Title: Geospatial inequalities in women’s malnutrition in Pakistan
Version: 1 Date: 05 Mar 2024
Reviewer's report:
Overall
• This is a necessary report and an update on the geospatial correlates of maternal malnutrition
in Pakistan. I commend the authors for this undertaking.
• While this is a necessary paper, it requires clear research questions, a better theoretical
framework to define:
[a] why the specific analysis method was used (that is not to say it’s inappropriate, it just needs
to align with theory and research questions)
[b] why the independent variables were picked – the socioeconomic determinants of health are
a hot topic and this study corroborates it, but the reasons for picking the variables used in this
analysis need better explanation and elaboration in a theoretical framework.
Background
• Overall, this section is well-written and provides a good context for the analysis.
• The authors mention “magnitude of malnutrition”, which may require rephrasing. Is this a
reference to prevalence of malnutrition? Is this prevalence covering both lack of sufficient
nutrition (not having enough to eat, leading to underweight) and lack of proper nutrition (having
the “right” things to eat)? Even though the term “malnutrition” is used relatively frequently,
it might serve the paper well to go into the definition of malnutrition within the first two
paragraphs.
• The authors do a good job of setting the Pakistani context of malnutrition. Iron-deficient anemia
is a significant problem for maternal and child health. Having made that important point about
an effect of malnutrition, it would help to look at further aspects of malnutrition instead of the
sole focus on IDA, especially since the paper is not looking at anemia as an outcome.
• It might also help to set the context somewhat of the variables that are later included
in the analysis model. Socioeconomic determinants of malnutrition are important, and need
addressing in the background. The authors mention LMICs, but the variables they use need
more justification for selection. This is especially important if those variables are going to
be interpreted as part of the final model. To this end, it is important to present a theoretical
framework for the analysis, a proposal of how these independent variables are linked to the
outcome, and what is the theory behind their connection.
• What is the research question?
Methods
• In reporting descriptive frequencies, were DHS weights used? Was the complex sampling
design accounted for in the analysis? This needs to be mentioned in the “Sample and Data”
section.
• The use and justification for socio-economic variables, especially their significance to SDGs
needs elaboration in the Background section. The link between these variables and malnutrition
also needs to be elaborated in the Background, so that when they are mentioned in Methods their
selection for the analysis is a matter of course.
• How is “urban” vs “rural” defined?
• The analysis is appropriate in retrospect, but how would a research question (there could
be more than one) and the theoretical framework (or some guiding theory) justify the type of
analysis chosen? How do they justify the variables chosen?
• The authors may have mistakenly missed saying who developed and distributed the R package,
which is alright and may be rectified by just citing the package.
Results and Discussion
• The first important thing to mention in the results is the prevalence of malnutrition in the study
sample. The N(%) for the various BMI cut-offs also need to be presented at the top of Table 2.
• These are fascinating results!
• Going back to my point under “Background”, the independent variables have been interpreted
here, but the authors need to present a better picture or theoretical framework so that
the interpretations make sense. Why is having an unimproved toilet associated with being
overweight/obese? What is the link between information consumption and malnutrition? What
is the theory behind this?
• Minor correction: The description of the figures needs to match the figures themselves – the
description currently states “left” and “right”, while the figure has these as “top” and “bottom”.
• Which research question is being answered by Figure 2? This is not so clear in the paper,
even though this is talked about further in the Discussion section. This is also not laid out in
the Background.
• Since there can be a high degree of variation in outcome between and within geographic
locations, it is ideal to have the highest resolution in terms of geography as possible. Does the
data allow for the analysis to present spatial effects at the district level? Currently, the results in
figure 1 seem to take the provinces as monolithic, and not accounting for the variation that could
exist between districts with higher population density or urban economies (Karachi, Lahore,
Multan, etc) and rural/agrarian ones (Tharparkar, Thatta, Bahawalpur, etc). If it is possible to
present results at the district level, it would be much more useful.
• Elaborate more on the "so what" - what specifically can policymakers take from this paper to
help mitigate malnutrition in Pakistan? What would a targeted intervention look like?