Title: Chronic Non-Communicable Disease burden among reproductive-age women in India:
evidence from recent demographic and health survey
Version: 2 Date: 03 Jul 2022
Reviewer's report:
This study used NFHS data, collected during 2019-2021 from India to assess chronic disease
profiles among 695,707 non-pregnant women of reproductive age along with the effects of
various attributing factors on multimorbidity. I believe, this research idea has potential for
maternal health and is related to chronic disease as well as multimorbidity followed by policy
implications. Though, there are some major concerns those are needed to be addressed before. I
believe the authors have the data to do so and, with substantial revision, this article could make
a useful contribution to the multimorbidity literature.
Abstract
1. Define multimorbidity
2. I think, instead of mean age for both groups and WHR, other important data related to this
study’s objective can be provided here. Provide important findings only which were previously
unknown.
3. Not all programs and policies are focused on the elderly population. NCDs like hypertension
and diabetes are screened from the age of 30 years and older. The authors need to change this
statement. It is my request to go through NHM websites and NPCDCS guidelines before writing
the policy implication part so that the gap can be recognized by the authors.
Keyword
I would like to suggest, “women of reproductive age” or such a similar word as a keyword.
Main Manuscript
1. Background
The overall flow of the background is not satisfactory yet. I suggest the authors revise the
language with proper English with no grammatical errors.
i. Line no. 18-22 says, NCD in the mother is a risk factor for the child. But in the next sentence,
that has been used as a risk factor for mothers. Please rectify this.
ii. Line no. 35: please use the correct citation style.
iii. Line no. 36: “Gender can be a significant confounding factor”. Did the authors take gender
into account as a confounding factor in the analysis? I think the dataset used here is completely
on women. So, sex is not a confounding factor for this study as this sentence is quite irrelevant.
iv. Line no: 41-42; 44-46; 61-62: seems incomplete or incorrect sentence.
v. Line no. 53: “In addition, women are more likely to report multimorbidity than men.” –
Provide a reference to this statement.
2. Methods
The method section also lacks clarity in many places. I request the authors to rewrite the methods
in a clear and crisp way. Some points have been given too much importance which was not
required and a few points were completely missing.
i. Line no. 80: “all the Indian states and…” – correct the word.
ii. Line No. 96-97: What about the participants aged below 18 years. How their consent was
taken?
iii. Outcome and predictor variables:
a. Clarity is required on how the independent variables were created.
b. Line no. 102: Which kind of heart diseases were self-reported? Was it termed as chronic heart
disease?
c. Line no 104: Is the word correct or it should be “diagnosis” instead of “diagnoses”?
d. Line no 105-106: Was it an average score or BP was measured just once per participant?
e. Line no 121: Authors need to clarify why “parity” and “menopause” was included as a socio-
demographic and economic factor?
f. Line no 130-131: Can authors please explain, how MCA-derived scores helped in categorizing
the type of diet, Healthy and Unhealthy? Also, the need for Cronbach's alpha ‘#’ is not clearly
mentioned.
g. Line no 137: It is not clear, high risk for what condition?
If for obesity, then did the author consider both WHR and BMI for obesity? If not considered
WHR for obesity, then why?
iv. Statistical analysis
a. Line no 144: Use “was used” instead of “has been used”. Always use the past tense.
b. Line no 144: Should this be “chronic disease score (CDS) burden” or “chronic disease
burden”?
c. Line no 147-150: The way the proportional odds model (POM), that the authors tried to explain
is not satisfactory. I request the authors to reframe the sentences.
d. Line no 148: “will be checked”; Did the authors not check? Use past tense only. This is not
a proposal.
e. Line no 151-152: the first sentence seems to be a part of the previous paragraph.
f. Line no 168-169: As NFHS 5 is a survey data, an explanation of how sampling weights were
used is required.
3. Results
i. The description before table 1 is not much of interest. It is requested just to write the novel and
important findings from the table 1. Also, the first table can be sent to the supplementary file.
ii. Figure 1: The group “heart disease”; is it Chronic Heart disease or includes acute ones (like
angina) also? Please correct the mentioned section.
iii. Figure 2: The title of the figure is not correct. It should be like, “Distribution of chronic
diseases”; not only Multimorbidity is explained in the figure.
iv. If the study population is women only, no need to mention “Among women”.
v. Line no 224: Did the authors check the distribution before calculating central tendency? If so,
mean should be presented with standard deviation.
vi. Line no 224-225 vs line no 399-400: Analysis seems not to be matching with Conclusion.
vii. Line no 229-231: If “exactly one morbidity” is written as just “one morbidity” or “one
chronic condition” would have been enough. The word “multi” in multimorbidity is explanatory
enough to express ‘>2 chronic conditions.
viii. Title of table 2: Are the contents of the table matching with the title provided here? What
is the "chronic disease score" here?
ix. Line no 265: If I’m correct, the study sample includes women aged 15 and above. How come
15 years women are considered as "midlife"?
x. Line no 269-271: The interpretation is not up to the mark. To be rewritten with appropriate
English and components to be explained.
xi. Line 286-288: The way authors have explained the odds of having multimorbidity is not
satisfactory. Though from line 266, it has been explained as an odds ratio, but in the Table 3,
it has been mentioned as an unadjusted relative risk ratio (URRR). Authors need to clarify or
rectify these issues.
xii. Table 3 & Table 4: Why “Diet” was not used in both, unadjusted and adjusted, regression
models?
xiii. Line no 295-297: These three lines (line no. 295-297) are just the copy of line no. 266-268
with minor alteration.
xiv. Line no 327-329: OR or RR is generally reported with 95% CI in the write-up also, which is
missing in the manuscript. Additionally, as this is a survey data analysis, a 95% CI for prevalence
needs to be calculated.
xv. Table 3 & Table 4:
a. Firstly, in the presence of 95% CI, the p-value does not have much of importance.
b. Secondly, if the p-value is calculated as 0.000, it is advised to write as <0.001. it’s a better
way of presentation
c. Maintain similarity in the number of digits after the decimal both in OR and 95% CI.
xvi. Which part of the result is referred to as disease profile (as mentioned in the objective)?
4. Discussion
i. Line no 336-338: Use “probably because” instead of “because” in the sentence. The exact
reason cannot be found directly.
ii. Line no 338-339: Dissimilarity in the presentation of the results: In the abstract, the mean age
for a single chronic condition was mentioned as 30 years.
iii. Other strengths can be added as:
a. Nationally representative samples
b. Robust sample size
iv. Line no 387-389: Authors have mentioned the same in limitations. So, I think, this statement
should be avoided, as cross-sectional studies are poor to establish temporal relationship/
causality.
v. Line no 391-392: Why do the authors think this is a limitation for this study. It doesn’t seem
that identifying the sequence of occurrence of eight chronic conditions was an objective for this
study.
5. Conclusion
i. Line no 399-400: Numbers different from abstract. (Can be addressed in 3. Results, l.)
Overall Comments:
1. I request the authors to rewrite the manuscript,
• concise the writeup,
• give importance to the study objectives and related variables only and
• remove unnecessary or irreverent lines and words.
2. Keep an eye on numbers.
3. Put less important tables and/or graphs in the supplementary file, if the authors think so.