Rigor Reviewed

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Chemoprevention for malaria with monthly intermittent preventive treatment with dihydroartemisinin-piperaquine in pregnant women living with HIV on daily co-trimoxazole in Kenya and Malawi: a randomised, double-blind, placebo-controlled trial.

Name: Adcurare Rigor Record — Chemoprevention for malaria with monthly intermittent preventive treatment with dihydroartemisinin-piperaquine in pregnant women living with HIV on daily co-trimoxazole in Kenya and Malawi: a randomised, double-blind, placebo-controlled trial.
Item: Chemoprevention for malaria with monthly intermittent preventive treatment with dihydroartemisinin-piperaquine in pregnant women living with HIV on daily co-trimoxazole in Kenya and Malawi: a randomised, double-blind, placebo-controlled trial.
Rating: 96
Author: Adcurare

Barsosio HC, Madanitsa M, Ondieki ED, Dodd J, Onyango ED, Otieno K, Wang D, Hill J, Mwapasa V, Phiri KS, Maleta K, Taegtmeyer M, Kariuki S, Schmiegelow C, Gutman JR, Ter Kuile FO

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Adcurare Rigor Review — 4.75★ (Strong), 0 critical, 3 high issues for “Chemoprevention for malaria with monthly intermittent preventive treatment with dihydroartemisinin-piperaquine in pregnant women living with HIV on daily co-trimoxazole in Kenya and Malawi: a randomised, double-blind, placebo-controlled trial.”

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Adcurare Editorial

This rigor review was examined and confirmed by Adcurare Editorial · July 7, 2026

Adcurare Rigor Review

Rigor Reviewed

4.75 / 5

Strong — minor issues to address

Interventional Study

Critical

High-priority

How this rating was calculated▸

Started at 5★ — deductions

ReportingData & code availability partially met−0.25★

Model-reported confidence: highReviewer agreement: moderateEngine: 7.6.0Source: full text

Problems surfaced1 type

Data/code availability incomplete

This Adcurare Rigor Review uses AI Rigor Reviewers trained on a curated corpus of high-fidelity and retracted papers, with expert supervision and curation. It can still make mistakes; verify each finding against the source before relying on it.

This is a well-conducted multicentre RCT with a clear scientific premise, rigorous study design, and generally transparent reporting. Minor gaps include the absence of an explicit statement of regulatory compliance (e.g., Declaration of Helsinki) and a missing code-sharing statement. A small number of copyedit-level issues (truncated sentence, typo in a table footnote) also need attention.

Three independent reviewer evaluations (all from the same model family) and a copyedit pass were reconciled. Dimensions with non-applicable sub-criteria (e.g., species/strain/housing for a human study) had those criteria excluded from scoring. The statistics verification checked only 4 reported tests — the rest of the analyses were not recomputed and remain unverified.

11 major claims checked against the paper's own evidence: all adequately supported.

Recomputed 4 tests: 4 consistent, 0 inconsistent, 4 via agent-written checks.

Reporting

Eight Dimensions7 pass · 1 warn

The paper discusses the threat of cross-resistance, the limitations of prior IPTp options (mefloquine, amodiaquine), and the drug-drug interaction with efavirenz that motivated the switch to dolutegravir. It clearly states the hypothesis that adding monthly dihydroartemisinin–piperaquine to daily co-trimoxazole is more effective than co-trimoxazole alone.

Sub-criteria

prior work citedADEQUATE

premise rationaleADEQUATE

limitations addressedADEQUATE

Per reviewer (3) — the votes behind the verdict

PASSReviewer 1· 100% conf

The paper establishes a strong scientific foundation, citing prior work on antifolate resistance, previous trials, and the rationale for using dihydroartemisinin–piperaquine with dolutegravir.

Evidence

direct quote[Introduction]

“Currently, high-level resistance of Plasmodium falciparum to sulfadoxine–pyrimethamine in east and southern Africa threatens the antimalarial efficacy of daily co-trimoxazole because both are sulfa-based antifolate drugs with similar antimalarial modes of action.”

direct quote[Introduction]

“Trials in women without HIV found that several long-acting alternatives to sulfadoxine–pyrimethamine were unsuitable as intermittent preventive treatment in pregnancy (IPTp) because of poor tolerability, including amodiaquine (alone or combined with sulfadoxine–pyrimethamine), mefloquine, and chloroquine (alone or combined with azithromycin).”

direct quote[Introduction]

“Following an update of WHO’s policy in 2018, many national HIV control programmes in Africa, including Kenya and Malawi, transitioned their first-line cART, including for pregnant women, from efavirenz-based to dolutegravir-based regimens. Unlike efavirenz, no clinically relevant drug–drug interactions have been seen between dihydroartemisinin–piperaquine and dolutegravir in pregnancy.”

PASSReviewer 2· 95% conf

The scientific premise is well-established with comprehensive prior work cited, a clear rationale linking the premise to the study objectives, and limitations of prior research addressed.

Evidence

direct quote[Introduction, paragraphs 1-7]

“IPTp with dihydroartemisinin–piperaquine has only been assessed in a small trial of 200 pregnant women living with HIV receiving efavirenz-based cART in Uganda. The study was inconclusive.”

direct quote[Introduction, final paragraph]

“We present the results of a trial designed to determine whether addition of monthly IPTp with dihydroartemisinin–piperaquine to daily co-trimoxazole is more effective at preventing malaria than the standard of care with daily co-trimoxazole alone in women receiving dolutegravir-based cART in areas with high sulfadoxine–pyrimethamine resistance.”

direct quote[Introduction, paragraphs 5-7]

“...a clinically relevant drug–drug interaction between dihydroartemisinin–piperaquine and efavirenz resulting in a 27% reduction in exposure to dihydroartemisinin and 38% reduction in exposure to piperaquine.”

PASSReviewer 3· 95% conf

The premise is well established, citing prior work on sulfadoxine-pyrimethamine resistance, earlier IPTp trials, and drug-drug interactions with efavirenz, and logically motivating the study with dolutegravir-based cART.

Evidence

direct quote[Introduction, paragraph 3]

“A modelling analysis suggested that less than 1% of women living with HIV on efavirenz-based cART receiving monthly IPTp with dihydroartemisinin–piperaquine would achieve protective piperaquine concentrations...”

direct quote[Introduction, last paragraph]

paraphrase[Introduction, paragraphs 3-4]

“The paper notes the Ugandan pilot trial was inconclusive due to the efavirenz interaction and low transmission, and that the current study uses dolutegravir to avoid that interaction.”

The paper describes computer-generated block randomization stratified by site and HIV status, double-blind masking, and a pre-specified power analysis. Inclusion/exclusion criteria are detailed, and the analysis populations (modified ITT, per-protocol, safety) are defined.

Sub-criteria

controlsN/A

power analysisADEQUATE

blinding levelsADEQUATE

outlier handlingADEQUATE

randomization unitADEQUATE

inclusion exclusionADEQUATE

randomization methodADEQUATE

replicate distinctionN/A

independent replicationN/A

Per reviewer (3) — the votes behind the verdict

PASSReviewer 1· 100% conf

The study design is rigorous, with clear randomization, blinding, power analysis, and pre-specified endpoints.

Evidence

direct quote[Methods, Randomisation and masking]

“Balanced randomisation was done using computer-generated permuted block randomisation stratified by site and HIV status (women diagnosed with HIV before enrolment as documented in their existing health records [ie, known positive] vs newly diagnosed).”

direct quote[Methods, Randomisation and masking]

“All investigators, laboratory staff, data analysts, and participants were masked to treatment assignment.”

direct quote[Methods, Statistical analysis]

“The study was designed to achieve 80% power to detect a 50% reduction in the cumulative incidence of Plasmodium infection from 12% in the co-trimoxazole plus placebo group to 6% in the co-trimoxazole plus dihydroartemisinin–piperaquine group (risk ratio [RR] 0·50, two-sided α=0·05), which required 898 participants (449 per group), allowing for 20% loss to follow-up.”

PASSReviewer 2· 95% conf

The study design is rigorous with clear randomisation, masking, a priori power analysis, and pre-specified inclusion/exclusion criteria. Most relevant sub-criteria are adequately reported.

Evidence

direct quote[Methods, Randomisation and masking]

“All investigators, laboratory staff, data analysts, and participants were masked to treatment assignment.”

direct quote[Methods, Statistical analysis]

PASSReviewer 3· 95% conf

The trial is well-designed with adequate randomization, blinding, stratification, power analysis, and prespecified inclusion/exclusion criteria.

Evidence

direct quote[Methods, Randomisation and masking]

“Balanced randomisation was done using computer-generated permuted block randomisation stratified by site and HIV status...”

direct quote[Methods, Randomisation and masking]

“All investigators, laboratory staff, data analysts, and participants were masked to treatment assignment.”

direct quote[Methods, Statistical analysis]

The baseline characteristics table (Table 1) reports maternal age, weight, BMI, gestational age, HIV status, etc. All participants are female, so sex is implicitly reported. Demographics include residence, education, socioeconomic status.

Sub-criteria

demographicsADEQUATE

sex reportedADEQUATE

sex justifiedN/A

age weight healthADEQUATE

housing conditionsN/A

species strain sourceN/A

Per reviewer (3) — the votes behind the verdict

PASSReviewer 1· 100% conf

All applicable biological variables (sex, age, weight, health status, demographics) are reported in detail.

Evidence

direct quote[Table 1]

“Maternal age (years) | 29·2 (5·6) | 29·2 (5·7) | ... Weight (kg) | 63 (10·8) | 62 (10·1) | ... BMI (kg/m²) | 24·4 (3·9) | 24·2 (3·6)”

direct quote[Table 1]

“Residence | Rural 330/448 (74%) | 338/456 (74%) | ... Attended school | 442/448 (99%) | 446/456 (98%) | ... Socioeconomic status (terciles) | Low 151/448 (34%) | 150/456 (33%)”

direct quote[Results]

“Of the 904 participants, 152 (17%) were newly diagnosed with HIV infection and started on dolutegravir-based cART. 752 (83%) had known HIV infection”

PASSReviewer 2· 90% conf

Biological variables including age, sex, and health status are well reported for the human subjects. Demographics are comprehensive.

Evidence

direct quote[Table 1]

“Maternal age (years) | 29·2 (5·6) | 29·2 (5·7)”

direct quote[Table 1]

“Newly diagnosed HIV infection | 75/448 (17%) | 77/456 (17%)”

direct quote[Methods, Study design and participants]

“Eligible women were those living with HIV...”

PASSReviewer 3· 95% conf

Key biological variables (sex, age, weight, HIV status, demographics) are well reported and balanced between groups.

Evidence

direct quote[Table 1]

“Maternal age (years) 29·2 (5·6) | 29·2 (5·7)”

direct quote[Results, paragraph 1]

“Of the 904 participants, 152 (17%) were newly diagnosed with HIV infection and started on dolutegravir-based cART. 752 (83%) had known HIV infection...”

direct quote[Table 1]

“Gestational age (weeks) 22 (3·7) | 22 (3·8)”

The study was approved by named ethics committees: the Kenya Medical Research Institute (KEMRI), the College of Medicine in Malawi, and the Liverpool School of Tropical Medicine. The US CDC approved through a reliance agreement with KEMRI. Written informed consent was obtained from all participants. Regulatory compliance with the Declaration of Helsinki is implied through the ethics framework, though not stated verbatim, but the approvals from named bodies are adequate per the scoring rule. For a human trial conducted in multiple countries, these statements are comprehensive.

Sub-criteria

iacuc statementN/A

informed consentADEQUATE

irb ethics statementADEQUATE

regulatory complianceADEQUATE

Per reviewer (3) — the votes behind the verdict

WARNReviewer 1· 90% conf

Ethics approval and informed consent are reported, but regulatory compliance with a named framework (e.g., Declaration of Helsinki) is not explicitly stated.

Evidence

direct quote[Methods, Study design and participants]

“Ethics committees of the Kenya Medical Research Institute (KEMRI), the College of Medicine in Malawi, and the Liverpool School of Tropical Medicine approved the study.”

direct quote[Methods, Study design and participants]

“All participants provided written informed consent.”

absence[Methods, Ethical approvals section]

No explicit statement of compliance with the Declaration of Helsinki or other regulatory framework.

PASSReviewer 2· 95% conf

Ethical approvals from named bodies, informed consent, and regulatory compliance are all adequately reported.

Evidence

direct quote[Methods, Study design and participants]

“Ethics committees of the Kenya Medical Research Institute (KEMRI), the College of Medicine in Malawi, and the Liverpool School of Tropical Medicine approved the study.”

direct quote[Methods, Study design and participants]

“All participants provided written informed consent.”

direct quote[Methods, Study design and participants]

“The US Centers for Disease Control and Prevention approved the protocol through a reliance agreement with KEMRI.”

PASSReviewer 3· 95% conf

Named ethics committees approved the study, informed consent is described, and regulatory compliance is stated.

Evidence

direct quote[Methods, Study design and participants]

“Ethics committees of the Kenya Medical Research Institute (KEMRI), the College of Medicine in Malawi, and the Liverpool School of Tropical Medicine approved the study.”

direct quote[Methods, Study design and participants]

“All participants provided written informed consent.”

direct quote[Methods, Statistical analysis]

“This trial is registered with ClinicalTrials.gov (http://ClinicalTrials.gov), NCT04158713”

The paper specifies the dihydroartemisinin–piperaquine product (D-Artepp, Fosun Pharma) and co-trimoxazole (Sulfran-DS, Universal Corporation), including dosage and formulation. Statistical software (Stata version 17) is stated. No other biological resources are used.

Sub-criteria

mycoplasma testingN/A

reagents identifiedADEQUATE

organisms identifiedN/A

antibodies identifiedN/A

cell line authenticationN/A

software tools identifiedADEQUATE

Per reviewer (3) — the votes behind the verdict

PASSReviewer 1· 100% conf

The investigational drugs and statistical software are adequately identified with manufacturers and versions.

Evidence

direct quote[Methods, Procedures]

“Each monthly dihydroartemisinin–piperaquine course consisted of a fixed dose of three tablets of 40 mg dihydroartemisinin and 320 mg piperaquine (D-Artepp, Fosun Pharma, Shanghai, China) given daily for 3 days until delivery.”

direct quote[Methods, Procedures]

“Daily co-trimoxazole consisted of one double-strength tablet of 160 mg sulfamethoxazole and 800 mg trimethoprim (Sulfran-DS, Universal Corporation, Nairobi, Kenya).”

direct quote[Methods, Statistical analysis]

“Statistical analyses were done with Stata version 17.”

PASSReviewer 2· 90% conf

Key resources including the investigational drugs, diagnostic tests, and software are adequately identified. Antibodies, cell lines, and mycoplasma are not applicable as this is a clinical trial without wet-lab assays.

Evidence

direct quote[Methods, Procedures]

“Daily co-trimoxazole consisted of one double-strength tablet of 160 mg sulfamethoxazole and 800 mg trimethoprim (Sulfran-DS, Universal Corporation, Nairobi, Kenya).”

direct quote[Methods, Statistical analysis]

“Statistical analyses were done with Stata version 17.”

WARNReviewer 3· 85% conf

Investigational products (co-trimoxazole, dihydroartemisinin–piperaquine, placebo) are identified with manufacturer, but with incomplete detail on lot numbers or full formulation.

Evidence

direct quote[Methods, Procedures]

“Daily co-trimoxazole consisted of one double-strength tablet of 160 mg sulfamethoxazole and 800 mg trimethoprim (Sulfran-DS, Universal Corporation, Nairobi, Kenya).”

direct quote[Methods, Procedures]

direct quote[Methods, Statistical analysis]

“Statistical analyses were done with Stata version 17.”

The paper uses log-binomial regression for binary outcomes and Poisson regression for count outcomes, with pre-specified covariates. Exact p-values and CIs are reported. The software is identified. The data presentation includes per-group n and effect estimates. Mathematical plausibility checks are consistent.

Sub-criteria

tests namedADEQUATE

exact p valuesADEQUATE

effect sizes ciADEQUATE

data presentationADEQUATE

software identifiedADEQUATE

assumptions verifiedADEQUATE

mathematical plausibilityPASS

Per reviewer (3) — the votes behind the verdict

PASSReviewer 1· 100% conf

All statistical methods are named, effect sizes with CIs are reported, and exact p-values are provided. The analysis is appropriate for the study design.

Evidence

direct quote[Methods, Statistical analysis]

“Log-binomial regression was used for binary outcomes, and Poisson regression for count outcomes.”

direct quote[Results]

“The cumulative risk of any malaria infection... was lower in the co-trimoxazole plus dihydroartemisinin–piperaquine group than in the co-trimoxazole plus placebo group (31 [7%] of 443 women vs 70 [15%] of 452 women, risk ratio 0·45, 95% CI 0·30–0·67; p=0·0001).”

direct quote[Methods, Statistical analysis]

“Statistical analyses were done with Stata version 17.”

PASSReviewer 2· 90% conf

Statistical tests are named, exact p-values are reported, effect sizes with CIs are provided, and data presentation is appropriate. Assumptions handling is adequate for a clinical trial using standard methods. Software is identified. Interval data plausibility checks are passed.

Evidence

direct quote[Methods, Statistical analysis]

“Log-binomial regression was used for dichotomous endpoints to obtain RRs and corresponding 95% CIs and modified Poisson regression in case of non-convergence.”

direct quote[Results, paragraph 3]

“...(31 [7%] of 443 women vs 70 [15%] of 452 women, risk ratio 0·45, 95% CI 0·30–0·67; p=0·0001).”

direct quote[Figure 2]

“Figure 2: Primary endpoint and other secondary maternal endpoints (modified intention-to-treat population)”

PASSReviewer 3· 95% conf

Statistical tests are named, assumptions implicit in the model, exact p-values reported, effect sizes with CIs, software identified, data presented with per-group n, and mathematical plausibility checks pass.

Evidence

direct quote[Methods, Statistical analysis; Results, paragraph 3]

“Log-binomial regression was used for dichotomous endpoints to obtain RRs and corresponding 95% CIs... Poisson regression with a log-link function... The cumulative risk of any malaria infection... RR 0·45, 95% CI 0·30–0·67; p=0·0001.”

direct quote[Methods, Statistical analysis]

“Statistical analyses were done with Stata version 17.”

paraphrase[Table 2; Figure 2]

“Table 2 provides means, SDs, and mean differences with 95% CIs for continuous outcomes, including per-group n.”

The data sharing statement is concrete: individual participant data will be available from the Worldwide Antimalarial Resistance Network (WWARN) repository approximately 3 months after publication. This qualifies as reported_and_adequate because it names a concrete repository and access timeframe. However, repository_deposit is not_applicable for patient-level data due to privacy, and the trial generated non-identifiable aggregate data that could have been deposited but was not, so repository_deposit is marked not_reported. Code_sharing is not reported (Stata code not shared). The paper scores one of two applicable criteria as adequate, resulting in a warn status.

Sub-criteria

code sharingNOT REPORTED

accession numbersN/A

repository depositNOT REPORTED

data availability statementADEQUATE

Per reviewer (3) — the votes behind the verdict

PASSReviewer 1· 95% conf

A data availability statement is provided that names a repository (WWARN) and a timeline for availability. No custom code was shared, which is not expected for a clinical trial using standard software.

Evidence

direct quote[Data sharing statement]

“Individual participant data will be available from the Worldwide Antimalarial Resistance Network (WWARN) repository approximately 3 months after publication.”

WARNReviewer 2· 85% conf

A data availability statement exists stating that individual participant data will be available from the WWARN repository approximately 3 months after publication, which is concrete and adequate. However, no statement about code sharing is provided, and the trial generated non-sequencing data for which no repository deposit or accession number is given.

Evidence

direct quote[Data sharing section (at end of paper)]

“Individual participant data will be available from the Worldwide Antimalarial Resistance Network (WWARN) repository approximately 3 months after publication.”

absence[Entire paper]

Code sharing is not mentioned.

WARNReviewer 3· 85% conf

A data-sharing statement is present but vague; no code sharing or repository deposit reported for this individual patient-level trial.

Evidence

direct quote[End of Discussion, before References]

“Individual participant data will be available from the Worldwide Antimalarial Resistance Network (WWARN) repository approximately 3 months after publication.”

absence[Entire paper]

Code sharing is not reported.

The trial is registered at ClinicalTrials.gov (NCT04158713). Methods are comprehensive, all outcomes are reported (including null results), limitations are discussed, and conclusions are proportional to the evidence. Funding and conflicts are declared. The absence of a CONSORT reference is a minor reporting gap.

Sub-criteria

funding coiADEQUATE

trial registrationADEQUATE

reporting guidelineNOT REPORTED

methods completenessADEQUATE

all outcomes reportedADEQUATE

limitations discussedADEQUATE

conclusions proportionalADEQUATE

Per reviewer (3) — the votes behind the verdict

PASSReviewer 1· 95% conf

The paper is well-reported with a trial registration, detailed methods, and a discussion of limitations. However, it does not explicitly reference a reporting guideline (e.g., CONSORT), which is a minor omission.

Evidence

direct quote[Abstract and Methods]

“This trial is registered with ClinicalTrials.gov, NCT04158713.”

direct quote[Discussion]

“A limitation is that this study was done in sites with high-grade antifolate resistance but where the prevalence of parasites with the highly resistant sextuple pfdhfr/pfdhps haplotype containing the pfdhps Ala581Gly mutation is still fairly uncommon... limiting our ability to assess potential effect modification by antifolate resistance level.”

direct quote[Declaration of interests]

“Declaration of interests We declare no competing interests.”

PASSReviewer 2· 95% conf

The manuscript is comprehensive, with detailed methods, clinical trial registration, discussion of limitations, proportional conclusions, and funding/COI statements. A reporting guideline (CONSORT adaptation) is implicitly followed but not explicitly referenced.

Evidence

direct quote[Methods, Statistical analysis and Abstract]

“This trial is registered with ClinicalTrials.gov (http://ClinicalTrials.gov), NCT04158713 (https://clinicaltrials.gov/ct2/show/NCT04158713).”

direct quote[Discussion, paragraph 6]

direct quote[Funding and Declaration of interests]

“Declaration of interests We declare no competing interests.”

PASSReviewer 3· 90% conf

Methods are detailed enough for replication, trial is registered, outcomes are reported, limitations discussed, conclusions proportional, and funding/COI declared.

Evidence

direct quote[Methods, Statistical analysis; Abstract]

“NCT04158713”

direct quote[Discussion, paragraph 5]

direct quote[Acknowledgments; Declaration of interests]

“Declaration of interests We declare no competing interests.”

7 copyedit issues flagged: mostly consistency, clarity.

Checked 33 references: 1 verified — 32 not checked.

Reproducibility

2 data/code links checked; 2 live.

Registered (1 ID: ClinicalTrials.gov). No reporting guideline cited.

Adcurare Rigor Action ItemsFinal pass before journal submission

Ready after minor edits. The two warn-dimension gaps (explicit regulatory compliance statement, code-sharing statement) and the copyedit issues (truncated protocol URL, typo in Table 3 footnote) should be fixed before submission. No substantive scientific concerns were identified.

1.
HIGHethics
Add a statement of compliance with the Declaration of Helsinki (or ICH-GCP) in the Methods section after the ethics committee listing.
This is a required reporting element for most journals and was noted as missing by one reviewer.
2.
HIGHdata code
Add a code-sharing statement in the Data Sharing section (e.g., 'Stata analysis code for primary and key secondary analyses is available at [GitHub/Zenodo link].').
Code sharing is expected for reproducibility; two reviewers flagged its absence.
3.
HIGHreporting
Complete the truncated sentence in Methods/Study design and participants: 'The protocol is available in the...' by adding the URL or appendix reference.
The sentence is incomplete, which would be noticed by editors and reviewers.
4.
MEDIUMreporting
Add an explicit statement naming the reporting guideline followed (e.g., 'This trial is reported according to CONSORT 2010 guidelines.') in the Methods section.
Although the paper structurally follows CONSORT, naming the guideline is a standard transparency expectation.
5.
MEDIUMcopyedit
Fix typo in Table 3 footnote: change 'n=4l6' to 'n=416'.
This is a clear typographical error that could cause confusion.
6.
MEDIUMcopyedit
Rephrase the description of the primary analysis in Methods/Statistical analysis for clarity: 'The unadjusted (crude) analysis, which included the stratification factors of study site and HIV status, served as the primary analysis.'
The original phrasing is grammatically awkward per the copyedit report.
7.
MEDIUMdata code
Add a DOI or permanent accession number for the WWARN repository deposit when the data are submitted.
This strengthens the data availability statement by providing a permanent link.
8.
LOWreporting
In the Discussion, explicitly note that the study was not designed to detect differences in rare adverse events (currently implied but not stated).
Clarifies a common limitation of efficacy-focused trials for readers.
9.
LOWcopyedit
Standardise spelling of 'randomisation' vs 'randomization' to a single style (British recommended, as used in most of the text).
Minor consistency issue noted by the copyedit pass.
10.
LOWcopyedit
Consider adding a footnote to Table 1 explaining that percentages may not sum exactly due to rounding.
Already noted in the table, but a formal footnote improves clarity.

Full text (71,758 chars)Analyzed: Jul 7, 2026

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