SysRev of Peer-led vs Obesity in Children Ngoc-Minh Nguyen, USyd 2018
Page 187 of 191 Authors’ response to reviewers
Manuscript title: Perceptions and practices related to obesity in adolescent students and
their programmatic implications: Qualitative evidence from Ho Chi Minh City, Vietnam.
Manuscript ID: MACI-D-16-00792R1
Dear Editor,
We would like to thank the reviewers for their constructive comments that helped us improve the manuscript. Below we have addressed the comments point by point. We have also revised the manuscript based on the comments and highlighted the relevant changes.
Reviewer 2
We thank this reviewer for identifying some potential limitations of our study and
suggesting us to address questions as limitations and potentially incorporate them into recommendations in the manuscript. In general, we have modified the limitation
paragraphs of the discussion section (page 19) and the ‘Conclusion and
recommendations’ section (page 20-21) in the revised version of the manuscript. Below, we have addressed the reviewer’s comments point by point.
1. Sample size is quite small, and codes were developed based on only 3 interviews.
Stratified analysis of a larger sample would have been helpful, especially allowing for separate consideration by gender and age subgroups (and perhaps BMI or obesity status).
Sample size: We thank the reviewer for this feedback. We consider the sample size of this qualitative exploratory study adequate. Since our aim is not to provide results in a statistical form, this qualitative study does not require a large sample size. Our aim is to identify a range of key issues that have potential influence for an intervention designed to reduce risk of obesity in adolescent school children. We included varies types of respondents who would have roles in such an intervention such as, students, their physical education teachers, parents and education department official in our sample population. We are confident, the various types of respondents including direct and proximal target populations provided us data to achieve our objective. Moreover, the total number of respondents included in the study is not small for our qualitative
explorative study comparing with many other published qualitative studies on the similar topic. We agree that stratified analysis of a larger sample would be helpful for a
quantitative analysis, but our study adopts a focused qualitative explorative approach. We addressed these issues in the paragraphs on potential limitation in pages 19-20 in the revised manuscript.
Coding: A draft code list was developed based on the three translated interviews independently by the senior author (Alam) and the first author (Nguyen). These two authors discussed the draft code list and developed a revised code list which was open
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to add new codes. Nguyen then continued reading each of the remaining transcripts in Vietnamese and added the new codes that emerged from the transcripts. The final code list was developed after all transcripts were read and coded. Thus, the codes developed from the three translated interviews was a draft list that was finalised based on all
interviews included in the analysis. We have described the coding process on page 6 of the paper, and noted the possible limitations regarding coding process in the limitation section of the revised manuscript in pages 19-20.
2. What limitations are imposed by restriction to a middle class population and students
in Ho Chi Minh City?
There is potential limitation of studying the students from middle class population residing in Ho Chi Minh City in regard to generalizability of findings. Given the scope of this qualitative explorative study aiming to generate knowledge to inform the design of an intervention targeting the same population, we do not consider it a major limitation of this study. However, we have addressed this issue as a potential limitation when we described the limitations of the study in pages 19-20 in the revised manuscript. 3. Is obesity truly a risk factor or more likely a risk marker?
We thank the review for raising this interesting question. While obesity is widely regarded as a risk marker, it can also be considered an independent risk factor as studies have accumulated evidence of obesity as a precursor of non-communicable health problems such as diabetes and cardiovascular diseases as reported by
Mandviwala and colleagues in a recent systematic review.1
4. To what extent are the intended interventions primary prevention as opposed to
secondary or tertiary prevention and treatment? Is middle school/junior high school too late for primary prevention?
Many high-income countries have implemented interventions to tackle obesity many years ago. Unfortunately, the situation in Vietnam is different where obesity prevention program is still a new area. The junior high schools are a good field of intervention because it would be an age where students can actually start to build up their healthy life style. Primary school students and younger children might be over-protected by the parents because of their too young age and thus attempts to intervene might fail. However, we agree to the reviewer that the intended intervention will be secondary or tertiary in nature. This could be a potential limitation of the intended intervention, not this study and the paper as the current study was designed and conducted to inform the design of the proposed intervention.
5. Literature on “addiction” to electronic devices and Internet activity should be
considered.
We agree that excessive use of electronic devices and large amount of time spent on the Internet by the adolescent students are crucial aspects hindering healthy life style
1Mandviwala T, Khalid U & Deswal A. (2016). Obesity and cardiovascular disease: a risk factor or a risk marker?
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that should be considered in the desired intervention. Our interviews also revealed sitting time and time spent on screens as an aspect of the students’ current behaviour that we descried in pages 15 and 19. We have also cited a relevant literature (Ref # 38).
6. In addition to academic burden of after-school classes and pressure for high
performance, are family responsibilities important (perhaps more so for girls)?
Family responsibilities are important for girls than boys in Ho Chi Minh City in general. A few girl students mentioned about it spontaneously during the interview. However, our data do not support the issue of family responsibility as a significant issue that has an impact on healthy life style, probably because of our focus on urban middle class and younger age population in the study. Moreover, family responsibilities would also include household chores that might have a role in reducing obesity by increasing physical activity.
7. Did any respondents discuss body image, shaming about obesity, or other social
pressures? Is it possible that overweight is a sign of affluence and not stigmatized? Might this have different significance for males and females?
We presented data on body image as many participants perceived obesity as just “looking fat.” However, no body shaming was reported. One girl felt unhappy with her body, but did not mentioned about the shaming clues from anyone. Overweight as a perceived sign of affluence was not vividly evident in our data, although we think general people might draw an association between wealth and obesity.
8. What about restrictions on exercise due to air pollution, traffic, and other
environmental factors near school and home?
We thank the reviewer for this insight. Air pollution and congested road traffic, and social environment issues such as robbery limit physical exercise opportunity outside home for young children in Ho Chi Minh City. We will consider these issues in the intended intervention.
9. The example of Thailand would be a useful case study -- national effort to curb the
growth of obesity due to consumption of extra snacks and meals (especially for middle class, and especially for boys due to differential feeding practices and allocation of resources) was quite effective as obesity emerged as a problem. Cooking classes and summer camps for boys as well as girls included educational efforts and attempts at culture shift.
We thank the reviewer for providing this thoughtful insight and information. Thailand and Vietnam have lots of cultural and economic seminaries. The experience in Thailand should be beneficial to use in Vietnam. We will consider the suggestions when we design the intervention.
Reviewer 3
1. Although I find the subject quite worthy of researching, the manuscript was too
SysRev of Peer-led vs Obesity in Children Ngoc-Minh Nguyen, USyd 2018
Page 190 of 191 likely that the first language of the authors is not English. Too many of the sentences lacked clarity of meaning. Please see uploaded manuscript edits in PDF.
We gratefully thank the reviewer for making edits and sending the PDF which was immensely useful. We have incorporated the edits into the revised manuscript. In addition, we have further edited the paper thoroughly to fix the errors, and increase readability and clarity.
2. Also, the numerous inclusions of statements from students, teachers and such made
reading very difficult to follow. These statements may be better served only within tables.
We included quotes of the respondents from the interviews. We understand, too many quotes would potentially create difficulty in following the flow of a scientific paper. We have revised and reduced the number of quotes considerably in the modified
manuscript. We followed the standard writing style widely used by qualitative
researchers and cited the quotes in the main body of the paper. We would retain this style, but have reduced the amount of quotes.
Reviewer 4
1. My major gratification is with the methodology. This work projects no leniency and or weaknesses of the research design and methodology and manuscript formation. Reviewers’ only contention is with the presentation and interpretation of the findings which could have been in more concise manner. The present study makes a decent contribution to the advancement of knowledge, theory, or practice.
We very much thank the review for her/his comment and suggestions for a more
concise presentation and interpretation of the findings. We have revised the manuscript to adhere to the reviewer’s comments.
Please find attached the revised manuscript. Thank you for considering publishing our manuscript in your well-regarded journal.