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  • Klaus Kraemer1,
  • Kalpana Beesabathuni1 and
  • Sufia Askari1
  • et al.

Reviewer 1: Anonymous Reviewer 2: Muhammad Bilal Sadiq Reviewer 3: Anonymous

Round 1

Reviewer 1 Report

Thank you for the opportunity to review the manuscript titled “Knowledge, Attitudes, and Practices of Pregnant Women and Healthcare Providers in Bangladesh towards Multivitamin Supplements During Pregnancy”.

I reviewed this work to determine suitability for publication based on a combination of factors, including whether the topic is well suited to the aims and scope of the journal/special issue, methodological considerations, and whether the findings make a sufficient contribution to the existing literature. Unfortunately, I believe the manuscript does not meet these requirements.

The work is primarily descriptive and does not seem to provide a solid base for designing or implementing interventions for improved child health.

Author Response

Thank you for your feedback. We have revised the work, adding more analysis as well as possible recommendations. In addition, we have addressed the rest of the comments hoping to make the manuscript more compelling:

 

  1. We have revised the abstract to add more statistics (Page 1; lines 23 -42)
  2. In the Introduction segment, we have added more context to help underscore the purpose of the manuscript (Page 2; lines 61-66 and 74-81)
  • Under Materials and Methods, we have detailed the methodology and approach, which we failed to do before (Pages 3 and 4; lines 124-139 and 150-155; as well as Page 5; lines 165-188; and lastly, Page 6, lines 228-235)
  1. In the Discussion segment, we have tried to make the segment more robust and added structure to it as well (Pages 10-12; lines 344-438)
  2. We have also made changes to the Limitations’ segment (Page 15, lines 549-555)

Author Response File: Author Response.docx

Reviewer 2 Report

Abstract: Please provide the method and sampling details. And support the findings with numerical result terms rather than general statements.

Introduction: What are the general requirements for each target age groups globally and what are the lacking factors to achieve those levels should be highlighted from valid data base.

Materials and methods:

If it was cross sectional study, how the target population and an appropriate sample size was calculated??

As mentioned, it was based on convenient sampling technique, please remove cross sectional study and add appropriate sample distribution i.e., total number and number from each region. 

The study design is not clear, how many pregnant females were selected??

Please provide survey details, questionnaire details its sections, total questions. Was the questionnaire was pretested?? 

Which model was used for data analysis etc??

The questionnaire is relative very simple and there must be a pretest of the survey before bringing it to the survey scale. 

Table 2, what is supplement 1, 2, 3 and 4???

 

Table 3 questions are not realistic, in laws not willing, reluctant to buy?? on which backgrounds this information was incorporated as a question in the survey??

What is relation between the participants as health professional and pregnant females?? any correlation?

Discussion is negligible and no in-depth analysis was carried out. 

Please provide the approval of the study from Institutional Ethical committee and how consent was taken from participants. 

Author Response

  1. Abstract: Please provide the method and sampling details. And support the findings with numerical result terms rather than general statements.

This has been addressed. We have added details pertaining to the methodology, the sampling and have added more numerical result terms. (Pages 3 and 4; lines 124-139-146; lines 150-155 as well as Page 5; lines 214-221)

  1. Introduction: What are the general requirements for each target age groups globally and what are the lacking factors to achieve those levels should be highlighted from valid data base.

Thank you for your perspective on this. The MMS is tablet is formulated as per the dietary requirements for pregnant women. It is developed by the United Nations Children’s Fund (UNICEF), United Nations University, and the World Health Organization (WHO). We have added the recommended amount for each of the MMS ingredients. The National Academies of Sciences, Engineering, and Medicine also provides recommended dietary allowances (RDA) for micronutrients and vitamins during pregnancy. These largely overlap with the recommendations by WHO. (Added in Page 2, lines 61-66)

In terms of the reasons/lacking factors for the micronutrient deficiency, these reasons are already in the paper in lines – 74-94.

  1. Materials and methods: If it was cross sectional study, how the target population and an appropriate sample size was calculated??

We have now removed ‘cross sectional’ wording. This has been revised to explain the same better. Under Materials and Methods, we have detailed the methodology and approach, which we failed to do before (Pages 3 and 4; lines 124-139; lines 150-155 as well as Page 5; lines 165-188; Page 6, lines 228-235)

  1. As mentioned, it was based on convenient sampling technique, please remove cross sectional study and add appropriate sample distribution i.e., total number and number from each region. 

Thank you for pointing this out. We have removed the term ‘cross sectional’ study and have added whatever details we did have. (Page 4, lines 150-155)

  1. The study design is not clear, how many pregnant females were selected??

We have tried to make this clearer in the text on page 4, lines 150-155. This is to add to what was already mentioned in lines 156-163 and Table 1 has also been added for some clarity.

  1. Please provide survey details, questionnaire details its sections, total questions. Was the questionnaire was pretested?? 

We have tried to provide as much detail as possible here on Page 5, lines 165-188. Two surveys were developed, one for the mothers and another for the providers. The questionnaires were pretested with 20 consumers and 15 providers . Two days of training were also conducted to ensure that the data colelctors knew how to administer the survey. Post the pre-testing and training, the questionnaires were tested with some preliminary respondents as well to check for ease of comprehension, time taken. Minor modifications were recommended to improve the quality of data and changes made.

Each questionnaire comprised of a screener questionnaire in the beginning.

The consumer questionnaire was made up of 43 questions spread across 4 sections:

  • Knowledge and Awareness section – 9 questions
  • Attitudes section – 11 questions
  • Practices section – 12 questions
  • Demographics – 11 questions

The provider questionnaire was made up of 36 questions spread across 3 sections:

  • Knowledge and Awareness section – 25 questions
  • Attitudes section – 5 questions
  • Practices section – 6 questions
  1. Which model was used for data analysis etc?? –

A KAP MODEL. We have explained the model in the revised paper. (Page 3, lines 124-134)

  1. The questionnaire is relative very simple and there must be a pretest of the survey before bringing it to the survey scale. 

Thank you for the comment. We have now added in details in Page 4, lines 165-181)

  1. Table 2, what is supplement 1, 2, 3 and 4???

 

  1. Table 3 questions are not realistic, in laws not willing, reluctant to buy?? on which backgrounds this information was incorporated as a question in the survey??

Thank you for this comment. The surveys were developed in several stages. First, a review of the literature was conducted as well as stakeholders engaged with to help understand some of the possible social and cultural barriers, as well as some of the physical barriers. Based on this, the surveys were drafted, and then pre-tested for cultural and contextual relevance. Details of this have now been added to the paper page 5, lines 165-187)

  1. What is relation between the participants as health professional and pregnant females?? any correlation?

Apologies, we are not very clear what this comment means.

To clarify, we interviewed pregnant women in the target locations – some were current users of prenatal supplements and others were pregnant women who were aware that prenatal supplements exist, but were not using them. As for the Providers, we went to SMC’s network of pharmacists and practising obstetricians and gynaecologists. These are medical professionals who have had at least 5 years of experience in prescribing prenatal supplements to pregnant women in Bangladesh.

No correlation has been recorded.

In case this does not clarify your comment, please do let us know what you meant to ask and we shall gladly provide an explanation.

  1. Discussion is negligible and no in-depth analysis was carried out. 

We have revised the discussion (Pages 10-12; lines 344-438). We have also added some recommendations. We hope the revisions make for a better manuscript this time.

  1. Please provide the approval of the study from Institutional Ethical committee and how consent was taken from participants. 

This has been shared with the journal today.

 

 

Author Response File: Author Response.docx

Reviewer 3 Report

 

This is a study that aims to detail the findings of two Knowledge, Attitudes, and Practices (KAP) in Bangladesh.

My comments:

1.      I suggest to the authors improve the quantitative information in the abstract, such as the sample details, % of the use of supplementation, and the main barriers to women consuming pregnancy supplements.

2.      It would be interesting to know about public health policies regarding supplementation in pregnant women in Bangladesh in the introduction section. Are there any health policies? Do women diagnosed with anemia receive any health treatment from the government?

3.      Do the author have the prevalence data of anemia in the pregnant women group who take prenatal multivitamin supplements and the group who don’t take them? It would be interesting data to discuss.

4.      Considering Table 3, I suggest informing in Table 1 of the percentage of pregnant women who live with their husband or the child’s father. It is well described in the literature the influence of the husband on women’s lives and decisions. It also should be better discussed in the discussion section. (lines 295-299)

5.      In line 320 “the belief that supplements can be substituted by a nutritious diet”, do the authors evaluate any particularity of the diet that aims to prevent micronutritional deficiency? Is there any study that corroborates this hypothesis? I suggest better discussing this issue.  

6.      I suggest including the strengths and limitations of the study considering the cross-sectional design and convenience sampling.

Author Response

  1. I suggest to the authors improve the quantitative information in the abstract, such as the sample details, % of the use of supplementation, and the main barriers to women consuming pregnancy supplements.

Thank you for your feedback, we have revised this to the best of our abilities. We have added details and more numerical results in the abstract that we hope bolsters the purpose of the manuscript. Please refer to Page 1, lines 23-42.

 

  1. It would be interesting to know about public health policies regarding supplementation in pregnant women in Bangladesh in the introduction section. Are there any health policies? Do women diagnosed with anemia receive any health treatment from the government?

 

Thank you for this suggestion. We had referenced the ‘National Strategy on Prevention and Control of Micronutrient Deficiencies’ originally but have now explicitly mentioned it. The government does free iron-folic acid nationwide but to women of reproductive age (WRA) and not women with anaemia specifically. This is now referenced on Page 2, lines 74-81

 

  1. Do the author have the prevalence data of anemia in the pregnant women group who take prenatal multivitamin supplements and the group who don’t take them? It would be interesting data to discuss.

 

Thank you for sharing this recommendation, and we agree, this would have been interesting but sadly, it was not the focus of our study.

 

  1. Considering Table 3, I suggest informing in Table 1 of the percentage of pregnant women who live with their husband or the child’s father. It is well described in the literature the influence of the husband on women’s lives and decisions. It also should be better discussed in the discussion section. (lines 295-299)

 

All pregnant women in this study lived with their husbands.

We have added more on the father and family’s role in the Discussion segment, on Page 12, lines 425-438

 

 

  1. In line 320 “the belief that supplements can be substituted by a nutritious diet”, do the authors evaluate any particularity of the diet that aims to prevent micronutritional deficiency? Is there any study that corroborates this hypothesis? I suggest better discussing this issue.  

 

Thank you, great question. We have added a line and a reference to a study supporting that there is the gap between knowledge and practices of a nutritious diet, which is a barrier to taking MMS. We hope it adds to the case we are making. You can find this on Page 11, lines 391-403

 

  1. I suggest including the strengths and limitations of the study considering the cross-sectional design and convenience sampling.

 

Thank you, we have added this in page 15, lines 549-555.

Author Response File: Author Response.docx

Round 2

Reviewer 2 Report

The manuscript is revised as advised; however the experimental design is not very extensive or conclusive. 

Author Response

Dear Reviewer,

Thank you for your feedback. In view of this, we have added another limitation to show that we are aware that this is not the most ideal study for us to be able to generalise our findings. (Page 15, lines 556-560)

That said, since this is the first time an MMS product is due for launch and we had to study consumer (not beneficiary) and provider dispositions towards existing prenatal supplements (the only adjacency) we feel that using the KAP model really did help us identify what we could leverage and what we could dial up with the aim of creating demand for a novel product such as UNIMMAP formulated MMS. This was explained on Page 3, lines 124-132.

We sincerely hope you can understand how this study has been a landmark one for us and why we hope this makes some way for other studies where organisations and governments would opt for a market-based approach to introduce life-changing innovations. 

Best regards,

Puja

Reviewer 3 Report

The authors improved the manuscript according to suggestions and I recommend the acceptance.

Author Response

Dear Reviewer,

 

Thank you so much for your approval.

We remain forever grateful.

 

Regards,

Puja