28 Sep 2021

Dear editor,

Thank you for your comments and suggestions that improved our manuscript. All responses to the editor's comments and suggestions are included in the point by point response letter and finally we have submitted the Responses to Reviewers letter, clean version of the revised manuscript and the marked copy documents. We are kindly requesting to review our revision.

Thank you!

Submitted filename: Responses to Reviewers letter.docx

Click here for additional data file.

11 Oct 2021

Micronutrient intake status and associated factors among children aged 6-23 months in the emerging regions of Ethiopia: a multilevel analysis of the 2016 Ethiopia demographic and health survey

PONE-D-20-13718R6

Dear Dr. %Tsegaye Gebremedhin%,

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,

Mary Hamer Hodges, MBBS MRCP DSc

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

This is much improved and not worthy of publication. The abbreviation (MN) need NOT be introduced in the abstract since you do not use it again for the rest of the abstract.

Reviewers' comments:

14 Oct 2021

PONE-D-20-13718R6

Micronutrient intake status and associated factors among children aged 6-23 months in the emerging regions of Ethiopia: a multilevel analysis of the 2016 Ethiopia demographic and health survey

Dear Dr. Gebremedhin:

I'm 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 let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, 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.

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Thank you for submitting your work to PLOS ONE and supporting open access.

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on behalf of

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Academic Editor

PLOS ONE