PCLM-D-25-00227

“Heat is a danger to my health even though I said I am used to it”: Qualitative insights of workplace heat among community health workers and promoters in Kenya

PLOS Climate

Dear Dr. Maina,

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Academic Editor

PLOS Climate

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Does this manuscript meet PLOS Climate’s publication criteria?>

Reviewer #1: Yes

Reviewer #2: Yes

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2. Has the statistical analysis been performed appropriately and rigorously?-->?>

Reviewer #1: N/A

Reviewer #2: N/A

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3. Have the authors made all data underlying the findings in their manuscript fully available (please refer to the Data Availability Statement at the start of the manuscript PDF file)??>

The PLOS Data policy

Reviewer #1: Yes

Reviewer #2: No

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4. Is the manuscript presented in an intelligible fashion and written in standard English??>

Reviewer #1: Yes

Reviewer #2: Yes

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Reviewer #1: This is a well structured and written article covering an important and timely topic. The research rationale and approach is introduced well, and the methodology very thoroughly discussed - with a lot of detail on methods, ethics, rigour and reflexivity. Indeed I feel there is perhaps more here than would be expected in a paper (as opposed to a thesis) - so if space becomes an issue this is definitely something that could be cut (along with some editing of quotes - see below). The paper is on the whole quite descriptive, and in places quite repetitive, and I would have liked to see a little more development of some conceptual elements in order to make the most of the excellent empirical material.

The theoretical framework section should be strengthened, I feel. At present, it reads as a set of summarized results about the vulnerabilities identified through the research, rather than presenting and justifying a framework of concepts used to analyze the material. The authors make considerable reference to intersecting components of vulnerability (referred to as intersectionality) and a few references to dimensions of justice - but neither of these aspects are explored sufficiently in the paper, not in the theory or the discussion. I think this is where the authors could bring in more analytical depth.

- By focussing much more than at present in the discussion on how the 5 different sets of factors do actually interlink in the practice of health workers lives to magnify impacts and risks - ie where and how they overlap in the CF diagram, and with what effect - this will surely bring out aspects of the study that are more novel (at present the Discussion mainly deals with each 'factor' field separately (apart from one paragraph on p24)).

- There could also be a deeper connection made to the literature on social/environmental/climate justice and the ideas of that work - how do these research findings connect with such concepts. At present, justice is alluded to, but largely just in passing.

It is great to see so many quotes, but some are long and could have sentences removed without losing meaning. In fact a few would benefit from this e.g. the first sentence of the quote starting line 403 is not only superfluous but doesn't seem to make sense - the rest of the quote would actually work better without it.

Finally, I would question the statement made in the Conclusion on line 612 which says 'By incorporating intersectional approaches to policy and intervention design, our research calls...'. To my understanding this research did not involve policy and intervention design. it would be misleading to suggest this, I think.

Reviewer #2: Overall

Well-written paper, with clearly reported methods addressing an important and timely topic. A few suggestions for the authors to consider to strengthen the paper:

Please clarify who you mean with the term CHWs. CHWs in Kenya include Community Health Promoters-CHPs, and Community Health Assistants/Officers who supervise them. Important to clarify whether you are referring to just CHPs or both CHPs and CHAs. CHAs/CHOs are also usually employed by the government with variations (some may be on contract, others are permanent and pensionable employees), while until recently CHPs (formerly Community Health Volunteers) were volunteers. Across all the sections of the paper, the study group CHWs and CHPs, needs to be updated to be in line with the current names for these groups.

Abstract

Pg 1-You conducted 41 interviews with CHWs and CHPs in Mombasa and Tana River counties. State in brackets, how many per county i.e. Mombasa, n=?, Tana River, n=?

Introduction

Methods:

-What was the rationale for selecting the two study counties?

-Counties sometimes have differences in how they manage or organise their CHW programmes. Were there any differences in these counties, that might be useful to understand the context?

Pg 5: lines 123-126 You asked interested CHWs and CHPs to register, and purposefully selected from this list of the ones who registered.

• Does this not introduce a limitation to your study if you selected only from those who were interested. Is it possible that certain categories that you might have been interested in did not register at all.

• In describing that you selected purposefully from the list, I suggest, that you include wording like you sought to achieve maximum variation of work experience, age, time in current employment and age.

• From the results it seems that gender was also a criteria, so I suggest including it here.

• What kinds of characteristics were you looking for under work experience as a criteria.

• Were all the study respondents employed given that time in current employment was also a criteria? It is not uncommon for CHPs to be subsistence farmers, or small business owners.

Lines 140-141: Please provide your interview guide as a supplementary file.

Results

-Table 1 includes urban and rural in their demographic characteristics. Tana river county is considered a rural county while Mombasa largely urban, is this the case? Or does urban include a mix of respondents from both Mombasa and Tana River, and the same for the rural?

-Pg 15 Lines 335-338: CHWs and CHPs described experiencing HRIs during field visits, especially whenwalking long distances (over 4 km) over sloped or flooded terrain and performing intensephysical activity in high temperatures and were sometimes unaware the HRIs were caused by heat’. I suggest breaking this sentence in two to improve clarity as it is presenting two different ideas, i) that some CHWs and CHPs experienced HRIs, and ii) that some were unaware that the HRIs were caused by heat.

-In lines 351-352: I suggest adding some words like, ‘they [the CHPs] perceived that’...the combination of these conditions and extreme heat lead to.... This is so that it is clear that this is a perception/view held by the respondents.

-I suggest rather than stating the themes in just two words you could more fully describe the theme e.g. ‘climate variability’ in line 387, could be ‘effects of changing weather patterns on CHW work and livelihoods’. Please consider the same for ‘work conditions’ , ‘health disparities’ and ‘gender’. For example work conditions could be ‘work conditions and pressures’. The theme on health disparities could be ‘CHW experiences of HRIs and accessing healthcare’. While gender could be ‘gendered experiences of extreme weather and work challenges’

-You have very many quotes and I suggest reducing the quotes especially where you have used two quotes to prevent the researcher voice from being dampened

-Across the findings, were there any significant differences in experiences in the two counties? If not, I suggest highlighting this at the beginning of the results section where you present a summary of the themes to be presented in the results section (lines 222-236)

Discussion

-Lines 548 ‘gendered expectations’ I suggest rewording to ‘how gender and climate-related stressors intersect to..’ Suggesting this because it is not just expectations but also the experiences that were reported by the CHWs.

-Lines, 550: ‘economic class’ I think the results don’t specifically tell us about the economic class of the respondents, but that they experience economic inequality/income inequality. Economic class is a very specific term based on wealth quintiles, and using the term suggests that the study identified the CHWs as belonging to one/more the five different economic classes (lower class, lower middle class, middle class, upper middle class, and upper class), which is not the case as presented in the results.

Overall

-Review the whole paper for a few minor grammatical errors, missing words (missed prepositions), mixed tense.

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Reviewer #1: No

Reviewer #2: No

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Submitted filename: PLos Climate and extreme weather review.docx

“Heat is a danger to my health even though I said I am used to it”: Qualitative insights of workplace heat among community health workers and health promoters in Kenya

PCLM-D-25-00227R1

Dear Ms Maina,

We are pleased to inform you that your manuscript '“Heat is a danger to my health even though I said I am used to it”: Qualitative insights of workplace heat among community health workers and health promoters in Kenya' has been provisionally accepted for publication in PLOS Climate.

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Thank you again for supporting Open Access publishing; we are looking forward to publishing your work in PLOS Climate.

Best regards,

Sari Kovats, Ph.D.

Academic Editor

PLOS Climate

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Additional Editor Comments (if provided):

Reviewer Comments (if any, and for reference):