Effects of a locally available dietary interventions counselling on the community-based management of anaemia in children under five years in Ghana: Kumbungu cluster randomized controlled trial protocol.

Anaemia in children under five years remains a significant cause of mortality and morbidity in low-middle income countries. Globally, 27% of the world's population is anaemic, of which developing countries account for more than 89%. The global prevalence is worse in Africa and Asia. Anaemia has the potential of maintaining the cycle of poverty, as it prevents children from attaining their full development potential. An important part of anaemia in children under-five years are preventable. Locally available dietary (LAD) interventions may be the sustainable interventions to address the high prevalence of anaemia in our communities. The aim of the study is to determine the effect of counselling on Locally Available Diet, on anaemia among children aged 6-59 months in the Kumbungu District of the Northern Region, Ghana. This study will be a community-based cluster randomized, controlled trial, with two parallel arms; Iron + Folic Acid (IFA arm) hereby referred to as the Standard care arm and Iron + Folic Acid + Counselling on Locally available dietary intervention (IFA+LAD arm) referred to as the Standard Plus arm. Study participants are children between the ages of 6 to 56 months. All study participants would receive iron plus folic acid. The minimum number of children per arm is 330 and the number of community clusters is 10 (5 per study arm). Also, considering this study proposes two parallel arms, the total minimum study sample size of children under five years is 496, the minimum total number of community clusters is 10 and a minimum of 25 households per community cluster, 124 households per study arm and 248 households for the study. Randomization is at the level of the clusters (selected communities). The intervention group receives counselling on LAD at a household level aimed at promoting the intake of locally available iron, folate and vitamin B12 rich foods. Also encourage the intake of food rich in enhancers of iron absorption and discouraging the intake of food rich in inhibitors of iron absorption. The primary outcome is mean haemoglobin levels in study arms. Secondary outcomes would include measurement of weight, height/length, mid upper arm circumference, dietary record, serum iron, ferritin, and other parameters of full blood count. Ethical clearance has been obtained and trial registered with Pan African Trial Registry (www.pactr.org) PACTR201906918438423.

Introduction

Anaemia in children under five years is an important public health problem requiring urgent attention. Globally, 27% of the world’s population is anaemic of which developing countries account for more than 89% [1,2]. Anaemia is among the top five causes of years lived with disability in the year 2016 [1]. Preschool children and pregnant women are the most affected. Globally, the prevalence of anaemia (defined as haemoglobin level of <110 g/L) in children aged 6–59 months is 43% [3]. The global prevalence is worse in Africa and Asia. In Africa, the prevalence of anaemia among children under the age of five years is estimated at 62% [4]. This is above the 40% cut off limit of the World Health Organization’s (WHO) classification of anaemia as a severe public health problem [5]. The prevalence of anaemia in children under five years is estimated at 71% for west Africa [6]. In Ghana, the overall prevalence of anaemia in children under five years is 78.4% [7]. There are significant regional and community variations. In the northern region of Ghana, almost nine out of ten children under five years have anaemia [7]. A recent survey found contextual causes such as inadequate nutritional knowledge, food, diarrhoea, malaria, worm infestations, and inadequate dietary intake [8].

Anaemia has the potential of maintaining the cycle of poverty as it prevents children from attaining their full development potential [9]. These effects are often irreversible even if anaemia is corrected later in life [10]. In the shorterm, anaemia in children under five impairs cognitive, emotional, physical and brain development [11]. In the medium term, it negatively impacts on educational attainment and in the long-term, impacts negatively on adult life and earning abilities thereby increasing the likelihood of having anaemic children and maintaining the cycles of poverty and anaemia. Mortality estimates showed that, 5.8 million children under five years of age died in 2015 [11,12]. Sub-Saharan Africa in 2013 contributed 25% of global births and 50% of global deaths of children under five years which are respectively projected to reach 33% births and 60% deaths by 2030 [13]. Anaemia contributes significantly to deaths within this age group either directly or indirectly by complicating other conditions such as malaria, malnutrition, diarrhoea and pneumonia. It has been estimated that for each 1g/dl increase in hemoglobin, the risk of death falls by 24% [14]. Also 1.8 million deaths in children under five years within Africa could be avoided by increasing the hemoglobin of these children by 1g/dl.

Most of the causes of anaemia in children under-five years are preventable. Globally, Iron deficiency anaemia is the dominant causes of anaemia accounting for more than 60% of all anaemia [15]. Iron deficiency anaemia in children within developing countries is partly due to increased physiological demands associated with child growth [16] and also, reduced intake complicated by predominantly cereal based diet with high content of phytates, phenols and other ligands that impair iron absorption [17]. Increased loss of blood from hookworm infestation has also been estimated to account for a significant proportion of iron deficiency anaemia [18].

Reduction of the burden of anaemia requires multifaceted approaches, which have been a challenge for many developing countries resulting in over-reliance on hospital, based emergency management of anaemia where children often report too late to be saved. Cost implications for developing countries prevents adherence to universal iron supplementation recommended by the WHO for areas with anaemia prevalence exceeding 40% [5]. Locally available dietary (LAD) interventions may be the sustainable interventions to address the high prevalence of anaemia in our communities. LAD interventions use available and abundant diets in the community to manage or prevent dietary problems. The use of the LAD may provide the cheapest and easily accessible and culturally appropriate options to manage anaemia. Almost all communities have some distinctive varieties of food with good nutritional values that with the right knowledge can be a tool to address health problems [19]. The aim of the study is to determine the effect of counselling on Locally Available Diet, on anaemia among children aged 6–59 months in the Kumbungu District of the Northern Region, Ghana. The study would specifically determine the baseline prevalence of anaemia and iron deficiency anaemia among children under five years in the Kumbungu district of northern region. The study will also determine the factors associated with anaemia among children under five years and would test the effects of counselling on Locally Available Diet on anaemia among children aged 6–59 months in the Kumbungu district of the northern region, Ghana.

Methods

Study site

The study would be conducted in the Kumbungu district of the Northern region. Kumbungu in the northern region was selected because, it has one of the highest prevalence of anaemia in children under five years. Several activities by Governmental and Non-Governmental Organizations (NGOs) at addressing the problem of anaemia have shown little improvement. The Northern region has 26 districts. Kumbungu district is one of the smallest districts within the northern region with a total landmass of 1599 Square Kilometres. Kumbungu has 39,341 inhabitants within 4,133 households and a sex ratio of 100.2 males per 100 females. Children constitute 48.4% of the population. 7,101 of the population of Kumbungu are aged 0 to 4 years [20]. Average household size in Kumbungu is 9.5. The total fertility rate, crude birth rate and general fertility rate for the district are respectively 3.6, 23.4 per 1000 and 103.9 births per 1000 women aged 15–49. The household structure is mainly that of extended family system accounting for 71.8% of the household population while nuclear family system accounts for 14.6%. According to the recent census [21], only 15.2% of the population is literate in English language and 63.8% of persons aged 3 years and older in the district have never attended school. With regards to employment status, 98% of the population aged 15 years and older are employed in the private informal sector. Majority of the working population are in farming related occupations. The district has 115 communities, most with a population below 500. Only two communities have population above 5000. With regards to housing, 79.4% of the inhabitants in the district live in thatch/palm/raffia roofed houses [21]. The district houses the only major community water treatment facility in the northern region.

Culturally, meat is reserved for festive occasion. Though livestock, poultry are kept by some on small scaled free-range level, the eggs and meat are often sold for cash. Majority of the people in the Kumbungu district are farmers who cultivate small fragmented parcel of lands [22]. Cattles are the most valuable livestock that are rarely sold or slaughtered except for extreme shock such as crop failure or famine [22]. Also, smaller livestock and poultry are often kept by most household which provides immediate cash to purchase food, pay for medical bills, source of protein rich diet and also given out as gift/ sacrifice. Previous studies in the district have found high intake of phytates and tea which are known inhibitors of iron absorption [23]. Locally available diets that contain high amount of vitamin C such as tamarind, ripe shea fruit and baobab are seasonal and when available, are not expensive to buy.

Study design

This study will be a community-based cluster randomized, controlled trial, with two parallel arms. Eight communities shall be selected randomly from the list of communities as reported by the 2010 population and housing census, district analytical report of Kumbungu district [21]. The eight selected communities (clusters) would be randomly assigned to intervention and control groups. Four community randomly selected by balloting would be assigned to intervention group while the remaining four would be assigned to control group. Thus, cluster assignment is at the level of community. All eligible children within the household would be included in the study. The intervention clusters would receive counselling on locally available diets (LAD) for anaemia management. All study participants would receive iron plus folic acid. The study would follow the closed cohort of eligible households with children aged between 6 to 56 months at baseline for 12 weeks. The counselling on locally available diets would be administered at baseline and a month after. Primary outcome data would be collected at baseline (pre-intervention) and then at the end of 12 weeks (post intervention). Eligible children within the household are the unit for analysis and the clustering would be taken into account.

Cluster randomization was chosen for practical reasons and also to minimize contamination. Children of the same household eat from the same pot. Since the study assess counselling interventions targeting intake and avoidance of enhancers and inhibitors of iron absorption in a closely knit community system, it was more appropriate to randomize at the level of the community cluster, instead of individual or household randomization. Counselling on LAD intervention would be administered at household level. Households must have at least a child aged 6–56 months at baseline. There would be no matching between the study arms. And there would be no blinding because the specific intervention is a counselling on LAD intervention which makes blinding almost impossible at the participant level. Also, to minimize contamination, a community cluster randomization instead of household randomization would be used. Also selected communities on intervention would be selected to ensure that there are other communities who are not part of the study in between them.

Study arms

There shall be two study arms; Iron + Folic Acid (IFA) arm hereby referred to as the Standard care arm and Iron + Folic Acid + Counselling on Locally available dietary intervention (IFA+LAD) arm referred to as the Standard Plus arm.

Description of study population

Study participants are children aged 6 to 56 months at baseline. Children less than six months are expected to be exclusively breastfed according to prevailing guidelines. Counselling on LAD that promotes intake of enhancers of iron absorption and avoiding the intake of inhibitors of iron absorption would not be appropriate in the below 6-month age group. Participants must also be less than 56 months of age at baseline because the intervention is expected to last for three months and it is expected that, participant recruited must be below five years at post intervention. The mothers or caregivers of eligible children would receive the counselling on locally available diets.

All eligible children 6–56 months of age at baseline would be included in the study so as to answer the first two specific objectives of the study, which seek to determine the prevalence and factors associated with anaemia among children less than five years. To answer the third specific objective, which is the cluster randomized control trial on the effect of counselling on anaemia status, only children whose haemoglobin level at baseline is less than 11.0g/dl would be included. All children with haemoglobin level at base line above 11.0g/dl would be excluded.

Inclusion and exclusion criteria

Inclusion criteria at household level

At the household level, household inclusion to the study must satisfy the following:

The household must have at least a child aged 6 to 56 months at baseline.

All children within the eligible household aged 6 to 56 months at baseline would be included to answer specific objectives one and two.

For specific objective three, only children with haemoglobin concentration measured at baseline less than 11.0 g/dl would be eligible for inclusion.

The child should be residing in the selected community for at least the past three months.

Must have a legal guardian capable of providing informed consent.

Inclusion criteria at the participant level

Exclusion criteria

Eligible children with any of the following would be ex6cluded from the study:

Current infective illness (example; respiratory infection, diarrhoea) with fever. Current infective illness would be assessed from self-reported and verification of available medical records.

Diagnosed case of any clinical haemoglobinopathy (eg, beta-thalassemia major, HbE-beta thalassemia, Sickle cell disease). This will be assessed based on self-report and available medical and laboratory records.

Received iron supplements or iron containing MMP in the previous month.

Sample size calculation

The sample size was calculated to determine the minimum difference in outcome of management of anaemia between arms of the study. The following information was used:

Estimated prevalence of anaemia at baseline is 82% from previous study [7], and the sample size is predicted on an estimated absolute reduction of at least 22% of the baseline prevalence.

Estimated average cluster size is 55 children under five years and an estimated number of children under five years with anaemia in each community clusters is 45

An estimated intra-cluster correlation (ICC) of 0.035

Power of at least 80% (0.80)

Significance level of 5% (0.05)

A dropout rate of about 5% for the 12 weeks period, and

A contamination effect of 5%

With the above considerations, and using a menu driven facility for sample size calculation in cluster randomized controlled trial [24] available in STATA (version 14.1, StataCorp, Special Edition, College Station, Texas 77845 USA), the minimum sample size and number of community clusters per arm was calculated. The minimum number of children per arm is 248 and the number of community clusters per study arm is 5. Also, considering this study proposes two parallel arms, the total minimum study sample size of children under five years is 496 [of which an expected 82% (n = 407) would have haemoglobin levels less than 11.0g/dl]. Also, the minimum total number of community clusters is 10. From the most recent census, the average number of children under five years per household is 1.7, which is approximately 2. This means that, we need to recruit a minimum of 25 households per community cluster, 124 households per study arm and 248 households for the study.

Sampling process

A two-stage sampling approach will be used as follows:

All communities in the district with total population at the 2010 census above 500 would be eligible for selection. We found 20 out of 115 communities met this criterion.

The map of the district would be divided into north and south and one randomly selected.

The selected area (north or south) would be further divided into four quadrants. Two quadrants would be selected using simple random sampling technique of balloting without replacement. The first selected quadrant would have four communities selected by simple random sampling and assigned to intervention group. The second selected quadrant would have four communities selected by simple random sampling and assigned to control group.

If the selected communities are not large enough to give the desired number of at least 248 households and 496 children under five years, a simple random technique would be employed to select additional communities within the intervention quadrant or control quadrant until the desired number of household and children are achieved.

All children within the selected communities would be eligible for inclusion

Randomization

Randomization is at the level of the clusters (selected communities). The first selected quadrant of the selected half of the district shall be the intervention quadrant. Two communities would be selected from the intervention quadrant to be the intervention communities. The second selected quadrant would be the control quadrant. Two communities would be selected from the control quadrant to be the control communities. There would be no blocking and stratification.

Allocation concealment mechanism and blinding

The intervention is a counselling intervention, which makes concealment and blinding a near impossible task. This is because, at the individual participant level, the mother/ care giver of the child should be aware that she/he is being counselled on some locally available diet interventions to improve anaemia in his/her child. All eligible patients within the cluster would be included in the study. Independent laboratory staff that would analyse the samples would be kept blind to intervention assignment of the communities.

Interventions

Intervention pertains to selected intervention communities. The clusters assigned to counselling on LAD at a household level would each receive targeted one-on-one counselling on LAD intervention aimed at promoting the intake of locally available iron, folate and vitamin B12 rich foods, food rich in enhancers of iron absorption and discouraging the intake of food rich in inhibitors of iron absorption. The counselling would be administered at baseline and repeated monthly. Each session of counselling would last minimum of 20 minutes. The counselling guide is attached as supplement. The rest of the interventions are targeted at the individual participant level. All study participants would receive the current practiced standard treatment for anaemia; iron + folic acid.

The control or standard care arm would receive only the iron plus folic acid syrup. The standard plus arm (intervention arm) would receive iron, folic acid syrup treatment plus counselling on LAD intervention. All two arms of the study would run parallel and would be randomized in the ratio 1:1. The dosage of Iron and folic acid to be dispensed would be according to the current WHO recommended dose for age of the child [25]. The mothers/ legal caretakers would be advised to administer the supplement to children in the morning 1 to 2 hours before or after meals and not to be combined with meals.

Each study participant is required to take the prescribed doses daily. Monthly iron and folic acid requirement shall be dispensed to mothers/guardians. To address the issue of compliance to administered iron and folic acid syrups, a member of the study team shall visit each household every week to inspect the administration of the iron and folic acid syrup by observing the level of syrup in the bottles to ascertain compliance. A three-day food record would be administered at baseline and at end line. The food record question and a food frequency questionnaire are attached as supplement.

Counselling on LAD would be carried out by trained nurses with at least a diploma degree in nursing. A training on the counselling guide would be carried out by a team of nutritionist and doctor. The training is expected to last six hours and would include lecture, simulation and practical discussions. Food groups, locally available foods, enhancers of iron, inhibitors of iron, effective counselling methods would be discussed.

Outcome measures

Outcome measures mainly pertain to individual participant level. The study will evaluate the effect of counselling on LAD interventions on anaemia status of children in the study arm.

Primary outcome

The primary outcome measure is a reduction in the prevalence of anaemia within the study arms. The study would measure haemoglobin of children using haematological analyser and classify children with Hb <11.0 g/dL as anaemic. Since only children with Hb <11.0 g/dL would be included in the intervention, the baseline prevalence of anaemia in each arm would be 100%. At end line, the prevalence of anaemia within study arm would be determined by estimating the absolute proportion of children whose haemoglobin concentration is <11.0 g/dL.

Secondary outcome

Several secondary outcomes would be measured in this study. Secondary outcomes would include measurement of anthropometry; weight, height/length, mid upper arm circumference. Others would include dietary record; 24hour repeated food record, two on weekdays and one on a weekend at baseline and repeated at the end of the study. Blood and serum parameters such as serum iron, ferritin, and other parameters of full blood count would also be taken. Table 1 displays the baseline and outcome measures and the time points.

Table 1

Baseline and Outcome measures, intermediary factors and time points.

Primary and Secondary outcomes		Baseline	Week		End-line
		Week 0	4	8	Week 12
Primary outcome
1	Haemoglobin concentration	X			X
Secondary Outcomes
2	Anthropometry
	Weight	X			X
	Length/Height	X			X
	Mid Upper Arm Circumference	X			X
3	Biochemical outcome
	Serum Ferritin	X			X
	Serum Iron concentration	X			X
	Serum transferrin saturation	X			X
	Serum Vitamin B12 level	X			X
	Serum folate	X			X
4	Clinical Outcome
	General Examination
	Oedema	X			X
	Jaundice	X			X
	Pallor	X			X
	Skin and hair changes	X			X
5	Dietary recall and quantification
	24 hour repeated food record	X			X
	Enhancers of iron in diet	X	X	X	X
	Inhibitors of iron in diet	X	X	X	X
	Supplements used during the study	X	X	X	X

Recruitment of study participants and procedure for data collection

The process of approaching and enlisting households will be based on the following guidelines:

Conduct a quick House and Household Listing in all four selected communities

Survey eligible households with the selected village

Interview household Heads/Spouse (Care givers) per each household

All eligible children per selected household would be enumerated and included in the study

The data collection team would visit households and administer household questionnaires as well as individual child questionnaires after completing consent and assent procedures. A trained phlebotomist would carry out the bloodletting. Five millilitres of blood samples would be taken for haematological and biochemical analysis. The trained community health nurses would carry out the counselling intervention at week one, four and eight of the study. The independent data collection team would be blinded to the community randomisation. Other information to be collected would include household characteristics, medication history, details about intake of IFA supplements, adverse events of intervention, morbidity and mortality outcomes.

Ethical consideration

Written informed consent would be sought at the household level from the head of the household. Verbal assent would be obtained from individual study participant. The consent would be obtained at the baseline. Ethical clearance was obtained from the Tamale Teaching hospital institutional review board TTHERC/20/06/19/01. The trial has been registered with the Pan African Trial Registry (www.pactr.org) with unique identification number for the registry as PACTR201906918438423.

Data analysis

Data analysis would be by intention to treat basis. Descriptive statistics would be used to describe and display baseline characteristics of study participants by study arms to allow for comparing of the study arm after randomisation. The primary outcomes are the change in mean haemoglobin concentration and change in proportion of iron deficiency calculated from serum iron results for each arm of the study. This would be obtained by computing the mean change in haemoglobin concentration of each study participant within the study arm. For comparing arms, we would use mixed effects models with random effects at the cluster level for all outcomes, but including baseline adjustment for any continuous outcomes. Thus, we will adapt the treatment effect analysis approach considering the design effect of the study. Analysis of variance (equality of means test statistic) would be used to test the mean haemoglobin between categorical variables. Change in proportion of anaemic (ie, haemoglobin concentration <110 g/L), severely anaemic (ie, haemoglobin concentration <70 g/L) would be obtained for all groups. Nutritional z-scores will be calculated according to the WHO growth reference curves with the use of Epi Info version 7.2.2.2. Weight-for-height, height-for-age, and weight-for-age z scores of less than −2 would be classified as wasting, stunting, and underweight, respectively; z scores of less than −3 would be considered to indicate severe wasting, or severe underweight. Underweight (ie, weight-for-age Z scores less than −2), and wasting (ie, weight-for-height Z scores less than −2) would be analysed. Multivariate data analysis would be adapted considering a priori selected confounders based on literature (age in months and sex).

An impact evaluation analysis would be adopted to establish the hypothetical impact of the intervention. Multilevel mixed-effects generalized linear model (MEGLM) would be adopted based on the design nature of the study. The assumption for using MEGLM would allow for conditional normally of random effects.

Using a handy measure conversion, handbook, the gram weight of the food items consumed would be obtained and entered into the West Africa Food Analysis software for the analysis of nutrient/dietary data.

Discussion

The prevalence of anaemia in children under-five years is high and there is the need to reduce this burden. Iron supplementation programs have not achieved their full-anticipated effects because the bioavailability of non-haem iron is low. Many children continue to die because of anaemia and several others live with countless developmental disabilities. Given the abnormally high prevalence of anaemia in children under five years, and it’s associated enormous public health implications of developmental disabilities across the life span [26], better methods are needed to improve iron supplementation and reduce the prevalence of anaemia within this age group. Also, recommended iron supplementation for the treatment of anaemia in children usually produce large increase in colonic iron because, typical iron absorption is less than 20% of dose ingested [27]. Non-absorbed iron could be harmful to children because of its role in modifying the gut microbiota with the resultant effect of increasing intestinal pathogens [28]. Increasing number of studies in children under five years reports adverse effects with iron supplementation such as decrease growth, increased diarrhoea, interaction with other trace elements and increased inflammatory markers [29]. It is essential to explore new cost-effective ways of enhancing iron absorption and improving safety of supplemented iron. The possible synergistic role of these LAD activities outlined with IFA supplementation has not been fully explored. Individual anaemic children admitted or managed at health centres and or hospital might have been given supplemental iron, folate and or blood transfusion. However, there is no program in Ghana for iron and folate supplementation for children under 5 years. It is the hope that information from the study would be helpful in programmatic decision making.

Steps to addressing known confounders and limitations

Beyond the process of randomization, the following steps would be taken to address known confounders that may impact on the quality of the interventions. Intestinal worms can impair iron absorption or cause loss of iron leading to or worsening anaemia. Hence all children in the study would be given suspension Albendazole at baseline. Also, malaria parasite can cause red blood cell haemolysis and anaemia. Hence all eligible children would be tested for malaria and those found to have malaria referred for treatment. Also, the exclusion criteria are designed to exclude other potential confounders such as children with known hemoglobinopathies. Household food insecurity may be a confounder that may influence adoption of counselling intervention promoting intake of enhancers of iron absorption and discouraging the intake of inhibitors of iron absorption. Hence there is the need to measure at baseline and end-line food access.

Kumbungu cluster randomized controlled trial protocol.

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21 Jan 2021

PONE-D-20-28388

Effects of a locally available dietary interventions counselling on the community-based management of anaemia in children under five in Ghana: Kumbungu cluster randomized controlled trial protocol

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1. Does the manuscript provide a valid rationale for the proposed study, with clearly identified and justified research questions?

The research question outlined is expected to address a valid academic problem or topic and contribute to the base of knowledge in the field.

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

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2. Is the protocol technically sound and planned in a manner that will lead to a meaningful outcome and allow testing the stated hypotheses?

The manuscript should describe the methods in sufficient detail to prevent undisclosed flexibility in the experimental procedure or analysis pipeline, including sufficient outcome-neutral conditions (e.g. necessary controls, absence of floor or ceiling effects) to test the proposed hypotheses and a statistical power analysis where applicable. As there may be aspects of the methodology and analysis which can only be refined once the work is undertaken, authors should outline potential assumptions and explicitly describe what aspects of the proposed analyses, if any, are exploratory.

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Partly

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3. Is the methodology feasible and described in sufficient detail to allow the work to be replicable?

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: No

**********

4. Have the authors described where all data underlying the findings will be made available when the study is complete?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception, at the time of publication. 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

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: Yes

Reviewer #2: Yes

Reviewer #3: No

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above and, if applicable, provide comments about issues authors must address before this protocol can be accepted for publication. You may also include additional comments for the author, including concerns about research or publication ethics.

You may also provide optional suggestions and comments to authors that they might find helpful in planning their study.

(Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: The authors describe testing a promising intervention for the prevention and treatment of anemia in young children in Africa.

The study design appears sound and methods are generally adequately described.

English errors occur throughout the manuscript and the figures and tables contain alignment and formatting errors.

Comments:

Please describe the diet of the communities and whether the residents have access to the foods/beverages you plan to include in the counseling intervention. Is there published evidence that consumption of iron inhibitors and lack of consumption of iron enhancers is occurring in these communities? Are animal foods commonly consumed?

How will nutrient/dietary data be analyzed? What databases are to be used?

Is the sample size adequate to detect significant differences in the secondary outcome measures of s ferritin and iron?

Have these communities been exposed to supplemental iron and folate previously?

What instructions are provided to the caregivers regarding administration of the supplements (with meals or not; morning or evening)?

Explain the training for the LAD counseling.

The consent form should describe the collection of dietary data.

Reviewer #2: For the secondary outcomes, diet recall is often not accurate. A better approach would be to have the participants record food intake daily for more accuracy. Also information on supplements used during the study, if any, by the households should be included.

Reviewer #3: Abstract

- since the cluster is the unit of randomisation, indicate the total number of children, households and community clusters to be included.

- clarify which aspects of anthropometry will be measured.

Introduction

- typo in second-last paragraph of page 2 - 'diarrhoea'

- in first paragraph on page 3, you mean 'children under five years [of age]' not 'children lower than five years'. Also, 'which are respectively projected...' instead of 'is respectively projected...'

- second-last line on page 3 - you probably mean 'distinctive' rather than 'peculiar'.

Methods

- there's a potentially fundamental problem with the study design. In the design section, you refer to the communities as the clusters. So your effective sample size is two clusters per arm; however in the sample size calculation, you refer to the households as the clusters, and indicate that the number of clusters per study arm is 54. This needs to be clarified. Either the community is a higher-level unit of stratification (in the same way one might conduct stratified randomisation by country in a multi-country study), or if it is indeed the unit of clustering then the study design and sample size calculation needs to be thought through, as it is not appropriate if cluster randomisation is at the community level.

- a more appropriate analysis would involve a mixed effects generalised linear model of the endline outcome measures adjusted for baseline measures (for continuous outcomes only - analysis of covariance), with further adjustment for age, sex and any stratification factors. Mixed effects models, or other hierarchical models, appropriately adjust for the clustering in the expected data. The proposed approach involving a t-test is not appropriate as it doesn't adjust for the clustered design, and doesn't allow for adjustment for baseline continuous outcomes (which improves efficiency - for continuous outcomes only).

**********

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: Colleen M Croniger

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.

7 Jul 2021

Response to Reviewers’ comment

Thank you for the opportunity to submit a revision to this manuscript:

PONE-D-20-28388

Effects of a locally available dietary interventions counselling on the community-based management of anaemia in children under five in Ghana: Kumbungu cluster randomized controlled trial protocol

I am grateful for the inputs made by you and the reviewers, which greatly improved this manuscript.

Please find below the point-by-point response to reviewer comments.

Comments by Academic Editor:

1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming.

2. We note that Figure(s) 1 in your submission contain map images which may be copyrighted …….. If you are unable to obtain permission from the original copyright holder to publish these figures under the CC BY 4.0 license or if the copyright holder’s requirements are incompatible with the CC BY 4.0 license, please either i) remove the figure or ii) supply a replacement figure that complies with the CC BY 4.0 license. Please check copyright information on all replacement figures and update the figure caption with source information. If applicable, please specify in the figure caption text when a figure is similar but not identical to the original image and is therefore for illustrative purposes only.

3. Please include a caption for figure 1

Response:

Thank you, the figure has been removed

4. We note you have included a table to which you do not refer in the text of your manuscript. Please ensure that you refer to Table 1 in your text; if accepted, production will need this reference to link the reader to the Table.

Response

Please this has been carried out

5. Please include captions for your Supporting Information files at the end of your manuscript, and update any in-text citations to match accordingly. Please see our Supporting Information guidelines for more information: http://journals.plos.org/plosone/s/supporting-information.

Response

Please this has been carried out

Reviewer #1:

The authors describe testing a promising intervention for the prevention and treatment of anemia in young children in Africa.

The study design appears sound and methods are generally adequately described.

English errors occur throughout the manuscript and the figures and tables contain alignment and formatting errors.

Response

Thank you, English Errors corrected and the figure and table alignment and formatting errors corrected

Comments:

Please describe the diet of the communities and whether the residents have access to the foods/beverages you plan to include in the counseling intervention. Is there published evidence that consumption of iron inhibitors and lack of consumption of iron enhancers is occurring in these communities?

response

Majority of the people in the Kumbungu district are farmers who cultivate small fragmented parcel of lands [22]. Cattles are the most valuable livestock that are rarely sold or slaughtered except for extreme shock such as crop failure or famine [22]. Also, livestock and poultry are often kept by most household which provides immediate cash to purchase food, pay for medical bills, source of protein rich diet and also given out as gift/ sacrifice [23]. Previous studies in the district have found high intake of phytates and tea which are known inhibitors of iron absorption [23]. Locally available diets that contain high amount of vitamin C such as tamarind, ripe shea fruit and baobab are seasonal and when available, are not expensive to buy.

comment

Are animal foods commonly consumed?

Response

The following has been included on the section on study site; “Culturally, meet is reserved for festive occasion. Animal food; anyone who can afford animal food is a plus. Though livestock, poultry are kept by some on small scale, free range level, the eggs and meat are often sold for cash.”

comment

How will nutrient/dietary data be analyzed? What databases are to be used?

Response

Using a handy measure conversion, handbook, the gram weight of the food items consumed would be obtained and entered into the West Africa Food Analysis software for the analysis of nutrient/dietary data. The software makes use of the West African Food composition table.

This has been included in the data analysis section.

Comment

Is the sample size adequate to detect significant differences in the secondary outcome measures of s ferritin and iron?

Response

Thank you for pointing this to us. The sample size has been recalculated and powered to detect secondary outcome measures of serum ferritin and iron. Eight community clusters would be included and a minimum of 200 households with a minimum of 396 children would be included in the study.

comment

Have these communities been exposed to supplemental iron and folate previously?

Response

Individual anaemic children admitted or managed at health centres and or hospital might have been given supplemental iron and folate. However, there is no program in Ghana for iron and folate supplementation for children under 5 years. This statement was included in the discussion section.

Comment

What instructions are provided to the caregivers regarding administration of the supplements (with meals or not; morning or evening)?

Response

Women would be advised to administer the supplement to children in the morning 1 to 2 hours before or after meals and not to be combined with meals.

comment

Explain the training for the LAD counseling.

Response

Thank you for pointing this out. The following has been included in the section on intervention; last paragraph.

“Counselling on LAD would be carried out by trained nurses with at least a diploma degree in nursing. A training on the counselling guide would be carried out by a team of nutritionist and doctor. The training is expected to last six hours and would include lecture, simulation and practical discussions. Food groups, locally available foods, enhancers of iron, inhibitors of iron, effective counselling methods would be discussed.”

comment

The consent form should describe the collection of dietary data.

Response

Thank you. It has been included.

Reviewer #2:

For the secondary outcomes, diet recall is often not accurate. A better approach would be to have the participants record food intake daily for more accuracy.

Response

Thank you for emphasizing this. We would take a 24hour repeated food record. Two on weekdays and one on a weekend at baseline and repeated at the end of the study.

Comment

Also information on supplements used during the study, if any, by the households should be included.

Response

Thank you very much. Supplements used during the study if any is a potential confounder and information on that would be collected. This has been included in the table 1 and the preceding text on secondary outcomes to me measured

Reviewer #3:

Abstract

- since the cluster is the unit of randomisation, indicate the total number of children, households and community clusters to be included.

Response

Thank you, this has been clearly stated now as can be found in the section under sample size calculation and the abstract and restated here as follows: “The minimum number of children per arm is 198 and the number of community clusters is 8 (4 per study arm). Also, considering this study proposes two parallel arms, the total minimum study sample size of children under five with anaemia is 396 and the minimum total number of community clusters is 8 and a minimum of 25 households per community cluster, 100 households per study arm and 200 households need to be enrolled for the study”.

Comment

- clarify which aspects of anthropometry will be measured.

response

Weight, height/length, mid upper arm circumference was specified in the abstract section now.

Comment

Introduction

- typo in second-last paragraph of page 2 - 'diarrhoea'

- in first paragraph on page 3, you mean 'children under five years [of age]' not 'children lower than five years'. Also, 'which are respectively projected...' instead of 'is respectively projected...'

- second-last line on page 3 - you probably mean 'distinctive' rather than 'peculiar'.

Response

Really appreciate the suggestions; all were accepted and the changes effected.

comment

Methods

- there's a potentially fundamental problem with the study design. In the design section, you refer to the communities as the clusters. So your effective sample size is two clusters per arm; however in the sample size calculation, you refer to the households as the clusters, and indicate that the number of clusters per study arm is 54. This needs to be clarified. Either the community is a higher-level unit of stratification (in the same way one might conduct stratified randomisation by country in a multi-country study), or if it is indeed the unit of clustering then the study design and sample size calculation needs to be thought through, as it is not appropriate if cluster randomisation is at the community level.

Response

Thank you very much for pointing this out to us. We worked out the whole sample size calculation and design section accepting your useful recommendation. Community clusters were used instead of household clusters and the rational explained in the design section. In all, eight community clusters were to be included in the study after re-calculating the sample size to accommodate your suggestion. The design and sample size sections have been reviewed to reflect the changes.

Comment

- a more appropriate analysis would involve a mixed effects generalised linear model of the endline outcome measures adjusted for baseline measures (for continuous outcomes only - analysis of covariance), with further adjustment for age, sex and any stratification factors. Mixed effects models, or other hierarchical models, appropriately adjust for the clustering in the expected data. The proposed approach involving a t-test is not appropriate as it doesn't adjust for the clustered design, and doesn't allow for adjustment for baseline continuous outcomes (which improves efficiency - for continuous outcomes only).

Response

We agree with reviewer and have reviewed our initial analysis plan as below;

An impact evaluation analysis would be adopted to establish the hypothetical impact of the intervention. Multilevel mixed-effects generalized linear model (MEGLM) would be adopted based on the design nature of the study. The assumption for using MEGLM would allow for conditional normally of random effects. Very helpful.

Thank you

Benjamin Nuertey

Submitted filename: Response to Reviewers.docx

Click here for additional data file.

7 Dec 2021

Effects of a locally available dietary interventions counselling on the community-based management of anaemia in children under five in Ghana: Kumbungu cluster randomized controlled trial protocol

PLOS ONE

Dear Dr. Benjamin Demah Nuertey,

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Does the manuscript provide a valid rationale for the proposed study, with clearly identified and justified research questions?

The research question outlined is expected to address a valid academic problem or topic and contribute to the base of knowledge in the field.

Reviewer #1: Yes

Reviewer #3: Yes

**********

2. Is the protocol technically sound and planned in a manner that will lead to a meaningful outcome and allow testing the stated hypotheses?

The manuscript should describe the methods in sufficient detail to prevent undisclosed flexibility in the experimental procedure or analysis pipeline, including sufficient outcome-neutral conditions (e.g. necessary controls, absence of floor or ceiling effects) to test the proposed hypotheses and a statistical power analysis where applicable. As there may be aspects of the methodology and analysis which can only be refined once the work is undertaken, authors should outline potential assumptions and explicitly describe what aspects of the proposed analyses, if any, are exploratory.

Reviewer #1: Yes

Reviewer #3: Yes

**********

3. Is the methodology feasible and described in sufficient detail to allow the work to be replicable?

Reviewer #1: Yes

Reviewer #3: Yes

**********

4. Have the authors described where all data underlying the findings will be made available when the study is complete?

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

Reviewer #1: No

Reviewer #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

Reviewer #3: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above and, if applicable, provide comments about issues authors must address before this protocol can be accepted for publication. You may also include additional comments for the author, including concerns about research or publication ethics.

You may also provide optional suggestions and comments to authors that they might find helpful in planning their study.

(Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: The authors have made most of the recommended revisions and the manuscript is improved.

English errors remain and need correction. "Years" should be included when describing ages of children over 5 and adults.

Include articles (such as "the") when appropriate and check agreement of nouns and verbs for singular/plural.

"Meet" should be spelled "meat."

Reviewer #3: Thank you for your clear and comprehensive responses to the previous round of reviews. There are a number of key aspects of the protocol which I think would still benefit from improvement.

First, I would suggest that you revisit your sample size calculation, as this aspect of the study design is critical but doesn't seem correct in the current version of the protocol.

The key parameters of the sample size calculation are that the prevalence of anaemia is 82% and you hope to see an absolute 22% reduction over 12 weeks. You hope to have 80% power to detect this difference, at the 5% level of significance.

The cluster design aspects of the trial are inter-related. The cluster size and number of clusters to include are within your control. However, the ICC (ie. how similar the outcome is between individuals in the same community) is a natural phenomenon which you cannot vary. The design effect is the inflation factor by which you increase the basic sample size to account for the clustered design; it is function of the cluster size, number of clusters and ICC and does not need to be presented/calculated separately as you have done in (7) in your description of the calculation.

Given that the cluster size and number of clusters is what is within your control, these are the only aspects of the design that you can change. Currently you have decided that you'll recruit about 50 children per cluster - this is the cluster size. With this cluster size, assuming an ICC of 0.01, you will need 6 clusters per arm - so your current estimate of 4 per arm would not be sufficient.

If you are really only able to work with 4 communities in each arm, then you need to increase the cluster size i.e. the number of children you recruit in each cluster. With a cluster size of 100, all else remaining the same, you need 4 community clusters per arm, i.e. 8 community clusters total and 800 children total. If you anticipate any losses to follow-up, contamination/cross-over e.t.c. then you need to appropriately inflate the expected number of children per arm so that your actual cluster size will be more than 100 and the total expected number of children across the 8 community clusters will be more than 800.

Secondly, your analysis section still refers to the use of paired t-tests to compare continuous outcomes - this will not be appropriate for a clustered design, since the ordinary t-test does not include adjustment for clustering. For comparing arms, please plan to use mixed effects models with random effects at the cluster level for all outcomes, but including baseline adjustment for any continuous outcomes. The analysis section also says the study is powered to detect differences in some z-scores, yet the sample size calculation is only based on a reduction in prevalence of anaemia.

Lastly, you describe stepwise variable selection for variables to be included in the adjusted models - this is not appropriate for a randomised trial. In a randomised trial you only adjust for a priori potential confouners (e.g. age and sex) and any variables used for stratification - you don't use automated processes to identify variables to adjust for because by design you don't expect characteristics to differ between the randomised groups; if you expect any differences they you stratify randomisation by those characteristics, and then you also adjust for the stratification variables.

Please review these issues and if needed consult a statistician with experience in design and analysis of cluster randomised trials for further advice.

**********

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 #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.

12 Dec 2021

Reviewer #1:

Comment

The authors have made most of the recommended revisions and the manuscript is improved.

English errors remain and need correction. "Years" should be included when describing ages of children over 5 and adults. Include articles (such as "the") when appropriate and check agreement of nouns and verbs for singular/plural. "Meet" should be spelled "meat."

Response

Thank you very much for your thorough review which improved the manuscript. All the suggested changes have been carried out. Thank you.

Reviewer #3:

Comment

Thank you for your clear and comprehensive responses to the previous round of reviews. There are a number of key aspects of the protocol which I think would still benefit from improvement.

Response

We are deeply grateful for your suggestions, education, and support particular with the statistical aspect of this protocol. Your inputs were very valuable to us. Thank you.

Comment

First, I would suggest that you revisit your sample size calculation, as this aspect of the study design is critical but doesn't seem correct in the current version of the protocol.

The key parameters of the sample size calculation are that the prevalence of anaemia is 82% and you hope to see an absolute 22% reduction over 12 weeks. You hope to have 80% power to detect this difference, at the 5% level of significance.

The cluster design aspects of the trial are inter-related. The cluster size and number of clusters to include are within your control. However, the ICC (ie. how similar the outcome is between individuals in the same community) is a natural phenomenon which you cannot vary. The design effect is the inflation factor by which you increase the basic sample size to account for the clustered design; it is function of the cluster size, number of clusters and ICC and does not need to be presented/calculated separately as you have done in (7) in your description of the calculation.

Given that the cluster size and number of clusters is what is within your control, these are the only aspects of the design that you can change. Currently you have decided that you'll recruit about 50 children per cluster - this is the cluster size. With this cluster size, assuming an ICC of 0.01, you will need 6 clusters per arm - so your current estimate of 4 per arm would not be sufficient.

If you are really only able to work with 4 communities in each arm, then you need to increase the cluster size i.e. the number of children you recruit in each cluster. With a cluster size of 100, all else remaining the same, you need 4 community clusters per arm, i.e. 8 community clusters total and 800 children total. If you anticipate any losses to follow-up, contamination/cross-over e.t.c. then you need to appropriately inflate the expected number of children per arm so that your actual cluster size will be more than 100 and the total expected number of children across the 8 community clusters will be more than 800.

Response

Thank you for taking your time to give an in-depth education on cluster sample size calculations. We followed your advice and your suggested reviews were carried out. First we dropped the calculation on design effect as suggested. Also, we inputted the estimated average number of children per cluster which currently stands at 75 in to the calculation, maintaining all other variables as suggested. This gave us a total of four clusters per study arm and a total of 8 clusters.

Considering a 10% for loss to follow-up and contamination, our final sample size stands at 660 children under five years. Thus 330 children per arm of the study. This was possible with your kind suggestion. Thank you!

Comment

Secondly, your analysis section still refers to the use of paired t-tests to compare continuous outcomes - this will not be appropriate for a clustered design, since the ordinary t-test does not include adjustment for clustering. For comparing arms, please plan to use mixed effects models with random effects at the cluster level for all outcomes, but including baseline adjustment for any continuous outcomes. The analysis section also says the study is powered to detect differences in some z-scores, yet the sample size calculation is only based on a reduction in prevalence of anaemia.

Response

Thank you immensely for pointing out this to us. We have modified the data analysis section, (line 6). Hence, for comparing arms, we would use mixed effects models with random effects at the cluster level for all outcomes, but including baseline adjustment for any continuous outcomes. Thus, we will adapt the treatment effect analysis approach considering the design effect of the study.

The aspect that referred to the following statement was expunged; “The analysis section also says the study is powered to detect differences in some z-scores, yet the sample size calculation is only based on a reduction in prevalence of anaemia.”

Comment

Lastly, you describe stepwise variable selection for variables to be included in the adjusted models - this is not appropriate for a randomised trial. In a randomised trial you only adjust for a priori potential confounders (e.g. age and sex) and any variables used for stratification - you don't use automated processes to identify variables to adjust for because by design you don't expect characteristics to differ between the randomised groups; if you expect any differences they you stratify randomisation by those characteristics, and then you also adjust for the stratification variables. Please review these issues and if needed consult a statistician with experience in design and analysis of cluster randomised trials for further advice.

Response

Thank you for pointing out this to us. The aspect of the proposed analysis describing stepwise variable selection was deleted. Multivariate data analysis would be adapted considering a priori selected confounders based on literature (age in months and sex).

Submitted filename: response to reviewer comment.docx

Click here for additional data file.

8 Feb 2022

14 Feb 2022

Dear Dr. Frank Wieringa

Thank you very much for agreeing to step in as new academic editor

Academic editor comment

Please note the results of the national micronutrient survey in Ghana, published by Wegmuller et al in 2020 in PlosOne, showing iron deficiency contributed to roughly 30% of the anemia observed in children only. Hence, in your abstract, the sentence "Most of the causes of anaemia in children under-five years are preventable." should be rephrased to 'an important part of anemia...."

Response

Thank you, suggestion carried out

Reviewer 3

comment

The manuscript is much improved from the previous round of reviews and I commend the authors for taking previous comments on board. I have two main points to raise in this round:

(1) the sample size calculation only works if I assume a higher ICC of around 0.035, not 0.01 as cited in point 3 on page 8, and if I ignore the coefficient of variation of 0.9 cited in point 4, which is much too high given the parameters already specified. I would recommend that the authors drop point 4 as it is determined by other parameters, and also recheck the ICC used in the calculation. Another minor point is to be clear in point 1 on page 7 that the sample size is predicated on an estimated ABSOLUTE reduction of at least 22%

Response

1. A higher ICC of 0.035 was used as suggested

2. Point 4 (Estimate of coefficient of variation of cluster sizes of 0.90) was dropped as suggested

3. Also, the phrase “the sample size is predicted on an estimated absolute reduction of at least 22% of the baseline prevalence”.

comment

(2) given that the sample size calculation is based on the prevalence of anaemia, it is incorrect to state that the primary outcome is haemoglobin (page 10). The primary outcome should be reported as anaemia, as this is what the sample size calculation is based on. The authors should then go ahead and describe how anaemia will be determined, i.e. measuring haemoglobin using an analyser and classifying children with values below [threshold] as anaemic. Most of this is already indicated in page 10-11. Further, the authors should focus the primary outcome data analysis on anaemia and not haemoglobin (haemoglobin may be analysed as a secondary outcome). If the authors intended haemoglobin to be the primary outcome, then a whole new sample size calculation appropriate for this continuous outcome is required.

Response

Thank you very much for this important correction. The below statement has replaced the previous phrase.

“The primary outcome measure is a reduction in the prevalence of anaemia within the study arms. The study would measure haemoglobin of children using haematological analyser and classify children with Hb <11.0 g/dL as anaemic. Since only children with Hb <11.0 g/dL would be included in the intervention, the baseline prevalence of anaemia in each arm would be 100%. At end line, the prevalence of anaemia within study arm would be determined by estimating the absolute proportion of children whose haemoglobin concentration is <11.0 g/dL.”

Thank you

Benjamin Nuertey

Submitted filename: Response to reviewer comment.docx

Click here for additional data file.

16 Mar 2022

Effects of a locally available dietary interventions counselling on the community-based management of anaemia in children under five years in Ghana: Kumbungu cluster randomized controlled trial protocol

PONE-D-20-28388R3

Dear Dr. Nuertey,

I am 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.

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13 Apr 2022

PONE-D-20-28388R3

Effects of a locally available dietary interventions counselling on the community-based management of anaemia in children under five years in Ghana: Kumbungu cluster randomized controlled trial protocol.

Dear Dr. Nuertey:

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