Rural-urban differentials in the prevalence of diarrhoea among older adults in India: Evidence from Longitudinal Ageing Study in India, 2017-18.

INTRODUCTION: Diarrhoeal diseases are common among children and older adults. Yet, majority of the scientific studies deal with children, neglecting the other vulnerable and growing proportion of the population-the older adults. Therefore, the present study aims to find rural-urban differentials in the prevalence of diarrhoea among older adults in India and its states. Additionally, the study aims to find the correlates of diarrhoea among older adults in India. The study hypothesizes that there are no differences in the prevalence of diarrhoea in rural and urban areas.
METHODS: Data for this study was utilized from the recent Longitudinal Ageing Study in India (2017-18). The present study included eligible respondents aged 60 years and above (N = 31,464). Descriptive statistics along with bivariate analysis was presented to reveal the preliminary results. In addition, binary logistic regression analysis was used to fulfil the study objectives.
RESULTS: About 15% of older adults reported that they suffered from diarrhoea in the last two years. The prevalence of diarrhoea among older adults was found to be highest in Mizoram (33.5 per cent), followed by Chhattisgarh (30.7 per cent) and Bihar (30.2 per cent). There were significant rural-urban differences in the prevalence of diarrhoea among older adults in India (difference: 7.7 per cent). The highest rural-urban differences in the prevalence of diarrhoea were observed among older adults who were 80+ years old (difference: 13.6 per cent), used unimproved toilet facilities (difference: 12.7 per cent), lived in the kutcha house (difference: 10.2 per cent), and those who used unclean source of cooking fuel (difference: 9 per cent). Multivariate results show that the likelihood of diarrhoea was 17 per cent more among older adults who were 80+ years compared to those who belonged to 60-69 years' age group [AOR: 1.17; CI: 1.04-1.32]. Similarly, the older female had higher odds of diarrhoea than their male counterparts [AOR: 1.19; CI: 1.09-1.30]. The risk of diarrhoea had declined with the increase in the educational level of older adults. The likelihood of diarrhoea was significantly 32 per cent more among older adults who used unimproved toilet facilities than those who used improved toilet facilities [AOR: 1.32; CI: 1.21-1.45]. Similarly, older adults who used unimproved drinking water sources had higher odds of diarrhoea than their counterparts [AOR: 1.45; CI: 1.25-1.69]. Moreover, older adults who belonged to urban areas were 22 per cent less likely to suffer from diarrhoea compared to those who belonged to rural areas [AOR: 0.88; CI: 0.80-0.96].
CONCLUSION: The findings of this study reveal that diarrhoea is a major health problem among older adults in India. There is an immediate need to address this public health concern by raising awareness about poor sanitation and unhygienic practices. With the support of the findings of the present study, policy makers can design interventions for reducing the massive burden of diarrhoea among older adults in rural India.

Introduction

Diarrhoea is the second leading cause of mortality and morbidity throughout the world [2]. Although diarrhoeal diseases are common among children and older adults, death due to diarrhoea is three times more among older adults and specifically among those who belong in the population above 70 years of age than children under five years of age [1]. It not only causes physical discomfort but emotional distress as well. For instance, a study found out that older adults infected with diarrhoea experienced emotional distress since they had no control over faeces—when and where it would occur. Additionally, they lived in constant fear of experiencing faeces incontinence in public while they were away from home [2].

Diarrhoea among older adults is mostly caused due to an infection called ‘shigella’, that causes 18.4 deaths per lakh population [1]. Along with it unhygienic eating habits, contaminated food and water account for the continuing high prevalence of acute diarrhoea among older adults [3]. Infection can occur due to spoilt food, untreated water or from individual to individual [4]. It is also caused by a variety of bacterial, viral and parasitic organisms [5-8]. However, a study reveals that sometimes the causes of diarrhoea are not known [9] but it usually starts after two to four days after the infection and may last for three to seven days [10].

Current guidelines for the management of diarrhoea by the Ministry of Health and Family Welfare, Government of India, recommend a salt solution and zinc supplementation as precautionary steps that can prevent diarrhoea among older adults [11]. According to traditional medicine conventional ORS treatment with plant extracts can result in the reduction in the length of diarrhoeal symptoms [12]. A previous study based on a systematic review at the global level found that hand washing reduces diarrhoea by 40 per cent, but the practice of handwashing after contact with excreta is low throughout the world [13]. So as evidence suggest, this disease can easily be prevented by following very simple steps of hand washing, practicising safe drinking water, healthy hygiene and better sanitation [14].

Developing countries observe more cases of diarrhoea due to lack of safe drinking water, sanitation, and hygiene combined with poor nutritional status [15]. For example, in India, although negligible rural-urban difference is found in hand washing, almost 80 per cent of households in urban areas use soap and water to wash their hands compared to a maegre 49.4 per cent households in rural areas. Again, only 48.4 per cent of households have improved sanitation facilities, and 89.9 per cent have improved sources of drinking water. However, when improved sanitation facilities is bifurcated with place of residence, it is observed that 54 per cent of households in rural areas have no toilet facility compared to only 11 per cent households in the urban areas [16]. This rural-urban disparity in basic entitlements which is also the cause for illness due to diarrhoea encouraged us to take up the present study.

India’s population over 60 years and above is projected to increase from 8 per cent in 2015 to 19 per cent in 2050 [17]. At the same time, 65 years and above population will increase from 6.4 per cent in 2019 to 8.6 per cent in 2030 [18]. Majority of the previous studies have focused on determinants of diarrhoea among children under five years of age in India [24-28], neglecting a vast and fast growing older adult population. On the other hand, acute diarrhoea is the most common diagnosis among older adults [19, 20]. Diarrhoea in developing countries like India, where there is poor sanitation and overcrowding [12, 21] is a major public health concern. Moreover, despite many governmental and non-governmental initiatives to restrict open defecation, Indians residing in rural areas still practise it, which is a cause for diarrhoeal infection [20-23].

Therefore, the present study is rationalised on the following arguments. One, based on the fact that the proportion of Indian older adults is increasing at an increasing rate and is likely to rise in the coming decades [17]. Two, considering that the older adults are at a high risk of being infected by diarrhoea and die due to diarrhoea. Three, research evidence suggests that people living in rural areas are more succeptible to diarrhoea because of poor sanitation. Finally, given the dearth of scientific studies on the prevalence of diarrhoea among older adults and its determinants in India, the present study aims to find the rural-urban differential in the prevalence of diarrhoea among older adults in India and its states. Additionally, the study aims to find the determinants of diarrhoea among older adults in India. The study hypothesize that there are no difference in the prevalence of diarrhoea among older adults in rural and urban areas.

Methods

Data

Data for this study was utilized from the Longitudinal Ageing Study in India (LASI) wave 1 [22]. LASI is a full-scale national survey of scientific investigation of India’s health, economic, and social determinants and consequences of population ageing, conducted in 2017–18 [22]. LASI is a nationally representative survey of over 72000 older adults aged 45 and above across all states and India’s union territories. The survey’s main objective is to study the health status and the social and economic well-being of older adults in India. LASI adopted a multistage stratified area probability cluster sampling design to arrive at the eventual units of observation: older adults age 45 and above and their spouses irrespective of their age. The survey adopted a three-stage sampling design in rural areas and a four-stage sampling design in urban areas. In each state/UT, the first stage involved the selection of Primary Sampling Units (PSUs), that is, sub-districts (Tehsils/Talukas), and the second stage involved the selection of villages in rural areas and wards in urban areas in the selected PSUs. In rural areas, households were selected from selected villages in the third stage. However, sampling in urban areas involved an additional stage. Specifically, in the third stage, one Census Enumeration Block (CEB) was randomly selected in each urban area. In the fourth stage, households were selected from this CEB. The detailed methodology was published in the survey report with the complete information on the survey design and data collection [22]. The present study included the eligible respondent’s aged 60 years and above. The present study’s total sample size was 31,464 (Rural-20,725 and Urban-10,739) older adults aged 60 years and above.

Variable description

Outcome variable

The outcome variable was in binary form, i.e., diarrhoea (no and yes). The information was assessed by asking that “whether, in the past two years, the respondent was diagnosed with diarrhoea by a health professional?” The response was stated as no and yes [23, 24].

Explanatory variables

The main explanatory variable was a place of residence and it was coded as rural and urban area. The classification was defined as in previous literature. It was found that disease prevalence varies significantly by place of residence [25-29].

Age was coded as 60–69 years, 70–79 years and 80 and above; Sex was coded as male and female; Education was coded as no education/primary not completed, primary completed, secondary completed and higher and above; Marital status was coded as currently married, widowed and others which includes separated/divorced/never married; Working status was coded as currently working, retired/not currently working and never worked; Overweight/obesity was coded as underweight, normal and overweight/obese. The respondents having a body mass index of 25 and above were categorized as obese/overweight.

Source of cooking fuel was coded as unclean and clean; Type of toilet facility was coded as unimproved and improved; Source of drinking water was coded as unimproved and improved, and type of house was coded as pucca, semi pucca and kutcha. The monthly per capita expenditure (MPCE) quintile was assessed using household consumption data. Sets of 11 and 29 questions on the expenditures on food and non-food items, respectively, were used to canvas the sample households. Food expenditure was collected based on a reference period of seven days, and non-food expenditure was collected based on reference periods of 30 days and 365 days. Food and non-food expenditures have been standardized to the 30-day reference period. The monthly per capita consumption expenditure (MPCE) is computed and used as the summary measure of consumption [22]. The variable was then divided into five quintiles, i.e., from poorest to richest. Religion was coded as Hindu, Muslim, Christian, and Others. Caste was coded as Scheduled Tribe, Scheduled Caste, Other Backward Class, and others. The Scheduled Caste includes a group of socially segregated population and by their financially/economically status as per the Hindu caste hierarchy. The Scheduled Castes (SCs) and Scheduled Tribes (STs) are among the India’s most disadvantaged socio-economic groups. The OBC is the group of people who were identified as “educationally, economically and socially backward”. The OBC’s are considered low in the traditional caste hierarchy. The “other” caste category is identified as having higher social status [30-32]. Geographical region was coded as North, Central, East, Northeast, West, and South.

Statistical analysis

Descriptive statistics and bivariate analysis were presented in the present study to reveal the preliminary results. Proportion test [33] was used to find the significance level for residential differences for diarrhoea prevalence. Moreover, binary logistic regression analysis [34] was used to analyse the association between the outcome variable (diarrhoea) and other explanatory variables.

The binary logistic regression model is usually put into a more compact form as follows:

The parameter β0 estimates the log odds of diarrhoea for the reference group, while β estimates the maximum likelihood, the differential log odds of diarrhoea associated with a set of predictors X, as compared to the reference group, and ϵ represents the residual in the model. The variance inflation factor (VIF) was used to check for the existence of multicollinearity, and the test found that there was no confirmation of multicollinearity [35, 36].

Results

Socio-demographic profile of study population (Table 1)

About 58 per cent of older adults belonged to the 60–69 years’ age cohort, 30 per cent were in the age group of 70–79, and the rest of (11 per cent) older adults belonged to the 80+ years, age group. A higher proportion of older adults from rural areas had no education/primary not completed (77 per cent), whereas, in urban areas, about 46 per cent of older adults had no education. About one-third and 12 per cent of older adults from rural and urban areas were underweight. Nearly 35 per cent and 20 per cent of older adults were currently working in rural and urban areas, respectively. Around 35 per cent of older adults in rural areas used clean cooking fuel, which was more than double in urban areas (81.5 per cent). In rural areas, three-fifth of older adults used improved toilet facilities while in urban areas, 88 per cent of older adults used improved toilet facilities. Moreover, a higher proportion of older adults from rural and urban areas used improved drinking water sources. About 42 per cent of older adults in rural areas lived in the pucca house, and this proportion was almost double in urban areas than in rural counterparts.

displays the prevalence of diarrhoea among older adults in the states of India. About 15 per cent of older adults in India suffer from diarrhoea (rural-17 per cent and urban-9 per cent). The prevalence of diarrhoea among older adults was highest in Mizoram (33.5 per cent), followed by Chhattisgarh (30.7 per cent), Bihar (30.2 per cent), and Rajasthan (30.2 per cent). Moreover, in rural areas, this prevalence was highest in Mizoram (33.2 per cent), followed by Chhattisgarh (32.6 per cent), Rajasthan (32.2 per cent) and Bihar (30 per cent) (Table 2). In the case of urban India, the highest prevalence of diarrhoea among older adults was observed in Mizoram (34 per cent), followed by Bihar (32.1 per cent), Haryana (25.9 per cent), Himachal Pradesh (25.7 per cent), and Madhya Pradesh (24.5 per cent) (Table 2).

Fig 1

Prevalence of diarrhoea among older adults by states of India, 2017–18.

Table 2

Percentage of older adults suffered from diarrhoea in states of India, 2017–18.

States	Rural (%)	Urban (%)	Total (%)
Jammu & Kashmir	8.9	4.0	7.2
Himachal Pradesh	19.9	25.7	20.1
Punjab	9.7	15.9	11.1
Chandigarh	0.0	8.7	8.4
Uttarakhand	7.3	9.7	7.8
Haryana	24.1	25.9	24.5
Delhi	0.0	12.9	12.9
Rajasthan	32.2	23.0	30.2
Uttar Pradesh	27.9	19.9	26.4
Bihar	30.0	32.1	30.2
Arunachal Pradesh	16.1	8.2	15.6
Nagaland	0.1	0.0	0.1
Manipur	18.1	22.2	20.3
Mizoram	33.2	34.0	33.5
Tripura	5.8	5.8	5.8
Meghalaya	6.2	5.5	6.1
Assam	7.3	2.6	6.5
West Bengal	8.9	5.0	7.9
Jharkhand	11.9	8.3	11.2
Odisha	6.3	5.1	6.2
Chhattisgarh	32.6	23.1	30.7
Madhya Pradesh	30.0	24.5	28.8
Gujarat	17.7	12.6	15.1
Daman & Diu	12.3	6.3	8.3
Dadra & Nagar Haveli	23.1	20.6	22.1
Maharashtra	5.7	1.8	4.2
Andhra Pradesh	2.0	0.0	1.5
Karnataka	11.3	1.8	6.5
Goa	4.4	1.6	2.9
Lakshadweep	2.4	1.2	1.6
Kerala	3.0	3.3	3.3
Tamil Nadu	5.6	4.0	5.1
Puducherry	5.3	0.4	2.4
Andaman & Nicobar Island	20.2	16.0	19.8
Telangana	0.9	0.9	0.9
India	17.1	9.4	14.8

Rural-urban differential in the prevalence of diarrhoea among older adults in India (Table 3)

Overall, the result shows a significant rural-urban difference in the prevalence of diarrhoea among older adults in India (difference: 7.7 per cent). The prevalence of diarrhoea was significantly higher among 80+ years older adults (17.6 per cent) than other age group. It has a negative association with the educational level of older adults. For instance, the prevalence of diarrhoea decreased with the increase in the level of education among older adults. A similar pattern was observed in rural as well urban areas. Diarrhoea was more prevalent among underweight older adults, and it was also true for rural and urban areas. Wealth quintile had negative association with the prevalence of diarrhoea, moreover it was higher in rural areas in all wealth groups than urban areas. The prevalence of diarrhoea was higher among older adults who used unclean cooking fuel (18.3 per cent) and those who used unimproved toilet facilities (20.3 per cent) compared to their counterparts. A similar result was observed for older adults who belonged to rural and urban areas. The highest rural-urban differences in the prevalence of diarrhoea were observed among older adults who were 80+ years old (difference: 13.6 per cent), used unimproved toilet facilities (difference: 12.7 per cent), lived in the kutcha house (difference: 10.2 per cent), and those who used unclean source of cooking fuel (difference: 9 per cent). Older adults who used improved drinking water (15.2%) reported more diarrhea than those who used unimproved drinking water (10.9%). Underweight older adults had a higher prevalence of diarrhoea irrespective of their place of residence.

Estimates from multivariate analysis for older adults who suffered from diarrhoea in India (Table 4)

The result depicts that the likelihood of diarrhoea was 17 per cent more likely among older adults who were 80+ years compared to those who belonged to the 60–69 years age group [AOR: 1.17; CI: 1.04–1.32]. Similarly, the older female had higher odds of diarrhoea than older male counterparts [AOR: 1.19; CI: 1.09–1.30]. Older adults with no education/primary not completed had higher odds to suffer from diarrhoea in reference to older adults with higher and above education [AOR: 1.43; CI:1.20,1.71]. With reference to scheduled caste older adults, scheduled tribe and other backward class older adults had 22 per cent and 24 per cent higher risk of diarrhoea, respectively. Older adults who belonged to urban areas were 22 per cent less likely to suffer from diarrhoea than those who belonged to rural areas [AOR: 0.88; CI: 0.80–0.96]. The risk of diarrhoea among older adults was higher in the Central region, whereas it was lower in other parts of India compared to the North region. The likelihood of diarrhoea was significantly 32 per cent more likely among older adults who used an unimproved toilet facilities than those who used improved toilet facilities [AOR: 1.32; CI: 1.21–1.45]. Similarly, older adults who used unimproved drinking water sources had higher odds of diarrhoea than their counterparts [AOR: 1.45; CI: 1.25–1.69].

Discussion

Although diarrhoeal diseases are common in older populations [19, 37], there is a paucity of study on them, making the preventable disease a major cause of concern. The present study analysed data from Longitudinal Ageing Study in India to estimate diarrhoeal prevalence among older adults in India and across its states. A significant rural-urban difference in the prevalence of diarrhoea among older adults is found. Those who are living in rural areas are more likely to suffer from the disease. Using unimproved drinking water, unimproved sanitation facility, and low access to health care facilities in rural areas are found to be positively associated with a high prevalence of diarrhoea [38, 39]. Furthermore, literary evidences mostly on childhood diarrhoea show that environmnetal as well as personal hygiene to be significant risk factors of acute diarrhoea among rural population [40, 41].

The study also found out a high prevalence of diarrhoea among underweight older adults who belonged to rural areas compared to urban areas. Improper nutrition among older adults who reside in rural areas could be a possible explanation for this finding as evidence from previous analysis on children showed undernutrition as an underlying cause associated with diarrhoea [42]. Again, a study on children in a rural community in South India showed that undernourished children had a higher risk for acute diarrhoea [40].

Drawing similarities from research on children in Indonesia, Bangladesh, Ethiopia [40-43] which emphasize that children who lived in houses with less dirty sewage, utilized latrine facilities, belonged to households where handwashing was practiced before preparing food had significantly lower diarrhoea prevalence, our study results exhibit that older adults who used unimproved toilet facility had higher odds of suffering from diarrhoea. Contradicting our result which shows that older adults with no education had higher likelihood of suffering from diarrhoea, a study on incidence and determinants of acute diarrhoea among Malaysian population showed that those with higher level of education had higher likelihood of acute diarrhoea [43].

Logistic regression results reveal that the prevalence of diarrhoea was positively associated with higher age of older adults, who belonged to Scheduled Tribe (22 per cent higher risk) and OBC social group (24 per cent higher risk). The finding is consistent with a study carried out among under-five children in India [44]. Moreover, the study reveals that older adults who belong to the Christian religion were more likely to have diarrhoeal risk than Hindu older adults. However, this finding is inconsistent with previous research on under-five children in India [38, 44].

Generally, the incidence of diarrhoea remains a tremendous burden on population from low- and middle-income countries due to multiple determinants such as low socioeconomic status, lack of safe drinking water, inadequate sanitation, poor hygiene and crowding but the present study contradicts the existing literature and shows that the odds of older adults suffering from diarrhoea is higher among those who belonged to a richer section of the population [38, 45]. Probable explanations for this finding could be: 1) A high prevalence of diabetes among older adults, in general and those belonging to high Socio Economic Status [46-48] and because diabetic diarrheoa is a major gastrointestinal discomfort [49, 50], older adults belonging to the richer section may have a high prevalence of diarrhoea. 2) Since multimorbidity is higher among older adults [51, 52], older adults may be consuming medicines that may cause diarrhoea.

Earlier studies on children under five in India, have shown regional disparity in the prevalence of diarrhoea [37, 48]. The present study shows a higher concentration of diarrhoea among older adults in central and northeastern parts of the country compared to the southern states of India [53]. The finding shows similarity with studies based on children in India [54]. This could be because of unequal access to health care facilities, use of untreated drinking water and low hygienic practices. The regional disparity in the prevalence of diarrhoea among older adults in India highlight the need for spatial studies to identify the hotspots that will help in the planning of controlling the disease.

Strengths and limitations of the study

The study contributes to the growing body of research documenting the high prevalence of diarrhoea in India, especially in rural areas among older adults and highlights the disease’s predictors. The primary strength of the study lies in the use of countrywide data on older adults. Earlier studies on diarrhoea focused on a particular region with smaller sample size and on children under five years of age [55, 56]. However, research evidences on diarrhoeal diseases among older adults is scarce [57]. The study has certain limitations too. First, diarrheoal prevalence was based on self-reporting and recall of the respondents; this leaves a scope for under-reporting of diarrhoea’s prevalence. Second, the study is based on one time point data, therefore trend could not be established. Third, the illustration of the causal relationship between diarrhoea and geriatric outcomes was also limited as we used a cross-sectional study design. Lastly, evidence suggests that hand wash plays a vital role in the incidence of diarrhoea. However, the absence of information on hand washing practice before preparation of food prevented us from examining its association with the incidence of diarrhoea among older adults.

Conclusion

The study found a high prevalence of diarrhoea among older adults residing in rural areas. Since, diarrhoea is caused due to public health challenges posed by poor sanitation, unhygenic practices like unsafe drinking water and lack of hand washing, policies should be implemented in rural areas in terms of spreading awareness of sanitation and hygiene practices. Thus, the findings of this study can be used to design target interventions for reducing the massive burden of diarrhoea among older adults in India. Also, as India is undergoing an epidemiological transition along with demographic transition, research on disease burden owing to acute diarrhoea and its associated risk factors among older adults need to be studied.

29 Jun 2021

PONE-D-21-09569

Rural-urban differentials in prevalence of diarrhoea among older in India: An evidence from Longitudinal Ageing Study in India, 2017-18

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Reviewer's Responses to Questions

Comments to the Author

1. 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: Partly

Reviewer #2: Yes

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

Reviewer #1: Yes

Reviewer #2: Yes

**********

3. 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

**********

4. 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

**********

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: Abstract: The abstract contains incomplete sentences and needs to be rewritten. No mention of rural urban differentials could be found in the objectives, which according to the title is supposedly the main aim of the paper. Sentence like "Descriptive statistics along with bivariate analysis was presented in the present study to reveal the preliminary analysis. " is not clear. Do the authors mean preliminary results?

In the abstract, Authors may first present the overall scenario in India and states and then can move to the rural urban differential and then the multivariate results.

The policy recommendations written in the abstract are not coming directly from the study. Authors should recommend policies or need based on their findings and results. This is a very broad recommendation. Authors should try to write the recommendations linking with their study results.

Authors should choose keywords more attentively. Using rural urban differential would be better than key words of prevalence and regression.

Introduction has many information but has to be reframed. There should be link and should be written with continuity and flow. Authors may only write Diarrhoea in place of Diarrhoea diseases . They can also write diarrhoeal disease but diarrhoea disease is not recommended.

"So present study focus on the older adults in India who are above 60 years of age and are suffering from diarrhoea." This sentence is very confusing and it seems that the authors only chose the older adults suffering from diarrhoea?

"Unlike children, the study found that diarrhoea is associated with emotional distress among the older adults" Which study? the authors should describe a little more while writing about any other study. In that way it will be easier to read.

" Acute diarrhoea leads to a substantial disease burden worldwide and most commonly diagnoses among the older adults [6, 7]. This is common in developing countries like India, where there are poor sanitation and overcrowding. Global Burden of Diseases, in 2016 estimated, diarrhoea was the eighth leading cause of mortality, responsible for more than 6 million deaths [8, 9]."--- India and global data are getting mixed up. Authors may first discuss about global and then on India specifically.

"A previous study found that hand washing reduces diarrhoea by 40 per cent, but the practice of handwashing after contact with excreta is low throughout the world "---Where was the study conducted and among whom? give more information.

Rural urban differential as mentioned in the title is missing from objectives.

"Data for this study was utilized from the recent release of the Longitudinal Ageing Study in India (LASI) wave 1 "-- sentences should be more simpler.

"The present study is conducted on the eligible respondent’s age 60 years and above. "--- or included?

Authors may simply describe about the variables and their categories. Giving references for each categories may be avoided as there are more than hundreds of research papers using the same variables and its categories. These are all established variables.

Results

Socio-demographic profile of study population (Table 1)---The study is on aged population, but the authors did not mention about the age categories here and percentage of elderly under each category.

Prevalence of diarrhoea among older adults in India (Table 2)--Author should first present about the overall scenario of states and India and then can focus on the rural urban differentials and other aspects.

There should be separate subheading and paragraph for rural urban differentials as this is one of the important aspect of the study.

Figure 1 displays the prevalence of diarrhoea .......... --- this should be written in a more presentable manner. India %? Give total column in Table 3

Estimates from multivariate analysis for older adults who suffered from diarrhoea in India (Table 4)--Consider rewriting and reframing some of the subheadings

Discussion-- needs to be rewritten. This discussion part is almost like Literature review. Authors may go through few literature and see how to frame the discussion part. The studies quoted in the discussion should support your findings (or contrary) and should not be written separately. Should be linked to your study findings. For example "A previous study based on rural Bangladesh suggested that hand washing before preparing food is particularly important to prevent diarrhoea [55, 56]. " With which finding from the present study are the authors linking this study in support or in contrary. There are many literatures mentioned like this is the discussion without linking them to the study results.

There are few portions under discussion which will be more appropriate for the need /scope of the study part.

"In the context of the increasingly ageing trend in India, the prevalence and correlates of agents among older diarrheal patients was needed to explore"-- not clear

"The research shows a significant rural-urban difference in the prevalence of diarrhoea among older adults in India"--- Should write whether it is high in rural or urban too

How are the results considering religion and economic condition?

Citing references should be done properly and only where necessary.

"Research related to the prevalence of diarrhoea among the geriatric age group should also be emphasized as the issue is growing at an unprecedented pace globally"-- which issue? Issue of ageing or diarrhoea? Recommended to write more clearly.

Separate section on strengths and limitations can be written other than merging with the discussion part .

Need to rewrite conclusion part. Focus on the main contribution from the paper. Try focusing on policy recommendations coming directly from the study.

Few references needs to be modified according to referencing style.

Tables- total column may be given in Table 1, 2, 3.

Table 2- In results section the urban rural and total percentage by few important background characteristics may be explained as a background before going to the rural urban differential.

Table 4- May consider reordering of the variables. First may give soci0 demographic, then economic and household variables.

I congratulate the authors for selecting this topic and working extensively on the literature review and analysis. But they have to revise the manuscript as the result, discussion, conclusion parts needs to be rewritten. The main findings from this study are getting disoriented and lost. They should also focus on the conclusion and policy recommendation part as this is a very important topic.

Reviewer #2: The manuscript sounds good, I recommened to accept the paper for publication. Although I have some observations. First is that author should rewrite the discussion part. As I found there is very less linking between the variables consisting older adults and diarrhoea among older. Also In discussion part author has quitely written the literature references to explain and support the current study results. But I think, he should consider the theme as a whole rather than going point by point. Second is that author should discuss more about the logistic regression and literature references to support his findings.

**********

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.

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: No

Reviewer #2: Yes: Tushar Dakua

[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.

21 Jul 2021

Review Comments to the Author

Reviewer #1: Abstract: The abstract contains incomplete sentences and needs to be rewritten. No mention of rural urban differentials could be found in the objectives, which according to the title is supposedly the main aim of the paper. Sentence like "Descriptive statistics along with bivariate analysis was presented in the present study to reveal the preliminary analysis. " is not clear. Do the authors mean preliminary results?

Response: Dear reviewer, I agree with your comment. The abstract is now rewritten. Moreover, preliminary analysis is now written as preliminary results.

In the abstract, Authors may first present the overall scenario in India and states and then can move to the rural urban differential and then the multivariate results.

Response: Comment incorporated.

The policy recommendations written in the abstract are not coming directly from the study. Authors should recommend policies or need based on their findings and results. This is a very broad recommendation. Authors should try to write the recommendations linking with their study results.

Response: The recommendation is now updated.

Authors should choose keywords more attentively. Using rural urban differential would be better than key words of prevalence and regression.

Response: Thanks for the suggestion. Amendment has been done.

Introduction has many information but has to be reframed. There should be link and should be written with continuity and flow. Authors may only write Diarrhoea in place of Diarrhoea diseases. They can also write diarrhoeal disease but diarrhoea disease is not recommended.

Response: Thanks for the suggestion, change has been made in the manuscript.

"So present study focus on the older adults in India who are above 60 years of age and are suffering from diarrhoea." This sentence is very confusing and it seems that the authors only chose the older adults suffering from diarrhoea?

Response: This sentence has been reframed, to clarify that this study include all population in this age group.

"Unlike children, the study found that diarrhoea is associated with emotional distress among the older adults" Which study? the authors should describe a little more while writing about any other study. In that way it will be easier to read.

Response: Few additional line on study area and target population is added in the manuscript.

"Acute diarrhoea leads to a substantial disease burden worldwide and most commonly diagnoses among the older adults [6, 7]. This is common in developing countries like India, where there are poor sanitation and overcrowding. Global Burden of Diseases, in 2016 estimated, diarrhoea was the eighth leading cause of mortality, responsible for more than 6 million deaths [8, 9]."--- India and global data are getting mixed up. Authors may first discuss about global and then on India specifically.

Response: Data has been put in sequence as suggested.

"A previous study found that hand washing reduces diarrhoea by 40 per cent, but the practice of handwashing after contact with excreta is low throughout the world "---Where was the study conducted and among whom? give more information.

Response: The study population referred in this particular study is being mentioned as per the suggestion.

Rural urban differential as mentioned in the title is missing from objectives.

"Data for this study was utilized from the recent release of the Longitudinal Ageing Study in India (LASI) wave 1 "-- sentences should be more simpler.

Response: Rural-urban differential has been mentioned in the objective. Sentence has been modified.

"The present study is conducted on the eligible respondent’s age 60 years and above. "--- or included?

Response: Thanks for the pointing out. Modification has been done.

Authors may simply describe about the variables and their categories. Giving references for each categories may be avoided as there are more than hundreds of research papers using the same variables and its categories. These are all established variables.

Response: Comment incorporated.

Results

Socio-demographic profile of study population (Table 1)---The study is on aged population, but the authors did not mention about the age categories here and percentage of elderly under each category.

Response: Percentage under each age categories has been mentioned.

Prevalence of diarrhoea among older adults in India (Table 2)--Author should first present about the overall scenario of states and India and then can focus on the rural urban differentials and other aspects.

Response: Comment incorporated.

There should be separate subheading and paragraph for rural urban differentials as this is one of the important aspect of the study.

Response: Comment incorporated.

Figure 1 displays the prevalence of diarrhoea .......... --- this should be written in a more presentable manner. India %? Give total column in Table 3

Response: Comment incorporated.

Estimates from multivariate analysis for older adults who suffered from diarrhoea in India (Table 4)--Consider rewriting and reframing some of the subheadings

Response: Amendment has been done.

Discussion-- needs to be rewritten. This discussion part is almost like Literature review. Authors may go through few literature and see how to frame the discussion part. The studies quoted in the discussion should support your findings (or contrary) and should not be written separately. Should be linked to your study findings. For example "A previous study based on rural Bangladesh suggested that hand washing before preparing food is particularly important to prevent diarrhoea [55, 56]. " With which finding from the present study are the authors linking this study in support or in contrary. There are many literatures mentioned like this is the discussion without linking them to the study results.

Response: Amendment has been done.

There are few portions under discussion which will be more appropriate for the need /scope of the study part.

"In the context of the increasingly ageing trend in India, the prevalence and correlates of agents among older diarrheal patients was needed to explore"-- not clear

Response: The discussion section has been revised accordingly

"The research shows a significant rural-urban difference in the prevalence of diarrhoea among older adults in India"--- Should write whether it is high in rural or urban too

Response: Comment incorporated

How are the results considering religion and economic condition?

Response: Thank you for pointing out this comment. These are discussed in discussion section.

Citing references should be done properly and only where necessary.

Response: Amendment has been done.

"Research related to the prevalence of diarrhoea among the geriatric age group should also be emphasized as the issue is growing at an unprecedented pace globally"-- which issue? Issue of ageing or diarrhoea? Recommended to write more clearly.

Response: Amendment has been done.

Separate section on strengths and limitations can be written other than merging with the discussion part.

Response: Separate section on strengths and limitations has been done.

Need to rewrite conclusion part. Focus on the main contribution from the paper. Try focusing on policy recommendations coming directly from the study.

Response: Amendment has been done

Few references needs to be modified according to referencing style.

Response: Comment incorporated.

Tables- total column may be given in Table 1, 2, 3.

Response: Total column has been added in Table 1, 2, and 3.

Table 2- In results section the urban rural and total percentage by few important background characteristics may be explained as a background before going to the rural urban differential.

Response: Changes have been made as per the suggestion.

Table 4- May consider reordering of the variables. First may give soci0 demographic, then economic and household variables.

Response: Changes have been made as per the suggestion.

I congratulate the authors for selecting this topic and working extensively on the literature review and analysis. But they have to revise the manuscript as the result, discussion, conclusion parts needs to be rewritten. The main findings from this study are getting disoriented and lost. They should also focus on the conclusion and policy recommendation part as this is a very important topic.

Response:

Reviewer #2: The manuscript sounds good, I recommened to accept the paper for publication. Although I have some observations. First is that author should rewrite the discussion part. As I found there is very less linking between the variables consisting older adults and diarrhoea among older. Also In discussion part author has quitely written the literature references to explain and support the current study results. But I think, he should consider the theme as a whole rather than going point by point. Second is that author should discuss more about the logistic regression and literature references to support his findings.

Response: Revised the discussion accordingly.

19 Nov 2021

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'.

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Academic Editor

PLOS ONE

Journal Requirements:

Additional Editor Comments (if provided):

Dear authors,

I would like to ask you to read the reviewers' comments and suggestions carefully.

The reviewers still find so many shortcomings in the paper.

I suggest to revise the paper and resubmit it. The revised version could be sent to new reviewers.

Best wishes,

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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: (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: (No Response)

Reviewer #2: Yes

**********

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

Reviewer #1: (No Response)

Reviewer #2: Yes

**********

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

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: (No Response)

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: Although the authors have done few changes in the manuscript, most of the parts still need serious modifications. Authors should consider the following comments as constructive that will help them to make the manuscript more suitable for publication.

Sentences in the abstract has not been reframed. Authors are recommended to read all the sentences. English should be checked properly as there are noticeable problems with prepositions, verbs. Sudden use of words like “Moreover”, “While” and “however” throughout the paper should be avoided.

Sentences like “Diarrhoeal diseases are seen among all age group” is not at all recommended.

Authors have not rewritten the abstract as recommended in the last review comments.

Under Methods section “during 2016-2017” should be moved to any other sentence as it is not having any meaning in the present sentence. It seems authors have only taken into consideration the specific comments to be changed in the abstract. Policy recommendations are still very broad in the abstract part.

“About 15 per cent of older adults in India were suffered from diarrhoea” reframe with correct forms of verbs.

Discussion:

“This study shows that the prevalence of diarrhoea is 7.7 percentage points higher in rural areas than urban areas”- avoid repeating the percentage from the results in the discussion part. But authors should discuss about the results and the main crux.

“However, the finding is not similar with previous research in India [44, 51].” Should be reframed.

“Our study contradicts the existing literature and shows that the odds of older adults suffering from diarrhoea were higher among those who belonged to richer section of population [44, 53].

” Try to discuss this more as this is an important finding. Also check the analysis as the results are opposite in table 3.

Paragraph starting with “ Geographical differences in prevalence of diarrhoea” should be rewritten.

There should be more discussion on the important findings from the study. Also, the discussion ends abruptly.

Strengths and limitations

“Therefore, very few studies have dealt with the older adults [57].” Not clear

This section should be written more clearly as the authors are suddenly starting to write about the limitations. Everything is getting mixed up.

English needs to be checked throughout the manuscript. Errors in verbs, singular plural, prepositions can be found throughout the paper.

References: References were not checked according to the last comment provided. Many references are not upto date. Check references 12, 10 and try to update them if necessary.

Kumar Panda Leuven SK, Kumar Bastia A. Anti-diarrheal activities of medicinal plants of Similipal Biosphere Re-serve, Potential Antibacterial Agent(s) against Foodborne Pathogens View project. Int J Med Aromat Plants. – wrong reference.

Many references are not having publication year and page numbers.

There is no uniform style. In spite of giving comments in the first review about the references, the authors failed to check the references. Authors need to check each reference and write them properly. Avoid writing responses to comments as “changes incorporated” when authors have not done any changes in the reference section.

Tables

“May consider reordering of the variables. First may give soci0 demographic, then economic and household variables”

This comment was given previously also. But the authors did not do the reordering of variables in all the tables. But in the response, they have written that they have made the changes. They should start with age, sex and then the other socio demographic, economic and household variables. Though the authors have stated this specific comment has been incorporated, the same is not the case. They have not modified the variables.

In table 3

Source of drinking water - adults suffering from diarrhoea

Unimproved 10.9 %

Improved 15.2 %

This result is very shocking. Nothing has been mentioned about this result in the whole paper. On the other hand, the results are opposite in the table with logistics regression. Authors may check the analysis for both the tables. And then mention them in results and discussion.

Another important finding that “prevalence of diarrhoea was more among underweight older adults” has also not mentioned in the discussion section. Discussion section should be properly written with focus on the interesting findings from the study along with linking with the previous literature. Similarly, the issue of living in kutcha pakka house is also missing from the discussion. Authors should go through the tables, results section and then write the discussion.

Reviewer #2: The authors have worked so nice. The paper sounds good. I recommend editor to ask the author for some minor rivisions like:

1. Write the abstract in a comprehensive way. Not copy and paste from the manuscript.

2. Outcome variable is something which really comes out from the analysis. Not from the data set. So, authors can rename the outcome variable or can constract or recode the outcome variable.

**********

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: No

Reviewer #2: Yes: Tushar Dakua

[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.

7 Dec 2021

Dear authors,

I would like to ask you to read the reviewers' comments and suggestions carefully. The reviewers still find so many shortcomings in the paper. I suggest to revise the paper and resubmit it. The revised version could be sent to new reviewers.

Reviewer #1: Although the authors have done few changes in the manuscript, most of the parts still need serious modifications. Authors should consider the following comments as constructive that will help them to make the manuscript more suitable for publication. Sentences in the abstract has not been reframed. Authors are recommended to read all the sentences. English should be checked properly as there are noticeable problems with prepositions, verbs. Sudden use of words like “Moreover”, “While” and “however” throughout the paper should be avoided.

Response: The authors agree with the comment. The changes are now incorporated in the manuscript.

Sentences like “Diarrhoeal diseases are seen among all age group” is not at all recommended.

Response: The sentence is now reframed.

Authors have not rewritten the abstract as recommended in the last review comments.

Response: Dear reviewer, the entire abstract is now changed.

Under Methods section “during 2016-2017” should be moved to any other sentence as it is not having any meaning in the present sentence. It seems authors have only taken into consideration the specific comments to be changed in the abstract. Policy recommendations are still very broad in the abstract part.

Response: The sentence is now reframed. Dear reviewer, the study found that diarrhoea among older adults is significantly more prevalent in rural areas than in urban areas. Therefore, authors recommend the policy makers to focus more on rural areas to reduce the overall residential gap specifically and in general to reduce the overall burden of diarrhoea among older adults.

“About 15 per cent of older adults in India were suffered from diarrhoea” reframe with correct forms of verbs.

Response: The sentence is now reframed with correct form of verbs.

Discussion:

“This study shows that the prevalence of diarrhoea is 7.7 percentage points higher in rural areas than urban areas”- avoid repeating the percentage from the results in the discussion part. But authors should discuss about the results and the main crux.

Response: The sentence is reframed.

“However, the finding is not similar with previous research in India [44, 51].” Should be reframed.

Response: We have reframed the sentence.

“Our study contradicts the existing literature and shows that the odds of older adults suffering from diarrhoea were higher among those who belonged to richer section of population [44, 53].

” Try to discuss this more as this is an important finding. Also check the analysis as the results are opposite in table 3.

Response: Thank you for the comment. Given the dearth of literature that could possibly explain this unusual relationship, we will take up a deeper analysis of the economic status of the older adults and their odds of having diarrhoea in future.

Paragraph starting with “Geographical differences in prevalence of diarrhoea” should be rewritten. There should be more discussion on the important findings from the study. Also, the discussion ends abruptly.

Response: Thank you for the comment. We have re-written the paragraph.

Strengths and limitations

“Therefore, very few studies have dealt with the older adults [57].” Not clear

This section should be written more clearly as the authors are suddenly starting to write about the limitations. Everything is getting mixed up.

Response: The authors agree with the comment. The sentence is now removed. The strength and limitation section is reframed for better understanding.

English needs to be checked throughout the manuscript. Errors in verbs, singular plural, prepositions can be found throughout the paper.

Response: The paper is now edited by a native English speaker.

References: References were not checked according to the last comment provided. Many references are not up to date. Check references 12, 10 and try to update them if necessary.

Kumar Panda Leuven SK, Kumar Bastia A. Anti-diarrheal activities of medicinal plants of Similipal Biosphere Re-serve, Potential Antibacterial Agent(s) against Foodborne Pathogens View project. Int J Med Aromat Plants. – wrong reference.

Response: References are changed

Many references are not having publication year and page numbers. There is no uniform style. In spite of giving comments in the first review about the references, the authors failed to check the references. Authors need to check each reference and write them properly. Avoid writing responses to comments as “changes incorporated” when authors have not done any changes in the reference section.

Response: References has now been changed

Tables

“May consider reordering of the variables. First may give soci0 demographic, then economic and household variables” This comment was given previously also. But the authors did not do the reordering of variables in all the tables. But in the response, they have written that they have made the changes. They should start with age, sex and then the other socio demographic, economic and household variables. Though the authors have stated this specific comment has been incorporated, the same is not the case. They have not modified the variables.

Response: Dear reviewer, authors had arranged the table 4 as per your suggestion. Apologize for not making change in table 1 & 3. Now we have arranged the table 1 & 3 too as per your suggestion. Kindly refer to Table 1, 3 & 4.

In table 3

Source of drinking water - adults suffering from diarrhea

Unimproved 10.9 %

Improved 15.2 %

This result is very shocking. Nothing has been mentioned about this result in the whole paper. On the other hand, the results are opposite in the table with logistics regression. Authors may check the analysis for both the tables. And then mention them in results and discussion.

Response: Dear reviewer, authors are also shocked by this inconsistency. We have checked the analysis again and found the same results. The reason for the opposite results in the logistic table might be because of the adjusted results.

Discussion person can discuss this issue in discussion section. Another important finding that “prevalence of diarrhoea was more among underweight older adults” has also not mentioned in the discussion section. Discussion section should be properly written with focus on the interesting findings from the study along with linking with the previous literature. Similarly, the issue of living in kutcha pakka house is also missing from the discussion. Authors should go through the tables, results section and then write the discussion.

Response: We have tried to incorporate the important findings of the paper. However, due to dearth of literature on the topic, at times it is difficult to support it with literature.

Reviewer #2: The authors have worked so nice. The paper sounds good. I recommend editor to ask the author for some minor revisions like:

1. Write the abstract in a comprehensive way. Not copy and paste from the manuscript.

Response: Dear reviewer, the authors edited the abstract as per your suggestion.

2. Outcome variable is something which really comes out from the analysis. Not from the data set. So, authors can rename the outcome variable or can constract or recode the outcome variable.

Response: Dear reviewer, I agree with the comment. The outcome variable was assessed using the question “whether, in the past two years, the respondent was diagnosed with diarrhoea by a health professional?” The variable was coded as no and yes in the dataset.

Submitted filename: Response to Reviewers.docx

Click here for additional data file.

10 Jan 2022

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Reviewer #1: Reviewer is still not convinced with few results coming from the tables. Also in spite of correcting the references, there are still modifications to be done as in few references the authors have provided the year in brackets after the name of the author and in some places they have provided the year without brackets after the journal name. Not sure what style they have followed.

There are some other observations too

>“Our study contradicts the existing literature and shows that the odds of older adults suffering from diarrhoea were higher among those who belonged to richer section of population [44, 53].

the results are opposite in table 3. Also no argument has been provided in the discussion part. While explaining the results of table 3, authors also have missed to write about this result.

Inspite of pointing this in the last comments this has not been mentioned in the results section. Authors should mention everything coming from their study. Presentation of only selective results from table 3 is not recommended.

>This is a very important finding.

Source of drinking water - adults suffering from diarrhea

Unimproved 10.9 %

Improved 15.2 %

This has yet not been written in the results section.

>The highest rural-urban difference in the prevalence of diarrhoea was observed among older adults who lived in kutcha houses. Studies conducted in Bangladesh and Ethiopia revealed the same findings [40-44].

References 40 to 44 includes india, Indonesia,along with Bangladesh and Ethiopia. They are not only on Bangladesh and Ethiopia. Also ref 40 talks about "Among the individual food-hygiene variables, children who lived in the house with less dirty sewage had significantly lower diarrhea prevalence" and not directly on kutcha pakka houses. Authors can be more descriptive while citing references so that the sentences becomes self explanatory.

>Also reference 43 by Luby did only talk about handwashing practices and diarrhoea among children. Why are authors citing references which are not talking about kutcha pakka houses. This is a wrong practice.

Also ref 44 is on Risk of Adverse Pregnancy Outcomes among Women Practicing Poor Sanitation in Rural India: A Population-Based Prospective Cohort Study.

>Findings from a previous study supported our results that older adults with high education had lower risk of diarrhoea [45]

Ref 45 is on Incidence and Correlates of Diarrhea, Fever, Malaria and Weight Loss Among Elderly and Non-Elderly

Internally Displaced Parents in Cibombo Cimuangi in the Eastern Kasai Province, Democratic Republic of the Congo. This talked about role of spouse's education. I am not sure how are the authors citing there references linking to their studies directly.

>Logistic regression results reveal that the prevalence of diarrhoea was positively associated with higher age of older adults, who belonged to Scheduled Tribe (22 per cent higher risk) and OBC social group (24 per cent higher risk). This finding is consistent with a study carried out in India [46].

Ref 46 is on under 5 children in India. Authors should not directly link to them. Even if linking they should mention about the study done among under 5 children. The representation not proper.

>A higher concentration of diarrhoea was found in central and northeastern parts than in southern states of India. This could be because of unequal access to health care facilities, use of untreated drinking and low hygiene practices.

it will be better if the authors can find any literature supporting their argument.

>Discussion part is still not adequate as this study has many important and striking findings.

>Moreover, the study reveals that older adults who belong to the Christian religion were more likely to have diarrhoeal risk than Hindu older adults. However, this finding is inconsistent with previous research in India [37,46].

In reference number 37 and 46- both the studies are on Children and also mentioned about Muslim children suffering more than Other religion. I am not sure whether authors can use these literature to show inconsistency, as their own results are concerned about the Christians and Hindus. and also on older adults.

So many mistakes and improper use of literature in Discussion part is unacceptable.

I suggest all the authors should go through the manuscript attentively and focus on their results and the discussion part. More literature review is required. They should also go through few other published papers and follow how to write the discussion part. They should resubmit the manuscript when they feel it is ready for publication.

Reviewer #2: If possible, please prepare the map of India propoerly by using ARC GIS software. Put lat-long and other spatial details in the map.

**********

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Reviewer #2: Yes: Tushar Dakua

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21 Feb 2022

Reviewer #1: Reviewer is still not convinced with few results coming from the tables. Also in spite of correcting the references, there are still modifications to be done as in few references the authors have provided the year in brackets after the name of the author and in some places they have provided the year without brackets after the journal name. Not sure what style they have followed.

Response: The authors have followed Vancouver style using Zotero. The references are now edited using the same software.

There are some other observations too

“Our study contradicts the existing literature and shows that the odds of older adults suffering from diarrhoea were higher among those who belonged to richer section of population [44, 53].

the results are opposite in table 3.

Also no argument has been provided in the discussion part. While explaining the results of table 3, authors also have missed to write about this result.

Inspite of pointing this in the last comments this has not been mentioned in the results section. Authors should mention everything coming from their study. Presentation of only selective results from table 3 is not recommended.

Response: Dear reviewer, relationship of diarrhoea with wealth quintile has been added in results section of table 3. Also we have added in the discussion section.

This is a very important finding. Source of drinking water - adults suffering from diarrhea.

Unimproved 10.9 %

Improved 15.2 %

This has yet not been written in the results section.

Response: This now added in the result section.

>The highest rural-urban difference in the prevalence of diarrhoea was observed among older adults who lived in kutcha houses. Studies conducted in Bangladesh and Ethiopia revealed the same findings [40-44].

References 40 to 44 includes India, Indonesia, along with Bangladesh and Ethiopia. They are not only on Bangladesh and Ethiopia.

Also ref 40 talks about "Among the individual food-hygiene variables, children who lived in the house with less dirty sewage had significantly lower diarrhea prevalence" and not directly on kutcha pakka houses. Authors can be more descriptive while citing references so that the sentences becomes self explanatory.

Response: Dear Reviewer, we apologize for the mistake. We have now added all the countries mentioned in reference 40-44. However, we have deleted India since it was on Risk of Adverse Pregnancy Outcomes among Women Practicing Poor Sanitation in Rural India: A Population-Based Prospective Cohort Study (Reference 44).

Dear Reviewer, we have rephrased the sentence.

>Also reference 43 by Luby did only talk about handwashing practices and diarrhoea among children. Why are authors citing references which are not talking about kutcha pakka houses. This is a wrong practice. Also ref 44 is on Risk of Adverse Pregnancy Outcomes among Women Practicing Poor Sanitation in Rural India: A Population-Based Prospective Cohort Study.

Response: Dear Reviewer, we apologize for the mistake. We have now specifically mentioned what each of the study deals with. Also, we have deleted reference 44 in this context.

>Findings from a previous study supported our results that older adults with high education had lower risk of diarrhoea [45]

Ref 45 is on Incidence and Correlates of Diarrhea, Fever, Malaria and Weight Loss Among Elderly and Non-Elderly

Internally Displaced Parents in Cibombo Cimuangi in the Eastern Kasai Province, Democratic Republic of the Congo. This talked about role of spouse's education. I am not sure how are the authors citing there references linking to their studies directly.

Response: Dear Reviewer, we have removed reference 45 and added “Incidence and Determinants of Acute Diarrhoea in Malaysia: A Population-based Study”.

>Logistic regression results reveal that the prevalence of diarrhoea was positively associated with higher age of older adults, who belonged to Scheduled Tribe (22 per cent higher risk) and OBC social group (24 per cent higher risk). This finding is consistent with a study carried out in India [46].

Ref 46 is on under 5 children in India. Authors should not directly link to them. Even if linking they should mention about the study done among under 5 children. The representation not proper.

Response: Dear Reviewer, we apologise for the mistake. We have made corrections accordingly and mentioned that the study was done among children under the age of five years.

>A higher concentration of diarrhoea was found in central and northeastern parts than in southern states of India. This could be because of unequal access to health care facilities, use of untreated drinking and low hygiene practices.

it will be better if the authors can find any literature supporting their argument.

Response: Dear Reviewer, though we were unable to support our study finding with literature on older adults, we could present some studies that dealt with children.

>Discussion part is still not adequate as this study has many important and striking findings.

>Moreover, the study reveals that older adults who belong to the Christian religion were more likely to have diarrhoeal risk than Hindu older adults. However, this finding is inconsistent with previous research in India [37,46].

Response: Dear Reviewer, we have tried to improve the discussion section.

In reference number 37 and 46- both the studies are on Children and also mentioned about Muslim children suffering more than Other religion. I am not sure whether authors can use these literature to show inconsistency, as their own results are concerned about the Christians and Hindus. and also on older adults.

Response: Dear Reviewer, we agree with you. However, due to lack of literature on diarrhea among older adults in India we could not support our finding. Hence, relied on literature on children in India.

So many mistakes and improper use of literature in Discussion part is unacceptable.

I suggest all the authors should go through the manuscript attentively and focus on their results and the discussion part. More literature review is required. They should also go through few other published papers and follow how to write the discussion part. They should resubmit the manuscript when they feel it is ready for publication.

Response: Dear Reviewer, we have tried to improve the discussion section.

Reviewer #2: If possible, please prepare the map of India propoerly by using ARC GIS software. Put lat-long and other spatial details in the map.

Response: Dear reviewer, the map is made using Arc GIS software. The spatial details are added.

Submitted filename: Response to Reviewers.docx

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23 Feb 2022

Rural-urban differentials in the prevalence of diarrhoea among older adults in India: Evidence from Longitudinal Ageing Study in India, 2017-18

PONE-D-21-09569R3

Dear  Kumar ,

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Your paper is now accepted.

Reviewers' comments:

3 Mar 2022

PONE-D-21-09569R3

Rural-urban differentials in the prevalence of diarrhoea among older adults in India: Evidence from Longitudinal Ageing Study in India, 2017-18

Dear Dr. Kumar:

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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Table 1

Socio-demographic and economic profile of older adults in India, 2017–18.

Background characteristics	Rural		Urban		Total
	Sample	%	Sample	%	Sample	%
Age (in years)
60–69	12139	58.6	6268	58.4	18410	58.5
70–79	6169	29.8	3354	31.2	9501	30.2
80+	2417	11.7	1117	10.4	3553	11.3
Sex
Male	10045	48.5	4835	45.0	14931	47.5
Female	10680	51.5	5904	55.0	16533	52.6
Education
No education/primary not completed	15984	77.1	4937	46.0	21381	68.0
Primary completed	2069	10.0	1511	14.1	3520	11.2
Secondary completed	1988	9.6	2598	24.2	4371	13.9
Higher and above	682	3.3	1693	15.8	2191	7.0
Marital status
Currently married	13017	62.8	6315	58.8	19391	61.6
Widowed	7280	35.1	4162	38.8	11389	36.2
Others	427	2.1	262	2.4	684	2.2
Body Mass Index
Underweight	6062	32.4	1142	12.2	7406	23.5
Normal	9742	52.1	4561	48.7	14203	45.1
Overweight/obese	2884	15.4	3658	39.1	6153	19.6
Working status
Currently working	7341	35.4	2106	19.6	9680	30.8
Retired/currently not working	8774	42.3	4719	43.9	13470	42.8
Never worked	4610	22.2	3913	36.4	8314	26.4
MPCE quintile
Poorest	4446	21.5	2396	22.3	6829	21.7
Poorer	4608	22.2	2197	20.5	6831	21.7
Middle	4375	21.1	2207	20.6	6590	21.0
Richer	3932	19.0	2117	19.7	6038	19.2
Richest	3364	16.2	1822	17.0	5175	16.5
Religion
Hindu	17309	83.5	8497	79.1	25871	82.2
Muslim	2021	9.8	1604	14.9	3548	11.3
Christian	623	3.0	269	2.5	900	2.9
Others	772	3.7	369	3.4	1145	3.6
Caste
Scheduled Caste	4572	22.1	1220	11.4	5949	18.9
Scheduled Tribe	2125	10.3	325	3.0	2556	8.1
Other Backward Class	9213	44.5	5056	47.1	14231	45.2
Others	4815	23.2	4139	38.5	8729	27.7
Place of residence
Rural					22196	70.6
Urban					9268	29.5
Source of cooking fuel
Unclean	13455	64.9	1984	18.5	16122	51.2
Clean	7270	35.1	8755	81.5	15342	48.8
Type of toilet facility
Unimproved	8035	38.8	1319	12.3	9744	31.0
Improved	12690	61.2	9420	87.7	21720	69.0
Source of drinking water
Unimproved	1200	5.8	1594	14.8	2660	8.5
Improved	19525	94.2	9145	85.2	28804	91.5
Type of House
Pucca	8512	41.8	8281	80.0	16015	50.9
Semi pucca	7064	34.7	1646	15.9	9931	31.6
Kutcha	4794	23.5	428	4.1	5519	17.5
Region
North	2655	12.8	1293	12.0	3960	12.6
Central	4920	23.7	1533	14.3	6593	21.0
East	5678	27.4	1573	14.7	7439	23.6
Northeast	691	3.3	226	2.1	935	3.0
West	2898	14.0	2662	24.8	5401	17.2
South	3883	18.7	3451	32.1	7136	22.7
Total	20,725	100.0	10,739	100.0	31464	100.0

Table 3

Percentage of older adults suffering from diarrhoea by their background characteristics in India, 2017–18.

Background characteristics	Total	Rural	Urban	Differences	p-value
	%	%	%	%
Age (in years)
60–69	14.2	16.3	9.2	7.0	<0.001
70–79	15.0	17.0	10.2	6.8	<0.001
80+	17.6	21.3	7.7	13.6	<0.001
Sex
Male	14.8	16.9	9.1	7.7	<0.001
Female	14.9	17.3	9.5	7.7	<0.001
Education
No education/primary not completed	16.3	17.8	10.5	7.3	<0.001
Primary completed	14.0	16.2	10.3	5.9	<0.001
Secondary completed	11.3	14.6	8.0	6.6	<0.001
Higher and above	8.3	10.7	7.1	3.6	<0.001
Marital status
Currently married	14.5	16.5	9.4	7.1	<0.001
Widowed	15.4	18.2	9.5	8.6	<0.001
Others	13.1	16.3	6.7	9.7	<0.001
Body Mass Index
Underweight	19.1	20.1	12.3	7.8	<0.001
Normal	14.9	16.4	10.8	5.6	<0.001
Overweight/obese	10.9	14.9	7.0	7.9	<0.001
Working status
Currently working	15.6	16.8	10.2	6.6	<0.001
Retired/currently not working	14.8	17.1	9.4	7.7	<0.001
Never worked	13.9	17.4	8.8	8.5	<0.001
MPCE quintile
Poorest	15.8	18.2	10.4	7.8	<0.001
Poorer	17.0	19.1	11.4	7.7	<0.001
Middle	14.1	16.0	9.2	6.9	<0.001
Richer	13.6	16.1	7.9	8.3	<0.001
Richest	12.9	15.2	7.5	7.8	<0.001
Religion
Hindu	15.1	17.5	9.0	8.5	<0.001
Muslim	16.3	18.7	12.2	6.6	<0.001
Christian	7.3	7.6	6.3	1.3	0.349
Others	9.2	9.8	7.6	2.2	0.915
Caste
Scheduled Caste	15.8	17.3	8.9	8.4	<0.001
Scheduled Tribe	16.2	16.4	14.4	1.9	0.043
Other Backward Class	15.0	17.8	8.3	9.4	<0.001
Others	13.6	15.8	10.3	5.5	<0.001
Place of residence
Rural	17.1
Urban	9.4
Source of cooking fuel
Unclean	18.3	19.2	10.2	9.0	<0.001
Clean	11.2	13.1	9.2	4.0	<0.001
Type of toilet facility
Unimproved	20.3	21.6	8.9	12.7	<0.001
Improved	12.4	14.2	9.4	4.8	<0.001
Source of drinking water
Unimproved	10.9	12.9	8.8	4.1	0.038
Improved	15.2	17.3	9.4	7.9	<0.001
Type of house
Pucca	12.6	15.0	9.3	5.8	<0.001
Semi pucca	15.3	16.7	10.9	5.8	<0.001
Kutcha	20.6	21.2	11.1	10.2	0.003
Region
North	20.8	22.3	17.0	5.4	<0.001
Central	27.5	28.9	21.9	7.1	<0.001
East	16.4	17.5	11.8	5.7	<0.001
Northeast	8.6	8.4	9.2	-0.8	<0.001
West	7.4	8.8	5.6	3.2	<0.001
South	4.2	5.5	2.4	3.1	<0.001
Total	14.8	17.1	9.4	7.7	<0.001

Difference = Rural-Urban.

Table 4

Logistic regression estimates for older adults who suffered from diarrhoea by their background characteristics in India, 2017–18.

Background characteristics	AOR
	95% CI
Age (in years)
60–69	Ref.
70–79	1.08(0.99,1.17)
80+	1.17*(1.04,1.32)
Sex
Male	Ref.
Female	1.19*(1.09,1.30)
Education
No education/primary not completed	1.43*(1.20,1.71)
Primary completed	1.33*(1.09,1.60)
Secondary completed	1.31*(1.10,1.58)
Higher and above	Ref.
Marital status
Currently married	Ref.
Widowed	1.08(0.98,1.17)
Others	1.01(0.80,1.28)
Body Mass Index
Underweight	1.02(0.91,1.15)
Normal	1.07(0.97,1.18)
Overweight/obese	Ref.
Working status
Currently working	Ref.
Retired/currently not working	0.96(0.88,1.04)
Never worked	0.80*(0.72,0.89)
MPCE quintile
Poorest	0.85*(0.75,0.96)
Poorer	1.01(0.90,1.13)
Middle	0.89*(0.79,1.02)
Richer	0.97(0.87,1.09)
Richest	Ref.
Religion
Hindu	Ref.
Muslim	0.93(0.83,1.04)
Christian	1.19*(1.01,1.41)
Others	0.63*(0.53,0.76)
Caste
Scheduled Caste	Ref.
Scheduled Tribe	1.22*(1.07,1.39)
Other Backward Class	1.24*(1.12,1.37)
Others	0.96(0.86,1.07)
Place of residence
Rural	Ref.
Urban	0.88*(0.80,0.96)
Source of cooking fuel
Unclean	1.03(0.94,1.12)
Clean	Ref.
Type of toilet facility
Unimproved	1.32*(1.21,1.45)
Improved	Ref.
Source of drinking water
Unimproved	1.45*(1.25,1.69)
Improved	Ref.
Type of house
Pucca	Ref.
Semi pucca	1.21*(1.11,1.32)
Kutcha	1.07(0.97,1.19)
Region
North	Ref.
Central	1.43*(1.29,1.6)
East	0.71*(0.64,0.79)
Northeast	0.46*(0.39,0.54)
West	0.38*(0.33,0.43)
South	0.18*(0.15,0.2)

Ref: Reference

* if p<0.05; CI: Confidence interval; AOR: Adjusted Odds Ratio.