Title: Prevalence and factors associated with underweight among 15–49-year-old women in
Sierra Leone: A secondary Data Analysis of Sierra Leone Demographic Health Survey of 2019.
Version: 1 Date: 03 Mar 2023
Reviewer's report:
Overall comment: Well done but consider the following
1. Title: Prevalence and factors associated with underweight among 15–49-year-old women in
Sierra Leone: A secondary Data Analysis of Sierra Leone Demographic Health Survey of 2019--
it is okay.
2. Abstract:
2.1. Method:
A multistage stratified sampling approach was used to select study participants, and data was
collected using validated questionnaires...Why being record review? Will check the detail in the
method section
Why being record review? Will check the detail in the method section
2.2. Results:
2. 1.1 Women who belonged to the 15–24-year age group (Adjusted Odds Ratio)
(AOR)=2.499,95%CI:2.394-2.596; p<0.001 were 2.5 times more likely to be underweight
compared to the 25–34-year age group.
15-24  is adolescent age group where marriage and birth are less likely but normal weight
could be more likely…25-34 age group marriage and birth more likely and…are they practically
comparable? Seems, the report focused on the statistical significance…please consider practical
significance as per the country context
Reporting like 2.50 (2.39, 2.60 ) is enough to prevent document congestion and attract readers
2.2.2. Women residing in the northern region AOR=0.734,95%CI:0.559-0.963; p=0.026 were
least likely to be underweight compared to the East
Being from northern region only may not practically  sound if not justified for action...
2.2.3. Women who did not listen to radios AOR=0.673,95%CI:0.673-0.826; p<0.001 were less
likely to be underweight compared to those who did..
Media information increases overall community awareness that may be true also for nutrition
awareness….is there other source of information that women can use other than radio? Needs
explanation in the discussion section
2.3. Conclusion:
2.3.1. The prevalence of underweight among women in the reproductive age in Sierra Leone is
low and the factor associated with underweight was age group (15-24 years).
How low is low? What is the standard to say low? Check it depending on global and local context
2.3.2. There is a need to address the socioeconomic determinants of underweight among women,
mainly due to poverty and other inequalities.
It seems your judgment without having evidence….why do you recommend about
socioeconomic status without reporting its finding here? Do you want to mean age group 15-24,
being from northern region etc are poor?
Recommendation should depend on the result report not because you know something about the
community that is not known by readers including  the reviewer…what we know is the current
report…the reason I suggested practical significance consideration….
Even data you are reporting was collected 4-5 years back and might not indicate current
status of the country unless explained as no change or….Better to be supported with current
information…sorry, I stand to be corrected as I am naïve about Sierra Leone and I would like
to inform the journal team to invite scholars from the same country for better comments.
3. Background:
3.1. Therefore, improving women's nutrition is one way of reducing under-nutrition in children
[10] and a strong pillar in global efforts to reduce maternal mortality [29].
Here, you need to justify why you are interested to use a bit old DSS data instead of focusing
on the current community status in terms of living standard…like 2019 to 2023 trends in terms
certain changes that can affect household wealth index and specifically women nutrition…it will
help readers to know about your country and come with appropriate comments.
In addition,  better to include  how could it help the policy makers, planners and implementers
as a justification.
4. Method:
4.1. Study setting:
As of July 2019, Sierra Leone had a population of 8.2 million people, ....
Do the DSS cover all or sampled one? If sampled, mentioned number of HH/population under
survey…then we can determine appropriateness of your sample size for the power..
In addition, issues of regions representation was not well described
4.2. Study sampling and participants:
The men's survey was conducted in one-half of the sampled households, and all men aged 15-59
years in the households were included
Why you need to report about men now being your study population is women?
The second paragraph is almost a page and please Please break into 2-3 paragraphs to make
life easy…
In addition, you merged sampling and data collection procedure…treat them separately
4.3. Analysis:
After that, we constructed a final model including individual characteristics adjusted for
household and community characteristics (wealth index)...
Better to report in the abstract section even if it is not associated as it is a major factor for
nutritional status of the household (HH); please show how you calculated it to reach HH wealth
index
4.4. Results
The sociodemographic and economic characteristics of women in reproductive age in Sierra
Leone (N=7,514) are presented in Table 1.
Population covered by DSS needs to be specified specifically that of reproductive age group
(15-49)
Prevalence of malnutrition: The total number of female populations in the 2019SLDHS was
15,574....
Were they RH age group or…? Your sample size seems 7,514, then why 15,574 that has to be
reported under study setting?
The report has to be based on your sample size not total population…please check and revise
Prevalence of malnutrition:
The minimum and maximum BMI measures were 14.5 and 99.8kg/m2, respectively
BMI 14.5 to 99.8…huge difference and needs to be reported <18.5, 18.5 to 25, then accordingly
depending on the WHO category for the LMIC then decide, underweight, normal, over weight,
obesity etc…where will you categorize BMI of 99.8 (outlier)…Is it weight or BMI?
please report frequency of such outlier findings and verify their being true report…
Figure 1 title has no 'when' part...and the same is true for tables
You reported under and normal weight; what about over weight and obesity because you reported
99 as BMI....???
If I were you, I would report more descriptive findings
The following was reported under table 1 as follow...
Table 1 shows that most Sierra Leone women of reproductive age were 20-29
years 2029/7514(33.6%), parity of up to four 3,892/7514(51.8%), rural residence
4422/7514(58.9%), male headed households 5356/7514(71.3%), household size of six and
above 4519/7514(60.1%), works 5234/7514(69.7%), married 4795/7514(63.8%), from the
south 1831/7514(24.4%), no formal education 3571/7514(47.5%); richer within the wealth
index  1634/7514(21.7%); do not watch Televisions 5625/7514(74.9%); do not listen to
radios 4372/7514(58.2%), do not read magazines 7025/7514(93.5%), do not smoke cigarettes
7290/7514(97.0%), and do not use alcohol 3081/3748(82.2%) what is the relevance of this
report? Seems footnote...
Why you didn’t include Household wealth index (HHWI) in the inferential statistics? What
criteria did you use to select IVs for MVA? No ground to exclude HH WI...needs explanation
5. Discussion:
To ensure optimum generalizability of our findings, we used a nationally representative data
from the Sierra Leone Demographic Health Survey of 2019 (19-SLDHS) [30].....
But you didn’t indicate how you treated to take care of representation in the planning phase
However, only age group of 15-24 years was significantly associated with being underweight
(Table 2).  I expect justification/argument in the discussion section and you need to argue its
practical significance...
Therefore, the observed difference in the prevalence of underweight among women of the
reproductive age (15-49 years) in the five countries mentioned above (Uganda, Kenya, Tanzania,
Nigeria, and Sierra Leone) is likely due to differences in characteristics of study participants,
such as the country of origin and their food security status.
Did you mention about food insecurity in your report/findings? Don’t compare with what you
didn’t do
Previous studies had shown that regions of residence were associated with under-nutrition in
similar low-income African settings....
What is the difference between under-weight and under-nutrition? Take for the consistency of
the terms used
A recent Sierra Leone report shows that nearly half a million children under five years suffer
from stunting, while 30,000 suffer from malnutrition and are at immediate risk of death due to
inadequate dietary intake and a high disease burden affecting them [67...
This is 2000 to 2019 report; then why said ‘recent’?
Experts argue that there are four primary factors contributing to Sierra Leone's overwhelming
poverty and these are government corruption, unestablished education system, absence of civil
right activities, and poor infrastructures [67]. It is reported that these four factors make poverty
challenging to beat in Sierra Leone, butthese authors argue that researchers should not overlook
the uniqueness of the characteristics of the population in northern Sierra Leone [67].
This is known common problems in LMIC especially Africa…we scholars should do something
instead of blaming others…research has to be evidence based and neutral…we have to use
diplomatic terms to persuade politicians on behalf of the society….
The cultures, the tribes, the dominant religious practices, marital arrangements, and social
dynamics of the population in the northern region of Sierra Leone are exclusive and in part
explains the unlikely chance of being underweight
Let me say few points from Africans scholars perspectives; we blame our community culture,
traditions, values and norms being affected by western culture, we blame the society who has
rich indigenous knowledge and skill…we are imposing them with the little knowledge we
got from developed country…had our education based on the indigenous resource, we could
change our society…please refrain from being judgmental about our society because your
explanation seems judgmental for me…sorry for being emotional and  I stand to be corrected
if misunderstand your report
Avoid figures from the discussion and focus on the interpretation, synthesis and evaluation of
the result.
Consider feasibility, homogeneity, affordability, relevance and other issues while comparing
and contrasting