Nutritional Vulnerability of Displaced Persons: A Study of Food Security and Access in Kumba Municipality, Cameroon

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

Reviewer notes

Title: Nutritional Vulnerability of Internally Displaced Persons 2 (IDPs): A Study of Food Access (Food Security) and Nutritional Status of IDPs in the Kumba Municipality

General comments:

This study explored nutritional vulnerability and food security situation of internally displaced persons in Kumba municipality in Cameroon. The study also collected food security, dietary, anthropometric and other socioeconomic and demographic factors to describe the state of the study population. Key concern: The food security, dietary and nutritional outcome of IDPs households or any vulnerable groups is already expected to be suboptimal. That is why emergency responses/interventions are put in place. This paper needs to clearly establish the purpose for the study. It is not surprising if displaced people who have left their livelihood, usual place of residence, etc. ends up being food insecure and or exhibit poor nutritional status. Authors need to frame the direction of the paper into examining/evaluating the food and nutrition state of IDPs a certain number of years after the implementation of an intervention programs to address the issue. This approach, I think, better justifies the purpose or intent of the study and hence, more specific conclusions/recommendations to program planners and implementers in the region.

Abstract

-        Lines 23-24: how was the nutritional status assessed? Anthropometry, dietary intake, biochemical or clinically? Please provide a brief hint here.

-        Line 26: who was stunted, children or the IDP adult person? 50.6% of children?

-        Lines 25-26: “In addition, 28.3% of the surveyed households had good dietary diversity” – this is ambiguous. What does one define good dietary diversity. Please use standard language to describe the dietary diversity as high or low/ or meets minimum requirement, above/ below minimum requirement, etc.

-        Lines 26-28: “…15% were wasting…” change to “15% were wasted”. Even better is to rewrite the whole sentence.

-        Lines 31: “increase family size and used of coping strategies were….” This doesn’t make sense. Please re-write. Or have a native English speaker polish the paper.

-        Line 35-36: “to address the root cause of food insecurity…” To recommend this, authors should first point out what these root causes were as per their study.

-        Lines 34-36: authors should consider being specific about the recommendation. E.g., suggest strategies to improve access to food instead of simply stating what needs to be done. Try to point to the “What” and “How” when suggesting recommendations.

 

Introduction

-        Reference might be needed at the end of the first sentence (Lines44-46)

-        Overall, authors provide a strong background outlining the contextual factors influencing the food security situation of IDP. However, authors fail to clearly formulate the research gap/problem their work is trying to provide an answer for. A clear purpose statement is needed around the end of the introductory section. What problem are you trying to solve with your work? What would be a unique contribution of your work to address this problem? Are you assessing impact of the emergency response & interventions carried out to address the food security of your target population? Please ensure your introductory section answers these questions.

-         

Methodology

-        Lines 122-125: some of these belong to the purpose statement paragraph in your introduction section.

o   Authors also need to be careful in how they connect nutritional status and food insecurity. Food security is a necessary but not sufficient condition for favorable nutritional status. Food security doesn’t always lead to nutrition security. Please explore this connection in your background and discussion sections.

-        Line 135: “probability proportionate to size …formula”- please insert the formula and reference here.

-        Lines 140-142: “IDP households were numbered for systematic sampling. Subsequently, households with children under 5 years were prioritized and included in the study.” This is a bit unclear. How did you accomplish prioritizing households with <5yrs old children if you selected households by applying systematic sampling? Did the IDP households always have under 5 children? That doesn’t seem the case if you have to prioritize some households having certain attributes (in this case having under 5 child). Please elaborate.

-        Also, how many adults did you consider in each eligible household. You did say just one under 5 child per household, but you didn’t specify # of adults considered per household and whether this included both female and male adults or only female caregivers…

-        Lines 151-168: who were the data collectors and how were they trained? Who measured what type data (e.g., who conducted all anthropometric measurements of children and adults)?

-        Line 172 – Epi info… please properly reference this tool (version, company, year, etc.)

-        Lines 179-182: you need to describe your data collection tools (e.g. HDDS or the HFIAS) in the previous section and focus only how you analyzed the data here.

-         

Results

-        Table 1: Duration of displacement was classified as “Less than 1 year”, “1-4 years” and “5-6 years”. Is this a standard classification? Why not <1y, 1-2yrs, 3-4yrs and 5-6yrs, etc.? Authors should describe the rationale for the classification they opted to use.

o   The experience of someone/households displaced for 1 year vs. 4yrs might be very different and putting them together might not accurately reflect the food and nutrition insecurity experiences of each household.

-        Lines 218-221: Please describe the criteria to classify households as food secure, insecure, etc. in the methods section before you present the data here. E.g., when do you say a household is severely food insecure?

-        Lines 226-234: It would be better if authors first describe the coping strategies asked and or how they classified them into four sections in the methods section. Here, only present the findings. No need to talk about the classification…

-        Lines 241-242: “The dietary diversity score considered the number of different food groups consumed by a household over 24 hours. In this study, data was collected on 17 distinct food groups.” – this also belongs in the methods section. Please describe each of your data collection instrument and how the data was analyzed in the methods section. Simply present your results here.

-        Lines 248-250: “These food groups were then recategorized into 9 broader groups for analysis: starchy staples, green leafy vegetables, Vitamin A-rich fruits/vegetables, other fruits/vegetables, organ meats, meat/poultry/fish, eggs, legumes/nuts/seeds and milk/milk products.” –this also belongs in the methods section. Describe the criteria for classifying HDDS in the methods section. Please do similar checks in the rest of your results section.

-        Table 3: It might be better to disaggregate the data for female and male adults as under nutrition in women and men might have significantly different pattern.

-        Lines 288-297: You are presenting a linear regressions analysis here. However, you have not described this in the methods section including whether your data met the assumptions to run multiple linear regression. Were your variables normally distributed, for example? What guided your decision as to which variable to include in the regression analysis?

Discussion, strength/limitations & conclusions

-        Discussion section is longer. It can be more focused and only discuss key findings/outcomes in relation to existing literature without repeating the results already presented in the result section.

-        Discussion section should also be one coherent section presenting the discussion of key findings. No need to use sub-headings here. A new paragraph can be used to discuss each key result (copping strategies, HDDS, nutritional status of adults or children, food insecurity, etc.)

-        Lines 377-391: What were the criteria for poor dietary diversity, or one that meets daily needs? Please define these in the methods section.  

Comments on the Quality of English Language

Generally understandable. However, the abstract the section and some part of the main text could be improved with proofreading and minor edits. 

Author Response

We thank you very much for taking out time to review our manuscripts. You comments are so pertinent has improved on our manuscript.

 

Reviewer notes

Title: Nutritional Vulnerability of Internally Displaced Persons 2 (IDPs): A Study of Food Access (Food Security) and Nutritional Status of IDPs in the Kumba Municipality

General comments:

This study explored nutritional vulnerability and food security situation of internally displaced persons in Kumba municipality in Cameroon. The study also collected food security, dietary, anthropometric and other socioeconomic and demographic factors to describe the state of the study population. Key concern: The food security, dietary and nutritional outcome of IDPs households or any vulnerable groups is already expected to be suboptimal. That is why emergency responses/interventions are put in place. This paper needs to clearly establish the purpose for the study. It is not surprising if displaced people who have left their livelihood, usual place of residence, etc. ends up being food insecure and or exhibit poor nutritional status. Authors need to frame the direction of the paper into examining/evaluating the food and nutrition state of IDPs a certain number of years after the implementation of an intervention programs to address the issue. This approach, I think, better justifies the purpose or intent of the study and hence, more specific conclusions/recommendations to program planners and implementers in the region.

Abstract

-        Lines 23-24: how was the nutritional status assessed? Anthropometry, dietary intake, biochemical or clinically? Please provide a brief hint here.

Response:  The nutritional status assessment was done using anthropometry and clinically assessment?

 

-        Line 26: who was stunted, children or the IDP adult person? 50.6% of children?

Response: The phrase has been modified to “50.6% of the children were stunted”.

-        Lines 25-26: “In addition, 28.3% of the surveyed households had good dietary diversity” – this is ambiguous. What does one define good dietary diversity. Please use standard language to describe the dietary diversity as high or low/ or meets minimum requirement, above/ below minimum requirement, etc.

Response: The phrase has been modified to “28.3% of the surveyed households had a high dietary diversity”.

-        Lines 26-28: “…15% were wasting…” change to “15% were wasted”. Even better is to rewrite the whole sentence.

Response: The phrase has been modified to “15% were wasted”.

 

-        Lines 31: “increase family size and used of coping strategies were….” This doesn’t make sense. Please re-write. Or have a native English speaker polish the paper.

Response: The sentence was rephrased to “increase family size among households and the use of coping strategies used by households to lessen food insecurity were associated with increased food insecurity”

-   Line 35-36: “to address the root cause of food insecurity…” To recommend this, authors should first point out what these root causes were as per their study.

Response: the phrase “low household monthly income and large household family sizes are the root causes of food insecurity in the study area” has been added to the conclusion.

-        Lines 34-36: authors should consider being specific about the recommendation. E.g., suggest strategies to improve access to food instead of simply stating what needs to be done. Try to point to the “What” and “How” when suggesting recommendations.

Response: The line 34-36 has been rephrased “These findings emphasize the urgent need for comprehensive interventions such as; the distribution food vouchers, cash transfers, and food banks, support home gardening and small-scale farming, and finally, provide rations, meal planning, and family planning services to address the root causes of food insecurity namely low household monthly income and large household family sizes, improve access to nutritious food, and ensure the health and well-being of IDPs.”.

 

Introduction

-        Reference might be needed at the end of the first sentence (Lines44-46)

Response: Requested citation has been added.

-        Overall, authors provide a strong background outlining the contextual factors influencing the food security situation of IDP. However, authors fail to clearly formulate the research gap/problem their work is trying to provide an answer for. A clear purpose statement is needed around the end of the introductory section. What problem are you trying to solve with your work? What would be a unique contribution of your work to address this problem? Are you assessing impact of the emergency response & interventions carried out to address the food security of your target population? Please ensure your introductory section answers these questions.

Response: The clear propose statement has been added at the end of the introductory section.

-         

Methodology

-        Lines 122-125: some of these belong to the purpose statement paragraph in your introduction section.

Response: The statement has been included in the introduction section.

o   Authors also need to be careful in how they connect nutritional status and food insecurity. Food security is a necessary but not sufficient condition for favorable nutritional status. Food security doesn’t always lead to nutrition security. Please explore this connection in your background and discussion sections.

Response: The statement has been rephrased to illustrate that food security is a necessary but not sufficient condition for favorable nutritional status.

-        Line 135: “probability proportionate to size …formula”- please insert the formula and reference here.

Response: Clarification of the probability proportionate to size was provided.

-        Lines 140-142: “IDP households were numbered for systematic sampling. Subsequently, households with children under 5 years were prioritized and included in the study.” This is a bit unclear. How did you accomplish prioritizing households with <5yrs old children if you selected households by applying systematic sampling? Did the IDP households always have under 5 children? That doesn’t seem the case if you have to prioritize some households having certain attributes (in this case having under 5 child). Please elaborate.

Response: The sentences were rephrased to explain that households were purposefully selected for housing children under five and adult caregivers who are responsible for food preparation were interview (It could male or female).

 

-        Also, how many adults did you consider in each eligible household. You did say just one under 5 child per household, but you didn’t specify # of adults considered per household and whether this included both female and male adults or only female caregivers…

Response: An adult caregiver responsible for food preparation was purposively selected per household. These participants were mostly female, but males were also selected in the case where they performed the activity for the household.

-        Lines 151-168: who were the data collectors and how were they trained? Who measured what type data (e.g., who conducted all anthropometric measurements of children and adults)?

Response: The principal investigator did the data collection and measured all the participants.

 

-        Line 172 – Epi info… please properly reference this tool (version, company, year, etc.)

Response: We have added the version, company and year of Epi info.

 

-        Lines 179-182: you need to describe your data collection tools (e.g. HDDS or the HFIAS) in the previous section and focus only how you analyzed the data here.

Response: the sentences have been rephrased to explain how the HDDS data was added.

 

Results

-        Table 1: Duration of displacement was classified as “Less than 1 year”, “1-4 years” and “5-6 years”. Is this a standard classification? Why not <1y, 1-2yrs, 3-4yrs and 5-6yrs, etc.? Authors should describe the rationale for the classification they opted to use.

Response: No standard classification was found in literature; however, the grouping was guided by the spread/deviation of the collected data.

 

• The experience of someone/households displaced for 1 year vs. 4yrs might be very different and putting them together might not accurately reflect the food and nutrition insecurity experiences of each household.
• Response: Yes, we agree with the reviewer, but no standard classification was found in literature; however, the grouping was guided by the spread/deviation of the data.

 

-        Lines 218-221: Please describe the criteria to classify households as food secure, insecure, etc. in the methods section before you present the data here. E.g., when do you say a household is severely food insecure?

• Response: the criteria for classification of household food security has been added.

-        Lines 226-234: It would be better if authors first describe the coping strategies asked and or how they classified them into four sections in the methods section. Here, only present the findings. No need to talk about the classification…

• Response: Yes, this has been clearly described on table 2.

 

-        Lines 241-242: “The dietary diversity score considered the number of different food groups consumed by a household over 24 hours. In this study, data was collected on 17 distinct food groups.” – this also belongs in the methods section. Please describe each of your data collection instrument and how the data was analyzed in the methods section. Simply present your results here.

• Response: Further explanation has been added on how the dietary diversity was analysed.

 

-        Lines 248-250: “These food groups were then recategorized into 9 broader groups for analysis: starchy staples, green leafy vegetables, Vitamin A-rich fruits/vegetables, other fruits/vegetables, organ meats, meat/poultry/fish, eggs, legumes/nuts/seeds and milk/milk products.” –this also belongs in the methods section. Describe the criteria for classifying HDDS in the methods section. Please do similar checks in the rest of your results section.

• Response: This criteria for classifying HDDS has be included in the method section. Also, the 9 food groups were considered putting more emphasis on micronutrient intake and on economic access to food.

 

-        Table 3: It might be better to disaggregate the data for female and male adults as under nutrition in women and men might have significantly different pattern.

• Response: This is very interesting idea but we did not have that as an objective. Also, because most of the nutritional variables we assessed were measuring at the household levels not at the individual levels.

-        Lines 288-297: You are presenting a linear regressions analysis here. However, you have not described this in the methods section including whether your data met the assumptions to run multiple linear regression. Were your variables normally distributed, for example? What guided your decision as to which variable to include in the regression analysis?

• Response: More information has been added on how data met the assumptions to run multiple linear regression.

 

Discussion, strength/limitations & conclusions

-        Discussion section is longer. It can be more focused and only discuss key findings/outcomes in relation to existing literature without repeating the results already presented in the result section.

• Response: We agree with the reviewer but other reviewers are asking for detail findings. This keeps us on a confused position.

-        Discussion section should also be one coherent section presenting the discussion of key findings. No need to use sub-headings here. A new paragraph can be used to discuss each key result (copping strategies, HDDS, nutritional status of adults or children, food insecurity, etc.)

Response: The subheadings have been deleted as suggested.

-        Lines 377-391: What were the criteria for poor dietary diversity, or one that meets daily needs? Please define these in the methods section.  

Response: The criteria for poor dietary diversity have been included in the methods section.

 

Comments on the Quality of English Language

Generally understandable. However, the abstract the section and some part of the main text could be improved with proofreading and minor edits. 

Response: The manuscript has been revised by a professional English language editor.

Author Response File: Author Response.pdf

Reviewer 2 Report

Comments and Suggestions for Authors

Challenges – MS 3309576

Title: Nutritional Vulnerability of Internally Displaced Persons (IDPs): A Study of Food Access (Food Security) and Nutritional Status of IDPs in the Kumba Municipality

Feedback to Author(s):

This paper examines global food insecurity and its impact on internally displaced individuals and their children.  Using a cross-sectional design, the focus is on the unique challenges of food insecurity experienced by individuals and children classified as internally displaced individuals due to political instability.  This is an appropriate topic for the Challenges journal and very relevant given the global concerns over food insecurity.  The authors provide a great deal of necessary detailed data, but it could be organized to enhance overall clarity.  The findings are very well summarized and outlined below are suggestions for enhancing the overall clarity of the paper and the presentation of this important data.

Here are some comments to help enhance this important work:

1.        The author(s) state that food is “used as a weapon of war”.  Since this is relevant to the IDP sample, some additional detail and context to help readers understand this provocative statement would be important.

2.        The context provided by the Sustainable Development Goals is an important framing notion and should be moved to early in the introduction, provided in more detail, and used throughout the paper to help shape/frame the importance of the current research.

3.        The World Food Program Emergency project is referenced at the end of the introduction, but its connection to the current research and methodology is unclear.  Some additional detail here would be relevant.

4.        The authors use a descriptive cross-sectional community-based methodology, and some detail on the underlying results of this selection would enhance the methods section.  Link this choice of methodology back to the key research question within this section would also be helpful.

5.        The authors provide a detailed description of the data collection and procedures.  Some additional information about the interviewers and how they were selected and prepared to interact with this population would enhance clarity.

6.        The data management and analysis section is clearly written; however, some additional details on the scoring (created by current researchers or something else) would be important to provide in more detail here.

7.        The section on the coping strategies among IDPs describes that they were “divided into 4 sections”.  How was this decided?  Is this based on prior research, and if so, should it be cited in the section?

8.        The rationale for the recategorization of the food groups should be provided (Section 3.4) so that it is clear how this fits within the research question and overall methodology.

9.        There are several very long tables included that provide a challenge for the overall flow of the paper.  I suggest putting the key findings in summary tables and moving the more detailed tables into an Appendix section of the paper.  More narrative highlighting key findings in these tables would also be helpful.

10.   An expanded and labeled section on the limitations of the current research design should be added.

Author Response

We thank you very much for taking out time to review our manuscripts. Your comments are so pertinent has improved on our manuscript.

 

Title: Nutritional Vulnerability of Internally Displaced Persons (IDPs): A Study of Food Access (Food Security) and Nutritional Status of IDPs in the Kumba Municipality

Feedback to Author(s):

This paper examines global food insecurity and its impact on internally displaced individuals and their children.  Using a cross-sectional design, the focus is on the unique challenges of food insecurity experienced by individuals and children classified as internally displaced individuals due to political instability.  This is an appropriate topic for the Challenges journal and very relevant given the global concerns over food insecurity.  The authors provide a great deal of necessary detailed data, but it could be organized to enhance overall clarity.  The findings are very well summarized and outlined below are suggestions for enhancing the overall clarity of the paper and the presentation of this important data.

Here are some comments to help enhance this important work:

1. The author(s) state that food is “used as a weapon of war”.  Since this is relevant to the IDP sample, some additional detail and context to help readers understand this provocative statement would be important.

Respond: More relevant information has been added to support the phrase.

2. The context provided by the Sustainable Development Goals is an important framing notion and should be moved to early in the introduction, provided in more detail, and used throughout the paper to help shape/frame the importance of the current research.

 

Respond: the sentence has been moved to the introduction section and more details provided.

 

3. The World Food Program Emergency project is referenced at the end of the introduction, but its connection to the current research and methodology is unclear.  Some additional detail here would be relevant.

 

Respond: A description of the study design use for the World Food Program Emergency project has been added. It worth noting that the two studies use similar study designs.

 

4. The authors use a descriptive cross-sectional community-based methodology, and some detail on the underlying results of this selection would enhance the methods section.  Link this choice of methodology back to the key research question within this section would also be helpful.

 

Respond: The relevance of the descriptive cross-sectional community-based methodology has been added.

 

5. The authors provide a detailed description of the data collection and procedures.  Some additional information about the interviewers and how they were selected and prepared to interact with this population would enhance clarity.

 

Respond: The detailed description of the data collection and procedures.  Some additional information about the interviewers and how they were selected has been added.

 

6. The data management and analysis section is clearly written; however, some additional details on the scoring (created by current researchers or something else) would be important to provide in more detail here.

 

Respond: More information of the data management and analysis has been added.

 

7. The section on the coping strategies among IDPs describes that they were “divided into 4 sections”.  How was this decided?  Is this based on prior research, and if so, should it be cited in the section?

 

Respond: More information has been added on how the categorization of food security, CSI and DDS was done.

 

8. The rationale for the recategorization of the food groups should be provided (Section 3.4) so that it is clear how these fits within the research question and overall methodology.

 

Respond: More information has been added on how the re-categorization of food security, CSI and DDS was done.

 

9. There are several very long tables included that provide a challenge for the overall flow of the paper.  I suggest putting the key findings in summary tables and moving the more detailed tables into an Appendix section of the paper.  More narrative highlighting key findings in these tables would also be helpful.

 

Respond: We agree with the reviewer, but the journal required all tables to be inserted just below the descriptions or narratives.

 

10. An expanded and labeled section on the limitations of the current research design should be added.

 

Respond: More information has been added on the limitation of the current study design.

 

 

Author Response File: Author Response.pdf

Reviewer 3 Report

Comments and Suggestions for Authors

 

Comments to the Author
This randomized cross-sectional study investigated the determinants of food security among the internally displaced persons living and their children under five and the influence on their nutritional status. The findings reveal an extremely high prevalence of food insecurity, forcing households to adopt various coping strategies, primarily through dietary modifications. The paper is commendably written and organized. Findings in this research emphasize the urgent need for comprehensive interventions to address the root causes of food insecurity and ensure the health and well-being of IDPs in Kumba Municipality. However, in my opinion the paper has some shortcomings in regards to some methodology and data analysis. Specific comments follow.

Introduction:

Line 103-104: Please add: almost half (49%) of IDPs residing in the 103 South-West region of Cameroon were food insecure. 

 

Materials and Methods:

1.     Line 152: What id the definition of “Clinical signs of Anaemia"?

2.     Line 181-182: Please clear state the total scores of Household Food Insecurity Access Scale (HFIAS) and the cut-off point for four food security categories.

3.     Line 189: bivariate analyses were conducted using Pearson's chi-square test.

However, using Pearson Chi-square will over estimation of statistical significance for small data (One cell of the table has an expected count smaller than 5). In Table 5, Table 6. Using Pearson Chi-square test to test the significance between Food secure/food insecure, there are many cell smaller the 5.

4.     Please add how you measure the 14 coping strategies in the questionnaire, Are they yes/no questions of questions using likert scale?

5.     2.3. Data Management and Analysis : Please describe how you conduct the Multiple linear regression? Did you control any covariates in the equation?

 

Results:

1.     Line 223: Fig 1: need provide the Cut-off for 4 food security scale.

2.     Line 287: Same as Materials and Methods: Q3

3.     Line 288-296: Please correctly explain your Multiple linear regression model

a.        for every one percent?  increase in the monthly salary of caregiv-290 ers, there is an associated 0.18 percent decrease in food insecurity (β=-0.182, p=0.023). I think it should be 1 Standard deviation increase. Same as the description of monthly average money spent on food, family size among households, coping strategies used by households.

b.   Are all the variables in Table 7 in one regression model? The R² = 0.557 is

 after included all variables?

c.   In table7, the anthropometric data from BMI and below, most are not

significant in this regression model. Is that possible because you use “enter” in SPSS analysis and these variable enter later than other variables?

d.  Multicollinearity also might happen in your regression model. Too many

independent variables in the model and some variables are highly correlated

which can negatively affect model predictions on unseen data.

            e.  Can you try to grouping variables into different categories? Such as model 1:

social demographic varibles, model 2: nutrition diversities, model 3:

anthropometric variables, model 4: coping strategies, put each model into

equation at a time to estimate whether each category has independent effect

to food security?

4.     Line 298: Please add what are the abbreviation of CSI group and DDS Score 17 to the footnote

Discussion;

1.     Line 318-320: Make sure these explanations are correct!

2.     Line 356: What is WFP?

Author Response

We thank you very much for taking out time to review our manuscripts. Your comments are so pertinent has improved on our manuscript.

This randomized cross-sectional study investigated the determinants of food security among the internally displaced persons living and their children under five and the influence on their nutritional status. The findings reveal an extremely high prevalence of food insecurity, forcing households to adopt various coping strategies, primarily through dietary modifications. The paper is commendably written and organized. Findings in this research emphasize the urgent need for comprehensive interventions to address the root causes of food insecurity and ensure the health and well-being of IDPs in Kumba Municipality. However, in my opinion the paper has some shortcomings in regards to some methodology and data analysis. Specific comments follow.

Introduction:

Line 103-104: Please add: almost half (49%) of IDPs residing in the 103 South-West region of Cameroon were food insecure. 

Respond: The sentence has been rephrased.

 

Materials and Methods:

1. Line 152: What id the definition of “Clinical signs of Anaemia"?

 

Respond: The clinical signs of anaemia have been added as requested.

 

2. Line 181-182: Please clear state the total scores of Household Food Insecurity Access Scale (HFIAS) and the cut-off point for four food security categories.

 

Respond: The total scores of Household Food Insecurity Access Scale (HFIAS) and the cut-off point for four food security categories has been added as requested.

 

3. Line 189: bivariate analyses were conducted using Pearson's chi-square test.

However, using Pearson Chi-square will over estimation of statistical significance for small data (One cell of the table has an expected count smaller than 5). In Table 5, Table 6. Using Pearson Chi-square test to test the significance between Food secure/food insecure, there are many cell smaller the 5.

Respond: For cell smaller than 5, Fischer’s exact test was used.

3. Please add how you measure the 14 coping strategies in the questionnaire, Are they yes/no questions of questions using likert scale?

 

Respond: We have included more detailed explanation on how coping strategies were measured. No we did not use a Likert scale.

 

5. 2.3. Data Management and Analysis: Please describe how you conduct the Multiple linear regression? Did you control any covariates in the equation?

Respond: Yes, the data were checked for basic assumptions of regression analysis and multicollinearity

 Results:

1. Line 223: Fig 1: need provide the Cut-off for 4 food security scale.

Respond: Yes, the Cut-off for 4 food security scale has been provided.

2. Line 287: Same as Materials and Methods: Q3

Respond: The same has been stated in the materials and methods section,

3. Line 288-296: Please correctly explain your Multiple linear regression model
4. a. for every one percent?  increase in the monthly salary of caregiv-290 ers, there is an associated 0.18 percent decrease in food insecurity (β=-0.182, p=0.023). I think it should be 1 Standard deviation increase. Same as the description of monthly average money spent on food, family size among households, coping strategies used by households.

Respond: The multiple linear regression model has been re-analysed and correctly explained.

 

1. Are all the variables in Table 7 in one regression model? The R²= 0.557 is after included all variables?

Respond: No, each model has a corresponding R², thus three R² for the three models.

1. In table7, the anthropometric data from BMI and below, most are not significant in this regression model. Is that possible because you use “enter” in SPSS analysis and these variables enter later than other variables?

Respond: No, a separate model was created for these variables and the variables were still not significant.

1. Multicollinearity also might happen in your regression model. Too many independent variables in the model and some variables are highly correlated which can negatively affect model predictions on unseen data.

Respond:  The basic assumptions of regression analysis and multicollinearity of the data was checked before bivariate and multivariate analyses were done.

 

1. Can you try to grouping variables into different categories? Such as model 1: social demographic varibles, model 2: nutrition diversities, model 3: anthropometric variables, model 4: coping strategies, put each model into equation at a time to estimate whether each category has independent effect to food security?

Respond: The variables have been regrouped and analysis redone as requested.

4. Line 298: Please add what are the abbreviation of CSI group and DDS Score 17 to the footnote

Respond: The abbreviation of CSI group and DDS Score 17 has been added to the footnote.

Discussion;

1. Line 318-320: Make sure these explanations are correct!

Respond: The explanation has been corrected.

2. Line 356: What is WFP?

Respond: The full meaning of WFP has been added.

 

Author Response File: Author Response.pdf

Round 2

Reviewer 1 Report

Comments and Suggestions for Authors

Authors have attempted to address most of the concerns. I have the following minor comments as a follow up:

- Check these sentences in lines 28-32: Please replace with "Multiple linear regression estimates revealed that the monthly salary of caregivers and monthly average money spent on food, were associated with decrease in food insecurity. On the other hand, large family size among households and coping strategies used by households to lessen food insecurity were associated with increased food insecurity." 

- Lines 163-164: "A proportionate sampling method (each individual in the population has the same probability of being sampled) was used to select participants from the various selected quarters and purposive sampling used to select IDPs household." - Please double check your definition of proportionate sampling method/sampling proportional to size. the definition your provided sounds like one for simple random sampling. In sampling proportional to size, you first determine/define the subgroups (the seven streets); next, calculate each subgroup's proportion/percent contribution to the total study population. Then, determine the sample size required from each subgroup based on the determined proportion. Once you determine how many to sample from each subgroup, you can randomly select your samples from each street until the predetermined sample size from each street is accomplished. 

- Data collection tool (HFIAS) and classification criteria not adequately descripted. Authors just inserted number ranges such 0-1 or 2-7, etc. without first describing what those numbers refer to. Please describe the HFIAS works briefly. what does higher or lower point on the scale mean?    

Author Response

We thank you very much for taking out time to review our manuscripts. Your comments are so pertinent has improved on our manuscript.

Authors have attempted to address most of the concerns. I have the following minor comments as a follow up:

- Check these sentences in lines 28-32: Please replace with "Multiple linear regression estimates revealed that the monthly salary of caregivers and monthly average money spent on food, were associated with decrease in food insecurity. On the other hand, large family size among households and coping strategies used by households to lessen food insecurity were associated with increased food insecurity."

Response: The phrase has been revised as advised by the reviewer. 

- Lines 163-164: "A proportionate sampling method (each individual in the population has the same probability of being sampled) was used to select participants from the various selected quarters and purposive sampling used to select IDPs household." - Please double check your definition of proportionate sampling method/sampling proportional to size. the definition your provided sounds like one for simple random sampling. In sampling proportional to size, you first determine/define the subgroups (the seven streets); next, calculate each subgroup's proportion/percent contribution to the total study population. Then, determine the sample size required from each subgroup based on the determined proportion. Once you determine how many to sample from each subgroup, you can randomly select your samples from each street until the predetermined sample size from each street is accomplished. 

Response: The phrase has been revised as suggested by the reviewer. 

- Data collection tool (HFIAS) and classification criteria not adequately descripted. Authors just inserted number ranges such 0-1 or 2-7, etc. without first describing what those numbers refer to. Please describe the HFIAS works briefly. what does higher or lower point on the scale mean?    

Response: The phrase has been revised as suggested by the reviewer.

Author Response File: Author Response.docx

Reviewer 3 Report

Comments and Suggestions for Authors

Thank you to the authors for their detailed responses; they have made the article much clearer. However, there are still a few questions that I have and need clarification on:

 

Abstract:

Line 346-39, Also seen in Line: 544-547: “such as; the distribution food vouchers, cash transfers, and food banks, support home gardening and small-scale farming, and finally, provide education on meal rationing, meal planning, and family planning service” . These are not related to your finding, nor in your discussion.

 

14 coping strategies were included in the CSI section

1.        Where is this part of questionnaire come from? I didn’t see the reference in your Data Collection Tool and Procedures part. If the questionnaire is developed by the authors, please provide the validity and reliability test for this part of questionnaire.

2.        What is the rationale, just use average in Table 2 to Figure 2? I think this is inappropriate that you interpret the coping strategies in this way.

97.9% of the households used dietary changes, rationing strategies (52.2%), strategies to increase the short-term supply of food (34.1%)….. Dietary change only two coping strategies and average 97.9%, Rationing strategy, 3 coping strategies and average 52.2%. If I only use first 2 coping strategies the percentage will increase to (88.7+81.4)/2 = 85.1%. it is meaningless.

3.        How do you use “CSI group” in your regression? A continuous or categorical variable? What are the values?

 

Materials and Methods:

1.        Line 189: bivariate analyses were conducted using Pearson's chi-square test.

Respond: For cell smaller than 5, Fischer’s exact test was used. Add this to Data Management and Analysis part

You should add “For cell smaller than 5, Fischer’s exact test was used” in the foodnote in your Tables.

Multiple linear regression

1.          I still don’t understand your dependent variable “Food security”  Countinous value from 0-27? or elss?

2.          Line 334-338: Please make sure these explanations are correct! every one standard deviation increase in the monthly salary of caregivers, there is an associated 0.30 (30%??) percent decrease in food insecurity (β=-0.303, p<0.001), Also I don’t think using percent is correct!

3.          Line 339: “increase in the family size among households (β= -0.186,” In your Table 7: β= 0.186 it is positive not negative!

 

 

 

Author Response

We thank you very much for taking out time to review our manuscripts. Your comments are so pertinent has improved on our manuscript.

 

Abstract:

Line 346-39, Also seen in Line: 544-547: “such as; the distribution food vouchers, cash transfers, and food banks, support home gardening and small-scale farming, and finally, provide education on meal rationing, meal planning, and family planning service”. These are not related to your finding, nor in your discussion.

Response: Our findings revealed that the participants had low monthly income and money spent on food monthly, more than one-thirds were farmers, majority of household meals rationing strategies, and had large family sizes (> 5 persons) which necessitate the above listed measures as possible short-term and long-term solutions. However, we are conscious that not all list measures stem directly from the findings, the reason we did not list these measures in our original submitted manuscript but one of the reviewers insisted that we specify all the possible measures.

 

14 coping strategies were included in the CSI section

1. Where is this part of questionnaire come from? I didn’t see the reference in your Data Collection Tool and Procedures part. If the questionnaire is developed by the authors, please provide the validity and reliability test for this part of questionnaire.

 

Response: The reference has been phrase has been revised as suggested by the reviewer.

 

2. What is the rationale, just use average in Table 2 to Figure 2? I think this is inappropriate that you interpret the coping strategies in this way.

97.9% of the households used dietary changes, rationing strategies (52.2%), strategies to increase the short-term supply of food (34.1%)….. Dietary change only two coping strategies and average 97.9%, Rationing strategy, 3 coping strategies and average 52.2%. If I only use first 2 coping strategies the percentage will increase to (88.7+81.4)/2 = 85.1%. it is meaningless.

Response: Yes, we agree with the reviewer point of view and deleted figure 2.

 

2. How do you use “CSI group” in your regression? A continuous or categorical variable? What are the values?

 

Response: We use the continuous variables generated from “in the past 7 days, if there have been times when you did not have enough food or money to buy food, how many days has your household had to: (0-7) per coping strategy used. In our study, after summing the scores from all the used strategies, we had a CSI range from 0-39 per household. This is what we named “CSI group” and used in the regression analysis.

 

 

Materials and Methods:

1. Line 189: bivariate analyses were conducted using Pearson's chi-square test.

Respond: For cell smaller than 5, Fischer’s exact test was used. Add this to Data Management and Analysis part

Response: The phrase “for cell smaller than 5, Fischer’s exact test was used” has been added to data management and analysis. 

 

You should add “For cell smaller than 5, Fischer’s exact test was used” in the foodnote in your Tables.

Response: The phrase “for cell smaller than 5, Fischer’s exact test was used” has been added  in the footnotes.

 

Multiple linear regression

1. I still don’t understand your dependent variable “Food security” Continuous value from 0-27? or elss?

Response: Yes, we use the continues values from 0-27 for Multiple linear regression.

 

2. Line 334-338: Please make sure these explanations are correct! every one standard deviation increase in the monthly salary of caregivers, there is an associated 0.30 (30%??) percent decrease in food insecurity (β=-0.303, p<0.001), Also I don’t think using percent is correct!

 

Response: The explanation has been corrected.

3. Line 339: “increase in the family size among households (β= -0.186,” In your Table 7: β= 0.186 it is positive not negative!

 Response: It is positive, the figure has been revised.

Author Response File: Author Response.docx

Round 3

Reviewer 3 Report

Comments and Suggestions for Authors  

I am very satisfied with the author's reply and have no other issues.

       

Author Response

Comment 1: I am very satisfied with the author's reply and have no other issues.

Response 1: Thank you.

Author Response File: Author Response.docx