Individual and Environmental Determinants of the Consumption of Iron-Rich Foods among Senegalese Adolescent Girls: A Behavioural Model

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

Abstract

-Enhance the description of environmental and individual factors: offer a more detailed description of what environmental and individual factors were considered. This can help in understanding the context within which the findings are applicable.
-Expand on practical implications: While practical implications are mentioned, expanding on what these might specifically entail could strengthen the abstract. Suggest potential applications of the findings in real-world settings, such as school-based nutrition programs or community health initiatives.

Introduction

-In the introduction of your article on adolescent dietary behaviors in Senegal, it is crucial to begin with a compelling hook that underscores the significance of the study. A striking statistic or fact about the impacts of dietary behaviors on public health in Senegal could serve as a powerful opening.

-Further elaboration on the specific gaps in the existing literature that your research aims to fill would solidify the necessity and relevance of your study. Clarifying these gaps helps position your study within the broader academic conversation, and explicitly stating the study's objectives here can also strengthen the introduction.

Methodology

-It is imperative to provide a clear and detailed description that assures the reader of the robustness and reliability of your study's approach. Firstly, a thorough explanation of the sampling method, including the criteria for participant selection and the rationale behind the chosen demographic, will enhance the credibility of your research. It is beneficial to mention any potential biases or limitations in the sampling process and how these were mitigated.

-Path Analysis: This was the core statistical method used to examine the relationships through which individual and environmental factors may influence the behavior of consuming IRF among the adolescent girls. The path analysis, conducted with MPlus software, helped to delineate the direct and indirect effects of the variables studied. This method is particularly suited to the complex models that include multiple variables and hypotheses about the relationships among them. While path analyses are a strong approach to understanding relationships between multiple variables, clarity in explaining how the model constructs were measured and validated is essential.

-Lastly, the description of how control variables were selected and handled during the analyses is also crucial. Information about the treatment of confounding variables, potential interactions, and the rationale for including certain variables and not others would strengthen the methodological section. The absence of this discussion might leave the reader questioning whether other influential factors were adequately considered.

-The sample size was calculated based on expected proportions, using a standard formula to ensure sufficient power to detect meaningful effects.

Results

-This section provides a comprehensive overview of the findings, but there are several areas where clarity and depth could be improved. Firstly, the presentation of the data could benefit from more detailed descriptions and interpretations of the statistical results. For instance, while the path analysis results are summarized, a more thorough explanation of the path coefficients, their significance levels, and the overall fit indices for the models would help in understanding the robustness and relevance of the findings.

Discussion
-It would be beneficial to include a discussion on the practical significance of the results, not just the statistical significance. Explaining what the findings mean in real-world terms, such as the actual impact of the identified factors on iron-rich food consumption among adolescents, would provide a clearer picture of the implications of the study.

Author Response

Thank you very much for your suggestions and comments. Please, kindly find below answers to each point that has been raised.

-Enhance the description of environmental and individual factors: offer a more detailed description of what environmental and individual factors were considered. This can help in understanding the context within which the findings are applicable.

Reply: A few examples of each were added to the abstract for readers to better understand the context of the findings.

-Expand on practical implications: While practical implications are mentioned, expanding on what these might specifically entail could strengthen the abstract. Suggest potential applications of the findings in real-world settings, such as school-based nutrition programs or community health initiatives.

- Reply: Excellent suggestion. Being mindful of the length of the abstract, we have added an example of real-world application of the results. Thank you.

Introduction

-In the introduction of your article on adolescent dietary behaviors in Senegal, it is crucial to begin with a compelling hook that underscores the significance of the study. A striking statistic or fact about the impacts of dietary behaviors on public health in Senegal could serve as a powerful opening.

- Reply: Thank you for this suggestion. The following paragraph has been added on page 2 of the revised manuscript: “Available literature shows that dietary intake does not seem to be optimal among adolescent girls living in Senegal, especially iron intake. Studies have revealed that between 55% and 80% of Senegalese adolescents had inadequate iron intake likely due to the limited consumption of iron-rich foods which has been estimated at about 60 g daily. Results from the Ndiaye et al.`s study have also shown that fish was the most commonly food eaten by adolescent girls followed by beef meat, chicken and eggs. The limited consumption of iron-rich food put girls at risk of iron deficiency anaemia which may have consequences on their cognitive ability, physical endurance and immunity. Given the high prevalence of anaemia among Senegalese adolescent girls, it is this imperative to address potential factors that could help at improving the consumption of iron-rich foods”.

-Further elaboration on the specific gaps in the existing literature that your research aims to fill would solidify the necessity and relevance of your study. Clarifying these gaps helps position your study within the broader academic conversation, and explicitly stating the study's objectives here can also strengthen the introduction.

- Reply: As stated in the introduction (paragraph 4 on page 2), there are no national studies that have been conducted in Senegal as well as elsewhere in Africa to assess environmental and individual potential determinants of the low consumption of iron-rich foods among adolescent girls although this situation is conducive to iron-deficiency anaemia.

Methodology

-It is imperative to provide a clear and detailed description that assures the reader of the robustness and reliability of your study's approach. Firstly, a thorough explanation of the sampling method, including the criteria for participant selection and the rationale behind the chosen demographic, will enhance the credibility of your research. It is beneficial to mention any potential biases or limitations in the sampling process and how these were mitigated.

- Reply: Thank you for this suggestion. In fact, part 1 of this paper which describes the methodology in details has been published previously in the Adolescents journal (reference #17). This has been specified in the first line of the first paragraph of the Design and sampling section. Information on the exclusion criteria for adolescent girls has also been added at the end of this paragraph.

-Path Analysis: This was the core statistical method used to examine the relationships through which individual and environmental factors may influence the behavior of consuming IRF among the adolescent girls. The path analysis, conducted with MPlus software, helped to delineate the direct and indirect effects of the variables studied. This method is particularly suited to the complex models that include multiple variables and hypotheses about the relationships among them. While path analyses are a strong approach to understanding relationships between multiple variables, clarity in explaining how the model constructs were measured and validated is essential.

- Reply: Details have been added to the analysis approach and the measurement of the variables. Most notably on the description of the models, the nature of the latent variables and the estimator approach, (page 4).

-Lastly, the description of how control variables were selected and handled during the analyses is also crucial. Information about the treatment of confounding variables, potential interactions, and the rationale for including certain variables and not others would strengthen the methodological section. The absence of this discussion might leave the reader questioning whether other influential factors were adequately considered.

- Reply: As stated in the first paragraph of page 6 of the manuscript, sociodemographic characteristics with significant differences (p < 0.01) between categories with regards to the consumption of IRF were considered in the path analysis at the same level than the environment as per the theoretical framework.

-The sample size was calculated based on expected proportions, using a standard formula to ensure sufficient power to detect meaningful effects.

- Reply: This is correct.

Results

-This section provides a comprehensive overview of the findings, but there are several areas where clarity and depth could be improved. Firstly, the presentation of the data could benefit from more detailed descriptions and interpretations of the statistical results. For instance, while the path analysis results are summarized, a more thorough explanation of the path coefficients, their significance levels, and the overall fit indices for the models would help in understanding the robustness and relevance of the findings.

- Reply: Descriptions and interpretation of statistical results are included in the discussion section, as each association is explained. Path coefficients, significance levels and overall fit indices are presented in Figure 3 and Table 2. However, a few more details have been added to the paragraph before Figure 3.

Discussion
-It would be beneficial to include a discussion on the practical significance of the results, not just the statistical significance. Explaining what the findings mean in real-world terms, such as the actual impact of the identified factors on iron-rich food consumption among adolescents, would provide a clearer picture of the implications of the study.

- Reply: Thank you for this suggestion. We have made a few additions on practical significant of the results in the discussion section on p.15.

 

Reviewer 2 Report

Comments and Suggestions for Authors

The presented manuscript to be published need in the body a lot of explanation/changes.

The aim is unclear. Is it iron rich food consumption among girls, or factors influencing girls food-habits/choices and was it evaluated “adolescent girls who had eaten any IRF the day or night before the study” (line 73)?

How data collection based only on the interview can be reliable, if some responders might want to hide uncomfortable (for them) data (e.g. regarding poverty or diseases). 

Why authors refer to the fact of adolescent girls who had eaten any IRF the day or night before the study? What it should confirmed, especially if 60% of girls (line 53) have an anemia and in your survey 84,7% ate IRF the day or night before the study. For 10-19 yo girls iron RDA is 15 mg. Eggs brings 1,2 mg/100g, beef 2,6 mg/100 g, lamb 1,9 mg/100g (products listed- line no.121), so to maintain health (no anemia) girls should have 1250 g of eggs every single day or 576 g of beef etc. Therefore, was there evaluation a portion size in the survey? Otherwise declaration of eating/not eating rich in iron food seeme to be useless.

In the survey : A score of 1 was assigned if she had eaten at least one of the aforementioned foods, and if none was ingested, a score of zero was given? Why this scale was used? The person might eat IRF whole week before and just the day before evaluation had a vegetarian/vegan meal. Moreover Muslims that were the biggest group in the survey, do not eat many of meat type, so are “excluded”.

What are figures 1, 2 and 3, what they present?

Surveys are too detailed (might be a supplementary data). Why they included information about a diseases that are just reported by participants (no medical confirmation) and anyhow influence iron rich food intake, especially if no blood analysis were conducted? The data about the factors influencing girl’s choices, should be given on the graph. Answers-made by the authors – no.7.1-7.4 (table 2) are all the same “The high price of IRF” or ”My parents/tutors do not give me enough money to buy IRF” means I do not have sufficient amount of money; “At home, we don’t cook IRF every day” or “At home, we don’t cook a sufficient quantity of IRF” should be explained WHY (we don’t like, we are vegetarian….). Given declaration do not give an explanation.

If authors will decide about the aim of the article and it would be an iron intake in food among girls, there should be much wider paragraph with typical type of food consumed in Senegal with pointing the rich in iron, supported with declaration how often is it consumed.

Technical

No location of the authors' universities provided. Tremendous number of shortcuts – it inable of reading because reader every time must go back to firs used and read explanation. 

Mistake of double numbering of literature.

 

Author Response

Thank you very much for comments and suggestions. Please, kindly find below answers to each point that you have raised.

The presented manuscript to be published need in the body a lot of explanation/changes.

The aim is unclear. Is it iron rich food consumption among girls, or factors influencing girls food-habits/choices and was it evaluated “adolescent girls who had eaten any IRF the day or night before the study” (line 73)?

- Reply: Thank you for the comment. As stated in the last paragraph of the introduction, the objective of the research was to identify pathways by which individual (attitude, subjective norm and the perceived behavioural control) and environmental factors may influence the consumption of iron-rich foods (IRF) among Senegalese adolescent girls. In other words, the behaviour of interest (the consumption of IRF) was effectively assessed by using the indicator recommended by the FAO (2021) which is commonly used in Demographic and Health Surveys to assess consumption of IRF among vulnerable groups of the population (ref #23).

How data collection based only on the interview can be reliable, if some responders might want to hide uncomfortable (for them) data (e.g. regarding poverty or diseases). 

- Reply: This form of data collection was to counter for possible literacy issues. Details have been added at the end of the data collection section.

Why authors refer to the fact of adolescent girls who had eaten any IRF the day or night before the study? What it should confirmed, especially if 60% of girls (line 53) have an anemia and in your survey 84,7% ate IRF the day or night before the study. For 10-19 yo girls iron RDA is 15 mg. Eggs brings 1,2 mg/100g, beef 2,6 mg/100 g, lamb 1,9 mg/100g (products listed- line no.121), so to maintain health (no anemia) girls should have 1250 g of eggs every single day or 576 g of beef etc. Therefore, was there evaluation a portion size in the survey? Otherwise declaration of eating/not eating rich in iron food seeme to be useless.

- Reply: Thank you for the comment. As stated previously, we aim to identify potential individual and environmental determinant of the consumption of IRF – and not to quantify iron intake neither the quantity of iron-rich foods- given that there were data available (ref #15) showing that iron intake was likely insufficient due to a limited consumption of IRF among Senegalese adolescent girls. Moreover, in the third and last paragraphs of the discussion section, we recognize the limitation of using the indicator on the declaration of girls about eating/not eating IRF although this indicator is commonly used in Demographic and Health Surveys to assess consumption of IRF among vulnerable groups of the population (ref #23).

In the survey : A score of 1 was assigned if she had eaten at least one of the aforementioned foods, and if none was ingested, a score of zero was given? Why this scale was used? The person might eat IRF whole week before and just the day before evaluation had a vegetarian/vegan meal. Moreover Muslims that were the biggest group in the survey, do not eat many of meat type, so are “excluded”.

- Reply: As per the FAO guidance (ref #21), we solicit a yes or no answers to questions related to the consumption of IRF. Given the dichotomous nature of the answer, we used the 0-1 scale. Moreover, the consumption of IRF (ref #23) was the behaviour of interest, as opposed to the consumption of all food sources of iron including plant sources. With regards the Muslims consumption of meat in Senegal, beef, lamb, chicken, liver, heart, other organs, fish and shellfish are commonly consumed (ref # 15).

What are figures 1, 2 and 3, what they present?

- Reply: Details have been added to describe the figures on page 4.

Surveys are too detailed (might be a supplementary data). Why they included information about a diseases that are just reported by participants (no medical confirmation) and anyhow influence iron rich food intake, especially if no blood analysis were conducted? The data about the factors influencing girl’s choices, should be given on the graph. Answers-made by the authors – no.7.1-7.4 (table 2) are all the same “The high price of IRF” or ”My parents/tutors do not give me enough money to buy IRF” means I do not have sufficient amount of money; “At home, we don’t cook IRF every day” or “At home, we don’t cook a sufficient quantity of IRF” should be explained WHY (we don’t like, we are vegetarian….). Given declaration do not give an explanation.

- Reply: Thank you for the comment but we would appreciate to have more details on which parts of the survey are too detailed. In any case, table 2 (on frequencies distribution) is now in a supplementary material given the length of the table. We would like to point out though that there are differences between formulations of the aforementioned items on the price of IRF. The high price of IRF can be perceived as a barrier to purchase IRF but having parents/tutors not giving enough money to buy them is different as IRF can be perceived as expensive by adolescent girls but parents can still provide them (if they have the means) with sufficient money to buy them. Similarly, the two items on cooking IRF at home are different: one may cook (or not) IRF every day but even though one cook them, quantities may not be sufficient to either, provide every member of the household with IRF first and second, or even if provided, the quantity might be small.

Unfortunately, we did not have enough resources to conduct biochemical and clinical tests to assess health and iron status of adolescent girls. However, we believe that their perception of adolescent girls of the current health status provides an acceptable overview of the health state of girls as self-perception of health have been associated with objective and subjective states of health, including physical, cognitive, social, emotional, and environmental aspects among children and adolescents (Bollen et al., 2021. https://doi.org/10.1016/j.ssresearch.2021.102538).

If authors will decide about the aim of the article and it would be an iron intake in food among girls, there should be much wider paragraph with typical type of food consumed in Senegal with pointing the rich in iron, supported with declaration how often is it consumed.

- Reply: Thank you for this suggestion. Some information was added in the first paragraph of page 2 of the manuscript.

Technical

No location of the authors' universities provided. Tremendous number of shortcuts – it inable of reading because reader every time must go back to firs used and read explanation. 

- Reply: This was to preserve anonymity. Shortcuts were used to lighten up the text and to avoid repetition.

Mistake of double numbering of literature.

- Reply: Thank you for this comment. This mistake has been addressed.

 

Reviewer 3 Report

Comments and Suggestions for Authors

Dear authors,

 

The manuscript addresses an important problem and uses an interesting framework, following are some recommendations to improve the work.

 

1. I think the behavioral model and intention framework could appear in the title, as for me it is the biggest highlight of the article.

 

2. Correct to cross-sectional in line 18

 

3. I think that only a validated questionnaire is sufficient. Perhaps a structured model would work better for this abstract.

 

4. Organize the introduction so that the issue of anemia appears first, then the studies on behavior and finally the research problem.

 

5. I believe that a flowchart of the development of the research would be interesting to better visualize the temporality of the study. Also add statistical analyzes into a subtopic.

 

6. Table two is too long, combine the mean and standard deviation to save time. I think table 3 is unnecessary, a sentence describing the consistency of the instrument is sufficient.

Comments on the Quality of English Language

Need revisions.

Author Response

Thank you very much for your comments and suggestions. Please, kindly find below answers to each point that you have raised.

The manuscript addresses an important problem and uses an interesting framework, following are some recommendations to improve the work.

1. I think the behavioral model and intention framework could appear in the title, as for me it is the biggest highlight of the article.

- Reply: Thank you very much for this insightful suggestion. The title has been modified to highlight this feature.

2. Correct to cross-sectional in line 18

- Reply: Oh yes! Thank you.

3. I think that only a validated questionnaire is sufficient. Perhaps a structured model would work better for this abstract.

- Reply: The abstract structure reflects the structure proposed by the journal.

4. Organize the introduction so that the issue of anemia appears first, then the studies on behavior and finally the research problem.

- Reply: Thank you for this suggestion. The introduction has been reviewed accordingly.

5. I believe that a flowchart of the development of the research would be interesting to better visualize the temporality of the study. Also add statistical analyzes into a subtopic.

- Reply: Thank you very much for this suggestion. A flow chart has been developed and inserted as a Supplementary material 1.

6. Table two is too long, combine the mean and standard deviation to save time. I think table 3 is unnecessary, a sentence describing the consistency of the instrument is sufficient.

- Reply: Thank you for this suggestion. The mean and standard deviation have been combined in the same column. Moreover, this table now constitutes the Supplementary material 2 of the manuscript.

 

Comments on the Quality of English Language

Need revisions.

- Reply: We have done a new read-through and have corrected a few mistakes that we have found.

 

Reviewer 4 Report

Comments and Suggestions for Authors

The problem of the level of intake of selected minerals, including. iron is an extremely important issue related to proper nutrition, especially for young women. Therefore, undertaking the research presented here is certainly important for general knowledge related to population feeding policy.

 

I think the work has been very carefully prepared. However, I have some questions, some ambiguities.

 

Firstly, was the study authorised by the relevant Ethics Committee for research involving human subjects?

 

The issues surrounding the selection of participants in the study are not entirely clear to me. If we are looking at 14 regions, then under 600 participants is surely a representative sample? Were there any exclusion criteria? The research methodology should be described in more detail. The discussion of the results and the summary could also be improved.

Author Response

Thank you very much for your comments and suggestions. Please, kindly find below answers to each point that you have raised.

The problem of the level of intake of selected minerals, including. iron is an extremely important issue related to proper nutrition, especially for young women. Therefore, undertaking the research presented here is certainly important for general knowledge related to population feeding policy.

- Reply: Thank you.

I think the work has been very carefully prepared. However, I have some questions, some ambiguities.

- Reply: We have added many details concerning the methodology and the interpretation of results.

Firstly, was the study authorised by the relevant Ethics Committee for research involving human subjects?

- Reply: Absolutely. The section on Ethics Committee approval has been provided as a separate section as per the journal guidelines

The issues surrounding the selection of participants in the study are not entirely clear to me. If we are looking at 14 regions, then under 600 participants is surely a representative sample? Were there any exclusion criteria? The research methodology should be described in more detail. The discussion of the results and the summary could also be improved.

- Reply: Thank you for the suggestion. The exclusion criteria have been added at the end of the first paragraph of the methodology section on p. 3. Moreover, in the same paragraph (first line), we have further specified that this manuscript is part 2 of a first paper (ref # 17) that has been published earlier this year and which provide more details on the research methodology. A flow chart has also been added to help readers to visualize the research process (Supplementary material 1).

We have done a new read-through and have corrected a few mistakes that we have found.

Round 2

Reviewer 2 Report

Comments and Suggestions for Authors

The manuscript has been corrected and the authors have addressed the issues raised in the review. However, I still do not see the justification for providing the survey outline (detailed) in the manuscript. 

Author Response

Comment:

The manuscript has been corrected and the authors have addressed the issues raised in the review. However, I still do not see the justification for providing the survey outline (detailed) in the manuscript. 

Response:

« In fact, we do not fully understand what is meant with this comment. If the comment refers to the number of details provided from our questionnaire in the article, we thought this to be necessary for the reader to get a better understanding of the constructs used in the behavioral model. If this is not what was intended with this comment, please refer to the specific section in the article (page, paragraph, line numbers if provided), and we will address it. Thank you! »