The authors have declared that no competing interests exist.
The Democratic Republic of Congo has implemented reforms to its national routine health information system (RHIS) to improve timeliness, completeness, and use of quality data. However, outbreaks can undermine efforts to strengthen it. We assessed the functioning of the RHIS during the 2018–2020 outbreak of Ebola Virus Disease (EVD) to identify opportunities for future development. We conducted a qualitative study in North Kivu, from March to May 2020. Semi-structured interviews were conducted with 34 key informants purposively selected from among the personnel involved in the production of RHIS data. The topics discussed included RHIS functioning, tools, compilation, validation, quality, sharing, and the use of data. Audio recordings were transcribed verbatim and thematic analysis was used to study the interviewees’ lived experience. The RHIS retained its structure, tools, and flow during the outbreak. The need for other types of data to inform the EVD response created other parallel systems to the RHIS. This included data from Ebola treatment centers, vaccination against Ebola, points of entry surveillance, and safe and dignified burial. The informants indicated that the availability of weekly surveillance data had improved, while timeliness and quality of monthly RHIS reporting declined. The compilation of data was late and validation meetings were irregular. The upsurge of patients following the implementation of the free care policy, the departure of healthcare workers for better-paid jobs, and the high prioritization of the outbreak response over routine activities led to RHIS disruptions. Delays in decision-making were one of the consequences of the decline in data timeliness. Adequate allocation of human resources, equitable salary policy, coordination, and integration of the response with local structures are necessary to ensure optimal functioning of the RHIS during an outbreak. Future research should assess the scale of data quality changes during outbreaks.
According to the World Health Organization (WHO), Health Information Systems, including Routine Health Information Systems (RHIS), are one of the six components of a health system [
In 2008, WHO encouraged health service reforms to better consider the needs and expectations of beneficiaries [
The Democratic Republic of Congo (DRC) established its RHIS in 1987 [
For the RHIS to function correctly, tools—such as patient records, registers, reporting forms, data entry platforms—need to be designed, updated, reproduced, and deployed; training needs to be organized and technologies such as computers and software need to be distributed to all levels of the health system [
The occurrence of an infectious disease outbreaks has severe consequences on many health system components. This has been the case with the Severe Acute Respiratory Syndrome (SARS) in Canada [
From 2018 to 2020, in the provinces of North Kivu, Ituri, and South Kivu, the DRC recorded its tenth EVD outbreak. This outbreak remains the most serious in the country in terms of its duration, the size of the affected area, and the number of victims [
Unlike the other components of the health system, the performance of the RHIS is seldom evaluated in the DRC and even more rarely during outbreaks of infectious diseases. For example, Lal et al. have focused on RHIS’ areas such as governance and coordination, infrastructure and resources of health systems during the Ebola and Covid-19 epidemics [
We used the Performance of Routine Information System Management (PRISM) conceptual framework developed by Measure Evaluation. PRISM makes it possible to evaluate RHIS components and make comparisons between countries and across time [
As shown in
This research was approved by the Ethics Committee of the Kinshasa School of Public Health (No ESP/CE/11/2020). Participation in the study was free, voluntary, without financial compensation and without individual benefit. The potential risks that were presented to participants in order to obtain their verbal consent were the loss of time spent on the interview and possible reprisals against their criticism or opinion. The verbal consent was also sought for the recording of the interview on a Dictaphone. Participants were informed of the confidentiality and anonymity measures in place. Indeed, the interviews were one on one and conducted in privacy. Finally, the results are presented in a global and anonymous way to prevent potential identification of participants. One informant did not wish to be recorded. He was not included in the study.
We conducted a qualitative case study of the performance of the RHIS during the 2018 to 2020 EVD outbreak in the Province of North Kivu, Eastern DRC. We selected 5 of 19 affected districts: as shown in
The interviews were conducted between March 9th and May 14th 2020. This period was part of the tail end of the outbreak, which was first declared on August 2nd 2018 and was officially declared over on June 25th 2020. However, all response interventions were still in place at the time of data collection. This includes case management, surveillance, contact tracing, vaccination, and free care in most healthcare facilities. This period also corresponds to the first cases of COVID-19 in the country. However, the study site was not heavily affected by this new pandemic at that time.
We recruited study participants from all staff involved in the production and use of health data at the provincial and operational levels. Key informants (KIs) from the Provincial Health Department were recruited from the office managers, analysts, and program managers. Representatives of non-governmental organizations (NGOs) that provided financial and technical support for routine health services were also targeted. At the operational level, KIs were selected from the health District’s office and the facilities. KIs from districts were physicians, administrators, or supervising nurses. In facilities, KIs were selected among nurses in charge of the health area and members of the hospital management committees, such as medical directors, chief of staff physicians, nursing directors, and administrators.
We interviewed 34 KIs. Even though we achieved saturation (this was reflected in the repetition of the same information and the absence of new ideas) with about 20 semi-structured interviews (SSIs), we continued interviewing other informants to have a better representation of several sub-samples such as the duration of the outbreak, the number of reported cases of EVD in the region, as well as the profile of the KIs. We also considered other events that may have positively or negatively affected the health services during the period under study. For example, it has been shown that the free healthcare policy (partial or total) had an important effect on the use of services was documented during the 2018 EVD outbreak in Equateur province [
Inclusion and exclusion criteria: the selected districts had to have reported 50 or more EVD cases and had their last case within the past 60 days. As for respondents, selected KIs were required to have been in their current role for at least one year before the EVD outbreak, as well as throughout the outbreak. They were also required to be present, available, and willing to participate in the study. Containment measures introduced as part of the fight against Covid-19 limited access to certain health facilities.
Data were collected through semi-structured interviews (SSIs) conducted with KIs. A pre-tested interview guide based on the PRISM framework was used. All SSIs were conducted either in French or Swahili by the first author who is a PhD student. Nearly all interviews were one-on-one, were conducted at the respondents’ place of work, and in private. One interview was conducted via telephone and one outside of regular office hours and location due to the availability of the respondent. Audio recordings were taken on a Dictaphone, as well as notes, including non-verbal expressions, were also taken during each interview, which on average lasted 50 minutes.
All interviews were conducted by the first author, which avoided the problem of delegation of tasks inherent to qualitative research. The triangulation of sources was chosen by the research team to ensure the quality of the data and therefore the validity of the results. This included the selection of KIs from several professional categories (doctors vs nurses vs administrators), functions (providers vs managers), levels in the health system pyramid (Health facilities vs districts vs provincial), and affiliation (governmental actors vs supporting partners). Finally, sharing and discussing the preliminary results with the management team and with the actors in the sector helped to minimize misinterpretations.
The audio recordings in French were transcribed verbatim, while those in Swahili were translated to French during transcription by two members of the research team who are fluent in both languages. The transcripts were read several times by the team alongside the audio recordings. This allowed for the accuracy of the transcription and translation to be assessed. It also allowed for familiarization with the content of the transcripts.
After cleaning, the transcripts were imported to Atlas-TI version 7.5.7 for coding. The analysis plan was developed using transcripts from the first five interview transcripts and core concepts of the PRISM framework. Thematic analysis was performed to understand participants’ lived experiences. This qualitative approach proceeds systematically by identifying, grouping, and examining expressions that emerge in a corpus and are related to the themes under investigation [
The study sample comprised 34 KIs selected from the provincial health department (n = 7) and the districts of Beni (n = 10), Butembo (n = 7), Katwa (n = 6), Mabalako (n = 3), and ZS Musienene (n = 1). The socio-demographic and occupational characteristics of KIs are described in
Socio-demographic characteristics | PHD |
District | Hospital | Health centre | Total |
---|---|---|---|---|---|
n = 7 | n = 10 | n = 6 | n = 11 | n (%) = 34 | |
Male | 6 | 7 | 6 | 8 | |
Female | 1 | 3 | 0 | 3 | |
35–40 | 1 | 2 | 0 | 0 | |
41–54 | 4 | 6 | 4 | 8 | |
55 + | 0 | 0 | 1 | 1 | |
Not specified | 2 | 2 | 1 | 2 | |
3–10 | 2 | 1 | 0 | 1 | |
11–20 | 2 | 5 | 5 | 6 | |
21 + | 0 | 3 | 1 | 4 | |
Not specified | 3 | 1 | 0 | 0 | |
Nurses | 2 | 5 | 2 | 11 | |
Administrators | 2 | 3 | 2 | 0 | |
Physician | 3 | 2 | 2 | 0 | |
Secondary | 0 | 0 | 0 | 3 | |
University | 4 | 9 | 6 | 8 | |
Post University | 3 | 1 | 0 | 0 |
PHD:
* including Non-Governmental Organization Staff.
As shown in
Respondents indicated that facilities continued to produce and transmit the same types of data using the usual forms and channels according to the set deadlines during the outbreak. The KIs did not report any changes in the guidelines for the frequency and deadlines of reporting. However, the KIs reported that there was a need for other types of data for the various response commissions and their partners. These include data related to case management in Ebola treatment centers, vaccination against Ebola, contact surveillance, point of entry and community level alerts, and dignified and safe burials. As described in
DHIS2:
Two trends emerged regarding the functioning of the RHIS during the EVD outbreak. A minority felt that the functioning was normal or almost normal. However, this minority came mainly from hospitals and first-line facilities that reported fewer cases of EVD or whose staffing had remained consistent throughout the outbreak. In contrast, the majority of KIs felt that the RHIS had been disrupted at the facility, district, and provincial levels. They mentioned that disruptions were most severe at the beginning of the outbreak and during three weeks following the notification of an EVD positive case. The following comment illustrates this idea:
" [Nurse, Facility / Code: IA_01_AS_IT_01]
The majority of KIs felt that the completion of registers was not affected because they were the source of verification for the purchase of services under the performance-based financing system and the basis for active epidemiological surveillance. It was therefore in the interest of the facilities to complete them regularly. On the other hand, a minority indicated that the registers were sometimes incomplete or completed late when data compilation took too long. According to them, the large flow of patients after implementation of the free healthcare policy had increased the providers’ workload. Below is a facility nurse’s quote:
" [Nurse, Facility / Code: IA_01_AS_IT_02]
The vast majority of KIs reported that data analysis suffered greatly during the EVD outbreak, sometimes resulting in inconsistent estimates. Informants reported that data validation meetings were held infrequently, with many postponements. Quorum problems, delays in receiving reports, and the prioritization of the response over routine activities emerged as causes for the non-scheduling of routine meetings. This resulted in a delay in decision-making. In contrast, a few KIs indicated that data validation meetings had continued normally. Due to the scarcity of supervision visits or data validation meetings, feedback was lacking. When it was given, the expected actions were not always carried out.
Inadequate analysis of data had consequences, including the late detection of other epidemics. Few informants reported that measles outbreak was identified late. Thus, the health system was not able to implement strategies that can improve health. All this required data availability, analyses, and holding meetings, as illustrated by this quote:
“ [Nurse, Provincial, / Code: IA_03_DPS_Analyst_01]
The vast majority of KIs reported that data transmission was significantly delayed. However, they acknowledged that data completeness was not an issue. In contrast, despite high levels of report completeness, a minority of informants felt that there was missing data in the templates. One respondent mentioned the loss of data on non-Ebola diseases treated in Ebola treatment centers. Indeed, after their investigation, when the patient’s condition improved and the Ebola test was negative, patients left the centers for home, resulting in under-reporting of their diseases. Another respondent noted that some private facilities had stopped reporting or were reporting after insistence from health officials, in protest at the fact they were not covered by financial aids as public facilities. For example, one nurse indicated that:
" [Nurse, Facility / Code: IA_04_AS_IT_02]
The majority of our KIs felt that the quality of health data was affected during the EVD outbreak. Some KIs felt that unintentional errors were likely to occur in the templates because of the very high volumes of data to be compiled and the pressure on providers to send in their reports within the deadline. A minority felt that some numbers were filled in on the templates without any underpinning because providers were avoiding sanctions from their superiors, as illustrated by this response:
"… [Supervisor, District / Code: IA_05_BCZS_IS]
The RHIS continues to face several additional challenges not specific to the EVD outbreak. These include geographical inaccessibility and poor internet coverage. Prior to the epidemic, facilities were sometimes the targets of threats from armed groups active in the region. Some facilities had even been burned or looted, and some health providers had been killed or kidnapped. In addition to these attacks, which continued or worsened during the outbreak, unhappy community members also attacked facilities, providers and supporting partners. Some informants explained that these attacks had been motivated by the fact that some providers had been found to be corrupt and complicit with those who instigated the EVD outbreak for their hidden interests. This environment of fear hindered work in general and data reporting activities specifically.
Moreover, one informant reported the destruction of registers and patient follow-up records of human immunodeficiency virus service by the disinfection team. This radical solution resulted in a huge loss of records for a system that is not digitized. Below is a quote from KIs to support this observation:
" [Supervisor, District / Code: IA_01_BCZS_IS]
Other respondents admitted that the departure of experienced staff also affected data reporting. To cope with this challenge, some facilities recruited agents responsible for collecting data with the support of NGO partners. Other facilities opted for teamwork, the delegation of tasks, or recruitment of staff, even if the necessary skills were sometimes lacking.
In expressing their wishes for the future, most respondents felt that the addition of staff or the establishment of an equitable salary policy between outbreak agents and routine health service providers should be considered. They explained that while workload reduction requires adding staff, fair treatment of providers is likely to encourage staff to stay in one facility for a longer period. To illustrate this, one managing director said:
"… [Administrator, Hospital / Code: IA_01_HGR_AG]
This study aimed to assess the RHIS performance during the EVD outbreak in North Kivu. We found that the RHIS had continued to function, notably because the data were still produced. The need to have sources of verification for disease surveillance and the purchase of services under the PBF and the fear of administrative sanctions were among the reasons for maintaining the RHIS during the outbreak. Other factors were previously identified by Chanyalew et al as predictors of data use in the Amhara Region, Ethiopia. These include the existence of the instructions, the need for use of data for target setting, and the culture of displaying performance data [
The study highlighted that the flow of health information changed with the creation of parallel data systems which were not integrated into the DHIS2. Indeed, the various commissions of the outbreak response and their partners needed additional information that was not included in the usual reporting forms. This multiplicity of reports had increased the volume of work and could lower the data quality [
The influx of patients following the introduction of free health care has led to an increase in the volume of work. At the same time, the number of staff decreased as many providers joined the response team. As a result, filling out registers and compiling data had become very laborious, leading to the decline in the timeliness of reporting. This likely moved the country away from its goal of migrating to real-time data reporting [
This study revealed the difficulty of maintaining regular data analysis, validation meetings, supervision, and feedback during an outbreak. The challenge of achieving a quorum and the poor timeliness of reports had made some meetings difficult to complete. As a result, a measles outbreak was identified late. This finding would be in line with the findings of Wickremasinghe et al. who reported that data availability, data quality, and human dynamics were among the barriers to data-driven decision making [
Informants thought that there was a decline in data accuracy during the EVD outbreak. It was reported that some templates were submitted with missing or fabricated data when it was difficult to respect the deadline as data compilation was laborious. This practice had the potential to increase discrepancies between the primary sources and the data encoded in the DHIS2. As a result, the problem of over- and under-reporting in facilities affected by the EVD outbreak under study may be more acute than those observed to varying degrees in Rwanda [
Overall, respondents’ views on the occurrence of disruptions in the functioning of the RHIS during the EVD outbreak were divergent. There were no disruptions for some, while there were for others. Based on the opinions of the KIs, there was a direct relationship between the magnitude of the outbreak, particularly the number of cases of EVD, and the level of disruption of the RHIS. Form some KIs, all activities related to data reporting were affected in the same way while for others, the compilation and holding of data analysis meetings were very much affected. Several respondents reported also that the critical periods were the beginning of the outbreak and the weeks following the notification of confirmed EVD cases. In a context of limited resources, efforts can be focused in the most affected districts, on the most vulnerable activities, and during the most critical periods. Limited access to the internet and electricity, as well as insecurity, were also reported as challenges to data reporting. However, these were not specific to the EVD outbreak because they have already been reported across the country [
Several initiatives that kept the RHIS functional during the outbreak were reported. They included the delegation of tasks, the creation of data manager positions, and increased staffing levels. Although assumed to be effective by respondents, the presence of a data officer had not improved the availability and completeness of data in Malawi in a non-epidemic setting [
While we acknowledge that the impact of the initiatives documented here extends far beyond the scope of this study, we believe that a deeper analysis of the causes of the disruptions is warranted before the appropriate solutions to these problems is identified. [
We did not objectively assess the quality of the data produced during the EVD outbreak to validate the opinions of our KIs. This limitation offers an opportunity for future research. Similarly, it may be important to assess the effect of initiatives taken during the outbreak on the performance of the RHIS. Nonetheless, the sample size and the selection of participants at three different levels, namely the provincial, the districts, and the facilities allowed the triangulation of data sources and improved the validity of the results.
This study assessed the process of health data production during the tenth outbreak of EVD in North Kivu, DRC. It showed that the flow of data did not change but that the RHIS faced several challenges that could affect its performance. The integration of the outbreak response into local structures to allow for a single command unit for routine services and the response, the allocation of human resources according to workload, the implementation of a fair and incentive-based salary policy, the simplification and centralization of data flow and the implementation of electronic registers should be considered to build an efficient RHIS during future public health crises.
(TIF)
We acknowledge the contribution of Ramazani Yuma, former Secretary-General for Health, Ministry of Health, DRC for supporting the study. We also thank doctor Justin Kabondjo, Director of the health information system, and doctor Janvier Kabuya, Head of the provincial Health Department in North Kivu for their support of the study. We are grateful to all the key informants for helping us obtain information on key parameters related to this study.
PGPH-D-21-01117
Assessing Routine Health Information System Performance during the Tenth Outbreak of Ebola Virus Disease in the Democratic Republic of the Congo: a qualitative study in North Kivu
PLOS Global Public Health
Dear Dr. Kyomba,
Thank you for submitting your manuscript to PLOS Global Public Health. After careful consideration, we feel that it has merit but does not fully meet PLOS Global Public Health’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 Mar 25 2022 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
Please include the following items when submitting your revised manuscript:
A rebuttal letter that responds to each point raised by the editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'. A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'. An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.
Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.
We look forward to receiving your revised manuscript.
Kind regards,
Ari Natalia Probandari, PhD
Academic Editor
PLOS Global Public Health
Journal Requirements:
1. Please ensure that the funders and grant numbers match between the Financial Disclosure field and the Funding Information tab in your submission form. Note that the funders must be provided in the same order in both places as well.
2. Please amend your detailed Financial Disclosure statement. This is published with the article, therefore should be completed in full sentences and contain the exact wording you wish to be published.
i). State the initials, alongside each funding source, of each author to receive each grant.
ii). State what role the funders took in the study. If the funders had no role in your study, please state: “The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.”
iii). If any authors received a salary from any of your funders, please state which authors and which funders.
3. Please update your Competing Interests statement. If you have no competing interests to declare, please state: “The authors have declared that no competing interests exist.”
4. In the online submission form, you indicated that “Data supporting the findings of this study are available from the corresponding author GKK on request.”. All PLOS journals now require all data underlying the findings described in their manuscript to be freely available to other researchers, either 1. In a public repository, 2. Within the manuscript itself, or 3. Uploaded as supplementary information.
This policy applies to all data except where public deposition would breach compliance with the protocol approved by your research ethics board. If your data cannot be made publicly available for ethical or legal reasons (e.g., public availability would compromise patient privacy), please explain your reasons by return email and your exemption request will be escalated to the editor for approval. Your exemption request will be handled independently and will not hold up the peer review process, but will need to be resolved should your manuscript be accepted for publication. One of the Editorial team will then be in touch if there are any issues.
5. Please provide separate figure files in .tif or .eps format only and ensure that all files are under our size limit of 20MB.
For more information about how to convert your figure files please see our guidelines:
Additional Editor Comments (if provided):
The authors should follow COREQ guideline for qualitative research reporting. In the guideline, the authors should provide overall coding tree and give examples of coding process. The authors also should provide explanation on researchers subjectivity and reflexivity (see COREQ). In addition to that, please respond to reviewers comment and give revisions accordingly.
[Note: HTML markup is below. Please do not edit.]
Reviewers' comments:
Reviewer's Responses to Questions
1. Does this manuscript meet PLOS Global Public Health’s
Reviewer #1: Yes
Reviewer #2: Yes
**********
2. Has the statistical analysis been performed appropriately and rigorously?
Reviewer #1: Yes
Reviewer #2: N/A
**********
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
Reviewer #1: Yes
Reviewer #2: Yes
**********
4. Is the manuscript presented in an intelligible fashion and written in standard English?
PLOS Global Public Health 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: Manuscript: "Assessing Routine Health Information System Performance during the Tenth Outbreak
of Ebola Virus Disease in the Democratic Republic of the Congo: a qualitative study in
North Kivu (PGPH-D-21-01117)" has been submitted to “PLOS Global Public Health” for consideration.
The manuscript can be accepted for publication in its current form..
Reviewer #2: Please see my comments in the attached file. This is a nicely executed study. I only have a number of minor, even trivial, comments, mostly meant to add clarity. If the editor decides to request a revision, please do not provide a point-by-point response to my comments. Instead, address them directly in the track-change version of the manuscript (and fine to remove my comments, as I have a separate copy saved).
**********
6. PLOS authors have the option to publish the peer review history of their article (
For information about this choice, including consent withdrawal, please see our
Reviewer #1: No
Reviewer #2: No
**********
[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,
Submitted filename:
Assessing Routine Health Information System Performance during the Tenth Outbreak of Ebola Virus Disease (2018- 2020) in the Democratic Republic of the Congo: a qualitative study in North Kivu
PGPH-D-21-01117R1
Dear Doctor Kyomba,
We are pleased to inform you that your manuscript 'Assessing Routine Health Information System Performance during the Tenth Outbreak of Ebola Virus Disease (2018- 2020) in the Democratic Republic of the Congo: a qualitative study in North Kivu' has been provisionally accepted for publication in PLOS Global Public Health.
Before your manuscript can be formally accepted you will need to complete some formatting changes, which you will receive in a follow up email. A member of our team will be in touch with a set of requests.
Please note that your manuscript will not be scheduled for publication until you have made the required changes, so a swift response is appreciated.
IMPORTANT: The editorial review process is now complete. PLOS will only permit corrections to spelling, formatting or significant scientific errors from this point onwards. Requests for major changes, or any which affect the scientific understanding of your work, will cause delays to the publication date of your manuscript.
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
Thank you again for supporting Open Access publishing; we are looking forward to publishing your work in PLOS Global Public Health.
Best regards,
Lucinda Shen, MSc
PLOS Staff Editor
on behalf of
Ari Natalia Probandari, PhD
Academic Editor
PLOS Global Public Health
***********************************************************
Please respond to the reviewer's comment and revise accordingly.
Reviewer Comments (if any, and for reference):
Reviewer's Responses to Questions
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 #2: All comments have been addressed
**********
2. Does this manuscript meet PLOS Global Public Health’s
Reviewer #2: Yes
**********
3. Has the statistical analysis been performed appropriately and rigorously?
Reviewer #2: N/A
**********
4. 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
Reviewer #2: Yes
**********
5. Is the manuscript presented in an intelligible fashion and written in standard English?
PLOS Global Public Health 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 #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 #2: I want to thank the authors for addressing all of my comments in the previous version.
**********
7. PLOS authors have the option to publish the peer review history of their article (
For information about this choice, including consent withdrawal, please see our
Reviewer #2: No
**********