When women eat last: Discrimination at home and women’s mental health

Payal Hathi; Diane Coffey; Amit Thorat; Nazar Khalid

doi:10.1371/journal.pone.0247065

Peer Review History

Original SubmissionAugust 21, 2020
20 Nov 2020 Decision Letter - Kannan Navaneetham, Editor PONE-D-20-26210 When women eat last: Discrimination at home and women's mental health PLOS ONE Dear Dr. Hathi, Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process. Please submit your revised manuscript by Jan 04 2021 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file. 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Please ensure that you refer to Table 3 in your text; if accepted, production will need this reference to link the reader to the Table. [Note: HTML markup is below. Please do not edit.] Reviewers' comments: Reviewer's Responses to Questions Comments to the Author 1. Is the manuscript technically sound, and do the data support the conclusions? The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented. Reviewer #1: Yes Reviewer #2: Yes ******** 2. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: Yes Reviewer #2: Yes ****** 3. Have the authors made all data underlying the findings in their manuscript fully available? The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified. Reviewer #1: Yes Reviewer #2: Yes ****** 4. Is the manuscript presented in an intelligible fashion and written in standard English? PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here. Reviewer #1: Yes Reviewer #2: Yes ****** 5. Review Comments to the Author Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters) Reviewer #1: Comments on Manuscript PONE-D-20-26210 This is an important and interesting paper that investigates whether women eating last in the household (a widespread practice in India) affects their mental health. The authors use a unique dataset to show that it indeed affects women’s mental health, and the relationship is robust to controlling for various observable characteristics such as education and asset. The authors also discuss other potential pathways such as women’s physical health and autonomy, although they cannot provide any direct evidence that would adequately establish these pathways. I have the following comments that the authors may consider in revising their paper. 1. It will be good to explore heterogeneity, especially on the intersectionality aspect considering caste. Various studies in the literature highlight the intersectionality (or the lack thereof) between gender and caste in the Indian context. So, the authors can estimate the full model separately for different castes to see whether the effect varies by caste (alternatively interaction of “women eat last” with caste dummies can be used). 2. I find it a bit strange that the autonomy variable included in Table 5 neither has any mediating effect nor it is significant itself. The authors do suggest that this measure may not be adequately capturing autonomy. Therefore, the authors investigate the effect of an alternative measure of autonomy from IHDS data and show that autonomy in that data strongly predicts the probability of eating last for the women. However, since IHDS do not have measure on mental health, they cannot investigate that relationship. Rather, they use the evidence from IHDS as a basis for discussion of their original result using SARI data. In my view, this analysis and the discussion are incomplete. In the regression presented in Table 5 (using SARI data), the measure of autonomy (i.e., “Ask for permission to go to neighbor’s house” variable) will be a significant mediator only if it is correlated with both “Women eat last” variable and the outcome variable (i.e. mental health). The autonomy variable itself is not a significant predictor of the outcome variable – this is visible from the results presented in the table. But is the autonomy variable also uncorrelated with “Women eat last” variable? That evidence is not presented. In other words, the authors could run a regression using the SARI data itself, where “Women eat last” is the dependent variable and autonomy is an explanatory variable. This is analogous to the IHDS regression presented in Table 6. Then results from this regression using SARI data could be put in contrast with the regression using IHDS data. If it happens to be the case that SARI measure of autonomy is not significant, while the IHDS measure of autonomy is significant (as seen from Table 6), then it would indicate more clearly that the SARI measure is inadequate to capture women’s autonomy. On the other hand, if SARI measure also comes out significant just like IHDS measure, then the interpretation will be different. 3. On line 621, it should be Table 6, not Table 5. 4. The paper does not mention in which year the SARI data was collected. Reviewer #2: This an important piece of work highlighting effect of gender discrimination, manifested as practice of women eating last, on mental health and well-being. I have few minor concerns and require some revision - 1. in line 261, 6 questions are selected from 20 without providing process and validity. Suggest adding both these in the method section. 2. In line 321, you have considered latrine ownership only in case of rural areas. While I am fine with the assumption that open defecation is practiced mainly in rural areas but access to safe sanitation facilities are major concern in urban areas with high population density and limited open space, particularly for those living in slum areas 3. Check table numbers mentioned in results section 4. In Table 3 - summary statistics - mean is referred for proportion of women who self-reported mental health symptoms in past 30 days. Need correction 5. Any specific reason for keeping Brahmin separate from general caste group? Also, Dalit and Adivasi are not constitutional terms. Suggest keeping it Scheduled Castes and Scheduled Tribes and mention their underprivileged condition for wider understanding. Also, avoid using upper caste and lower caste. These are privileged and underprivileged caste/tribe groups. 6. Measure on mobility is inadequate. Any standard population survey captures mobility to 4-5 location within vicinity and outside the community. Any reason for considering this in the study? You haven’t included this in Table 3. 7. I did not see any value of adding analysis of data on decision making from IHDS. ****** 6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files. If you choose “no”, your identity will remain anonymous but your review may still be made public. Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy. Reviewer #1: Yes: Soham Sahoo Reviewer #2: Yes:** Pranita Achyut [NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.] While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step. https://doi.org/10.1371/journal.pone.0247065.r001
Revision 1
1 Jan 2021 Author Response Dear PLoS One Editors, Thank you for the opportunity to revise our paper, “When women eat last: Discrimination at home and women's mental health” (PONE-D-20-26210) for resubmission to PLoS One. The reviewers made several helpful suggestions to improve the paper. Below (and in the attached 'Response to Reviewers', we describe how we have incorporated their feedback in response to each of their comments. For ease of re-review, reviewers’ comments are reproduced below in bold and indented, and our responses are in lightweight, indented text. Reviewer #1: Comments on Manuscript PONE-D-20-26210 This is an important and interesting paper that investigates whether women eating last in the household (a widespread practice in India) affects their mental health. The authors use a unique dataset to show that it indeed affects women’s mental health, and the relationship is robust to controlling for various observable characteristics such as education and asset. The authors also discuss other potential pathways such as women’s physical health and autonomy, although they cannot provide any direct evidence that would adequately establish these pathways. I have the following comments that the authors may consider in revising their paper. 1. It will be good to explore heterogeneity, especially on the intersectionality aspect considering caste. Various studies in the literature highlight the intersectionality (or the lack thereof) between gender and caste in the Indian context. So, the authors can estimate the full model separately for different castes to see whether the effect varies by caste (alternatively interaction of “women eat last” with caste dummies can be used). We agree that this would be an interesting addition to the paper. In a new supplementary appendix table (Table S2), we have conducted the main analysis (the association between eating last and mental health) for each caste group separately, including the full set of covariates. For each caste group, the direction of the coefficient is what we would expect (women who eat last report worse mental health), but results are only statistically significant for OBC women, which is the largest caste group in the sample. We suspect that sample sizes for the other groups are too small to be able to detect statistically significant results. We have added text to explain this finding. 2. I find it a bit strange that the autonomy variable included in Table 5 neither has any mediating effect nor it is significant itself. The authors do suggest that this measure may not be adequately capturing autonomy. Therefore, the authors investigate the effect of an alternative measure of autonomy from IHDS data and show that autonomy in that data strongly predicts the probability of eating last for the women. However, since IHDS do not have measure on mental health, they cannot investigate that relationship. Rather, they use the evidence from IHDS as a basis for discussion of their original result using SARI data. In my view, this analysis and the discussion are incomplete. In the regression presented in Table 5 (using SARI data), the measure of autonomy (i.e., “Ask for permission to go to neighbor’s house” variable) will be a significant mediator only if it is correlated with both “Women eat last” variable and the outcome variable (i.e. mental health). The autonomy variable itself is not a significant predictor of the outcome variable – this is visible from the results presented in the table. But is the autonomy variable also uncorrelated with “Women eat last” variable? That evidence is not presented. In other words, the authors could run a regression using the SARI data itself, where “Women eat last” is the dependent variable and autonomy is an explanatory variable. This is analogous to the IHDS regression presented in Table 6. Then results from this regression using SARI data could be put in contrast with the regression using IHDS data. If it happens to be the case that SARI measure of autonomy is not significant, while the IHDS measure of autonomy is significant (as seen from Table 6), then it would indicate more clearly that the SARI measure is inadequate to capture women’s autonomy. On the other hand, if SARI measure also comes out significant just like IHDS measure, then the interpretation will be different. We have added a new supplementary appendix table (Table S3) showing regression results of the association between asking for permission to leave the house and eating last, using SARI data. We find that having to ask for permission to leave the house decreases the proportional odds of eating last. This goes in the opposite direction of what we would expect if asking for permission is a sign of autonomy, helping us demonstrate that may not be an adequate measure to capture women's autonomy. During debriefing with interviewers during and after the survey, some said that they believed that this questions may have been capturing a courtesy that women paid to other members of the household, rather than a marker of their freedom of movement. This interpretation is consistent with the association in Table S3. Households in which people pay one another more courtesy would also be those in which women may be less likely to eat last. We have added text to explain this finding. 3. On line 621, it should be Table 6, not Table 5. Thank you! This error has been corrected. 4. The paper does not mention in which year the SARI data was collected. Years have been added into Table 1, and in the text. Reviewer #2: This an important piece of work highlighting effect of gender discrimination, manifested as practice of women eating last, on mental health and well-being. I have few minor concerns and require some revision – 1. in line 261, 6 questions are selected from 20 without providing process and validity. Suggest adding both these in the method section. The SARI questionnaire included the SRQ mental health questions as part of an experiment testing the feasibility of asking questions about mental health by phone. The SRQ questions were tested against a questionnaire called the Kessler-6, which includes six questionf focused on emotional symptoms of mental health distress. The six SRQ questions were selected to focus on physical symptoms, as a contrast to the Kessler-6 questions. They were tested during questionnaire piloting in late 2017 and early 2018, to ensure that respondents understood what was being asked. We have added more information about this process and validation to the text, and also cited a paper which describes the mental health questions in greater detail. 2. In line 321, you have considered latrine ownership only in case of rural areas. While I am fine with the assumption that open defecation is practiced mainly in rural areas but access to safe sanitation facilities are major concern in urban areas with high population density and limited open space, particularly for those living in slum areas We agree that sanitation is also an important issue in urban areas, however, India's open defecation is largely concentrated in rural areas. In addition, the Swachh Bharat Mission was largely focused on rural areas, so we wanted to get a sense of how that policy was working, particularly in terms of latrine construction and use. Another reason for only asking about latrine ownership and use in rural is now provided in the text: "...we did not ask urban residents about latrine ownership and use was that, in piloting, they sometimes became upset at the suggestion that they might defecate in the open." 3. Check table numbers mentioned in results section We have fixed table numbers for Table 3 and Table 6, and references to those tables in the text. 4. In Table 3 – summary statistics – mean is referred for proportion of women who self-reported mental health symptoms in past 30 days. Need correction We have added in "proportion" to the title of the column to clarify. 5. Any specific reason for keeping Brahmin separate from general caste group? Also, Dalit and Adivasi are not constitutional terms. Suggest keeping it Scheduled Castes and Scheduled Tribes and mention their underprivileged condition for wider understanding. Also, avoid using upper caste and lower caste. These are privileged and underprivileged caste/tribe groups. Thank you for this. We have disaggregated caste groups as much as possible, and as Brahmins have particular privilege in the states we study, we wanted to ask about them separately. Although the constitutional terms are Scheduled Caste and Scheduled Tribe, we have used the terms "Dalit" and "Adivasi" in the paper as these are the terms that were used in the survey. We chose them for the survey because they were more familiar to the respondents, many of whom were women with low levels of education. We have added a clarification to the text that Dalit and Adivasi correspond to SC and ST respectively. Thank you for the suggestion about removing "lower caste." We agree -- we have removed this reference. 6. Measure on mobility is inadequate. Any standard population survey captures mobility to 4-5 location within vicinity and outside the community. Any reason for considering this in the study? You haven’t included this in Table 3. Unfortunately, due to the time constraints of a phone survey, we were unable to include additional question capturing measures of women's mobility in SARI (just the one about whether she can go to her neighbor's house on her own or not). If we had been able to collect this data, we would have included it, but instead, we included questions on other manifestations of gender inequality. 7. I did not see any value of adding analysis of data on decision making from IHDS. The purpose of the analysis on decision making from the IHDS was to explore whether any other measures of autonomy, that we were not able to collect data on in SARI, could help us explain the connection between poor mental health and eating last. We have included a supplementary analysis of the association between SARI's measure of autonomy (asking for permission to go to a neighbor's house) and eating last, as a parallel to the IHDS analysis, which should make clear the purpose of looking at two different measures of autonomy. Attachments Attachment Submitted filename: Response to Reviewers.docx https://doi.org/10.1371/journal.pone.0247065.r002
1 Feb 2021 Decision Letter - Kannan Navaneetham, Editor When women eat last: Discrimination at home and women's mental health PONE-D-20-26210R1 Dear Dr. Hathi, We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements. Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication. An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org. If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org. Kind regards, Kannan Navaneetham, PhD Academic Editor PLOS ONE Additional Editor Comments (optional): Reviewers' comments: Reviewer's Responses to Questions Comments to the Author 1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation. Reviewer #1: All comments have been addressed Reviewer #2: All comments have been addressed ******** 2. Is the manuscript technically sound, and do the data support the conclusions? The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented. Reviewer #1: Yes Reviewer #2: Yes ****** 3. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: Yes Reviewer #2: Yes ****** 4. Have the authors made all data underlying the findings in their manuscript fully available? The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified. Reviewer #1: (No Response) Reviewer #2: Yes ****** 5. Is the manuscript presented in an intelligible fashion and written in standard English? PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here. Reviewer #1: Yes Reviewer #2: Yes ****** 6. Review Comments to the Author Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters) Reviewer #1: (No Response) Reviewer #2: (No Response) ****** 7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files. If you choose “no”, your identity will remain anonymous but your review may still be made public. Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy. Reviewer #1: Yes:** Soham Sahoo Reviewer #2: No https://doi.org/10.1371/journal.pone.0247065.r003
Formally Accepted
19 Feb 2021 Acceptance Letter - Kannan Navaneetham, Editor PONE-D-20-26210R1 When women eat last: Discrimination at home and women’s mental health Dear Dr. Hathi: I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department. If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org. If we can help with anything else, please email us at plosone@plos.org. Thank you for submitting your work to PLOS ONE and supporting open access. Kind regards, PLOS ONE Editorial Office Staff on behalf of Professor Kannan Navaneetham Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0247065.r004

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