Narratives of Risk: Parents and Community Perspectives on Food Insecurity, Alcohol Use and Sexual Risk Among Adolescent Girls in Underserved Communities

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

This is a study on an important problem with clear (though sadly unsurprising) findings. Data collection and findings are clearly described. However, some clarifications are needed, in particular for readers outside SA. This applies to the following concepts and terms:

• Caregivers. I first thought that this referred to formal carers (e.g. nurses, social workers), but I now understand that it refers to parents and possibly other people responsible for families, e.g. older sisters, aunts and so on. This should be clarified in the introduction.
• Community leaders. This is a somewhat vague term. It might be useful to provide some detail on what kind of people they are (e.g. are they teachers , doctors, religious leaders). 
• Underserved communities. In what ways are they underserved? 
• Transactional sex. It might be useful to make clear this refers to a sexual relationship in which sex is exchanged for material benefits like money, gifts, or services (if you agree with this definition). 

The following questions should also be answered:

• The two communities are deliberately kept anonymous, which is unusual in qualitative research (in contrast to anonymity of individuals). What is the motivation for this?
• While the role of insufficient financial resources is clear, only few of the quotes of participants refer to food insecurity specifically. "Having a good time" and "clothes" are mentioned more often. This part of the cascade might be discussed (and perhaps illustrated) more extensively.
• Who are the "older men"? This may be obvious to people in SA, but to me it is not clear whether they are youngsters aged 20-30 or men over 40. Also some other details might be useful. 
• Are these sexual relationships very transitory (e.g. one night) or do they sometimes involve longer-term relationships, as captured by the term "sugar daddy"?
• While stricter enforcement of the law about not selling alcohol to adolescents is mentioned as a possible remedy, there is no mention about the law prohibiting under-age sex. Why not?

Other points:

• In the title, it should be made clear that the article is about "adolescent girls", since the article is only about them.
• The last paragraph of the Discussion should be included in the Conclusion, or get a separate subheading like "Policy implications", which would give this valuable paragraph greater visibility. 

Author Response

Please see the attachment. 

Author Response File: Author Response.pdf

Reviewer 2 Report

Comments and Suggestions for Authors

Cascade of risk: Community and caregiver perspectives on adolescent food insecurity, alcohol use and sexual risk in underserved communities

Overall Assessment:
The manuscript addresses a highly relevant public health concern in South Africa — the intersection of food insecurity, underage alcohol use, and transactional sex among adolescent girls. The qualitative approach and inclusion of both caregiver and community leader perspectives are valuable, and the “cascade of risk” framing is compelling. The work is well-structured and policy-relevantI will give some suggestion you could explore to further strengthen the manuscript through deeper conceptual framing, enhanced methodological detail, and expanded critical discussion.

Suggestions to explore

1. Originality and Relevance

More explicitly position the “cascade of risk” concept in relation to existing theoretical frameworks in adolescent risk behaviour literature.

2. Methodology

Clarify how data saturation was determined.
Explain whether caregivers and community leaders were in mixed or separate focus groups, and how potential power dynamics were managed.
Describe socio-economic diversity within the “underserved” classification.

3. Results

Include more male participant perspectives where relevant and possible.
Shorten some lengthy quotations for readability.
Consider enhancing Figure 1 to better depict causal flows and feedback loops in the cascade of risk.

4. Discussion

Suggestions

Expand on limitations: social desirability bias, exclusion of adolescent voices in this sub-study, and restricted generalizability due to two-community sample.

The paper is strong and addresses an important issue.

Author Response

Please see the attachment.

Author Response File: Author Response.pdf

Reviewer 3 Report

Comments and Suggestions for Authors

Abstract

It is logical that there is a cumulation of risks, but the word "cascade" assummes causal effects (or a chain in causal effect). Even in a qualitative study how this should be justified, e.g., using ocrrelations between frequencies of certain words.

... participants who were caregivers of adolescents and community leaders. Who were the community leaders? For an international readership it is not understandable.

Introduction

line 26: The first sentence should be started with a general demographic situation before discussing the rate of adolescents.

Lines 32-33: This sentence needs a reference.

Line 34: Starting the secod paragraph about the heterogentiy of adolescents, we need to know more about the culture and ethnic variability of the population living here.

Line 51: Here agin we face with the word "community leaders" -  who they are???

In Introduction we read only about the need of study in underserved
communities. No definition is given about them. In addition, we knwo nothing concrete research results about South African adolescents while there are publications about them, see e.g., https://www.tandfonline.com/doi/full/10.1080/16070658.2019.1607481 https://journals.co.za/doi/pdf/10.10520/EJC-1d2af9cd6f https://link.springer.com/article/10.1186/s13011-018-0163-4 https://journals.co.za/doi/abs/10.4102/phcfm.v8i2.934 etc.

I also  recommend this paper: https://pmc.ncbi.nlm.nih.gov/articles/PMC9202454/

line 65: Aims of the study: not concrete and clear enough.

Methods: Clear.

Results: Again, as discussed earlier, quantitative analysis would be useful to justufy the cascade model. Without it, it remains a speculation.

Discussion:

Appropriate and logical.

Conclusion:

Unfinished. More concrete persepctive shoudl be given, e.g. about policy implications of the findings and/or mentioning successful program from other countries that may be followed.

 

 

Author Response

Please see the attachment.

Author Response File: Author Response.pdf

Round 2

Reviewer 3 Report

Comments and Suggestions for Authors

The authors did a great job in revising their papers, they responded all my requests. Still I am not sure about the English in some places, a stylistics checking of a native English speaks shoud be recommended.

Comments on the Quality of English Language

A stylistics checking of a native English speaks shoud be recommended. 

Author Response

Comment 1: The authors did a great job in revising their papers, they responded all my requests. Still I am not sure about the English in some places, a stylistics checking of a native English speaks should be recommended.

Response 1: Thank you so much for the positive response regarding the revisions. The manuscript has now been edited by a professional language editor. Attached is a copy of the Editor's letter. 

Author Response File: Author Response.pdf