Dear Dr Rwamwejo,

Thank you very much for submitting your manuscript "Assessing the knowledge, attitudes, practices, and perspectives of stakeholders of the deworming program in rural Rwanda" for consideration at PLOS Neglected Tropical Diseases. As with all papers reviewed by the journal, your manuscript was reviewed by members of the editorial board and by several independent reviewers. The reviewers appreciated the attention to an important topic. Based on the reviews, we are likely to accept this manuscript for publication, providing that you modify the manuscript according to the review recommendations.

The reviewers have taken time to suggest some relevant considerations for your paper. Overall, they have found the paper to be well-written and clearly outlined. Please be aware of their comments and address them in your response to reviewers as per PLoS NTD requirements. Some comments are directly embedded within the paper itself as comments, so please take note of those as well.

A few additional points to consider here-

Please note that there are papers that assessed the experiences of CHWs working in schistosomiasis campaigns (see the SCORE project papers) and examples from Kenya. While these may not be classified directly as KAP studies, they accomplish the same goals. (lines 21-23 of your paper).

Consider revising terminology like 'impoverished populations' to 'people living in impoverished situations' which is more empowering language.

Please prepare and submit your revised manuscript within 30 days. If you anticipate any delay, please let us know the expected resubmission date by replying to this email.

When you are ready to resubmit, please upload the following:

[1] A letter containing a detailed list of your responses to all review comments, and a description of the changes you have made in the manuscript.

Please note while forming your response, if your article is accepted, you may have the opportunity to make the peer review history publicly available. The record will include editor decision letters (with reviews) and your responses to reviewer comments. If eligible, we will contact you to opt in or out

[2] Two versions of the revised manuscript: one with either highlights or tracked changes denoting where the text has been changed; the other a clean version (uploaded as the manuscript file).

Important additional instructions are given below your reviewer comments.

Thank you again for your submission to our journal. We hope that our editorial process has been constructive so far, and we welcome your feedback at any time. Please don't hesitate to contact us if you have any questions or comments.

Sincerely,

Alison Krentel

Academic Editor

PLOS Neglected Tropical Diseases

Francesca Tamarozzi

Section Editor

PLOS Neglected Tropical Diseases

***********************

The reviewers have taken time to suggest some relevant considerations for your paper. Please be aware of their comments and address them in your response to reviewers as per PLoS NTD requirements. Some comments are directly embedded within the paper itself as comments, so please take note of those as well.

A few additional points here-

Please note that there are papers that assessed the experiences of CHWs working in schistosomiasis campaigns (see the SCORE project papers) and examples from Kenya. While these may not be classified directly as KAP studies, they accomplish the same goals. (lines 21-23 of your paper).

Consider revising terminology like 'impoverished populations' to 'people living in impoverished situations'

Overall, the paper is well-written and clearly outlined.

Reviewer's Responses to Questions

Key Review Criteria Required for Acceptance?

As you describe the new analyses required for acceptance, please consider the following:

Methods

-Are the objectives of the study clearly articulated with a clear testable hypothesis stated?

-Is the study design appropriate to address the stated objectives?

-Is the population clearly described and appropriate for the hypothesis being tested?

-Is the sample size sufficient to ensure adequate power to address the hypothesis being tested?

-Were correct statistical analysis used to support conclusions?

-Are there concerns about ethical or regulatory requirements being met?

Reviewer #1: -Are the objectives of the study clearly articulated with a clear testable hypothesis stated? Yes

-Is the study design appropriate to address the stated objectives? Yes

-Is the population clearly described and appropriate for the hypothesis being tested? Yes

-Is the sample size sufficient to ensure adequate power to address the hypothesis being tested? Yes

-Were correct statistical analysis used to support conclusions? Yes

-Are there concerns about ethical or regulatory requirements being met? Not to me

Reviewer #2: The objectives are clearly stated.

The study design is quite appropriate to address the stated objectives

Sufficient sample size

Statistical analysis are okay to support conclusions

No such concerns

--------------------

Results

-Does the analysis presented match the analysis plan?

-Are the results clearly and completely presented?

-Are the figures (Tables, Images) of sufficient quality for clarity?

Reviewer #1: -Does the analysis presented match the analysis plan? Yes

-Are the results clearly and completely presented? Mostly. Please see recommendations in attached comments file.

-Are the figures (Tables, Images) of sufficient quality for clarity? Yes

Reviewer #2: The analysis presented correspond with the analysis plan. The results are clearly presented

The tables and figures are of sufficient quality for clarity. The variables in the tables should be refined to avoid repeatition

--------------------

Conclusions

-Are the conclusions supported by the data presented?

-Are the limitations of analysis clearly described?

-Do the authors discuss how these data can be helpful to advance our understanding of the topic under study?

-Is public health relevance addressed?

Reviewer #1: -Are the conclusions supported by the data presented? Yes

-Are the limitations of analysis clearly described? Yes

-Do the authors discuss how these data can be helpful to advance our understanding of the topic under study? Yes they do, although please see comments for recommendation of additional further study that may be more directly contributive to the literature.

-Is public health relevance addressed? Yes, it is.

Reviewer #2: The conclusions are supported by the data presented. The limitations are clearly presented by the authors.

--------------------

Editorial and Data Presentation Modifications?

Use this section for editorial suggestions as well as relatively minor modifications of existing data that would enhance clarity. If the only modifications needed are minor and/or editorial, you may wish to recommend “Minor Revision” or “Accept”.

Reviewer #1: A number of recommendations for clarity are addressed in the attached comments (copied below).

Introduction

• Line 71: is citation 13 for both statements?

• Line 75: missing a word before citation 15, “children infected with” what?

• Line 76: remove comma, also a very wide range?

• Line 79: “in conjunction” rather than “conjunct”

• Line 91: “and CHWs,”

Methods

• Line 109/110: possible duplication of “Sample”?

• Line 118: would it be possible to give some examples of what roles “local leaders” perform in the community? (i.e. civil, religious, etc.)

• Line 144: I believe this is the first mention of “cells”. There is a definition given later, all the way down in line 316 of the results. Please move this description to line 144 where “cell” is first used.

• Line 149: Please give a short description of what is meant by “theoretical saturation”, and a reference for “purposive sampling”.

• Line 158: “Informed consent was obtained”

• Line 174: a citation for the Likert scale may be appropriate https://psycnet.apa.org/record/1933-01885-001

• Line 186: What was the pre-testing mentioned here? Is this internal with the research team or were potential respondents shown the draft survey?

• Line 201: A reference for Fisher’s exact test may be appropriate https://link.springer.com/referenceworkentry/10.1007/978-3-642-04898-2_253

• Line 202/3: From this, it is hard to understand what attitude and practice categories really are. Describing the possible categories in the methods may be useful.

• Line 206: The statement says that all statistical tests were performed with a p-value of 0.05. This is confusing, is it perhaps the case that the authors mean that all results of the statistical tests with a p-value <0.05 were deemed to be significant?

• Good description of the translation/coding in lines 207-210, maybe a citation for Dedoose software would be appropriate.

• Line 212: Does the University of Global Health Equity IRB have an identification number or code?

Results

• Table 1: It may be more clear to indicate that “Education level” is the “Highest Level of Education Attained”. Otherwise some may be confused that only 1 Teacher had a primary level of education while 314 had a secondary level of education.

• Table 1: Is “Training in deworming” the same as “training on worm infections”? It is a little confusing to see them presented one above the other as though they are maybe the same.

• Table 1: I am a little confused about the p-values in table 1 that are seemingly comparing across three columns and 2 rows at the same time with the same value. For example, what is the p-value 0.058 in the “Year when they received training on worm infections” actually comparing? This may be my own misunderstanding, but it doesn’t seem that it should be exactly the same for both of the year categories.

• Table 3: The format makes it seem as though maybe only strongly agree and strongly disagree results are presented, but given that the total is 100% I assume the parentheses indicate these are combined across strongly/regular agreement. If they are to be combined, I would recommend changing the column headings to make this more clear, i.e. Agreement (strong/regular) and Disagreement (strong/regular), but I think it would be best to present both strong/regular and then combined as separate columns.

• Table 5: The second poor water source option is a little confusing to a reader not from this region. Is Swamps/Rock indicative of surface water from swampy/rocky areas? Or is “Rock” meant to indicate groundwater from a spring that comes out of rocks?

Discussion

• Line 394/395 is “knowledge about symptoms and treatment” from the Ivory coast study? If so, it would be clearer to combine this with the previous sentence/citation.

• It would be interesting and useful to see further research or an addition to this study that indicates some method of improving/strengthening the program curriculum (as recommended in line 399). Perhaps conjecture in this direction could be made in the limitations/further study section at the end of the discussion?

• Line 438 says that a significant portion (35%) reported drinking untreated water, with no p-value reported. Please include the significant p-value (i.e. (35%, p<0.xx)).

Reviewer #2: The manuscript should be accepted after minor revision.

--------------------

Summary and General Comments

Use this section to provide overall comments, discuss strengths/weaknesses of the study, novelty, significance, general execution and scholarship. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. If requesting major revision, please articulate the new experiments that are needed.

Reviewer #1: Overall, this study does a very fine job of highlighting the KAP of the study population with regards to deworming practices. Some of the presentation of the results could have been clearer (please see attached comments), but the overall message is quite clear, and the primary results stand out. I think the authors did an excellent job of including relevant qualitative data from the interviews, and in answering a relevant public health question. I think it would be very useful for the conclusions to suggest potential further studies that could actually tease out what sort of improved training materials actually may improve the knowledge scores of CHWs and teachers in this and similar geographies. No major revisions recommended.

Reviewer #2: The study was able to highlight the role of teachers and health workers in the deworming campaign, however there are critical stakeholders that were not factored in the study, which is the school age children, who are the direct beneficiaries of deworming interventions. Their perspectives and insights will provide added value to the study findings.

--------------------

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.

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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: No

Reviewer #2: Yes: Obiageli Josephine Nebe

Figure 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. 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 us at figures@plos.org.

Data Requirements:

Please note that, as a condition of publication, PLOS' data policy requires that you make available all data used to draw the conclusions outlined in your manuscript. Data must be deposited in an appropriate repository, included within the body of the manuscript, or uploaded as supporting information. This includes all numerical values that were used to generate graphs, histograms etc.. For an example see here: http://www.plosbiology.org/article/info%3Adoi%2F10.1371%2Fjournal.pbio.1001908#s5.

Reproducibility:

To enhance the reproducibility of your results, we recommend that you deposit your laboratory protocols in protocols.io, where a protocol can be assigned its own identifier (DOI) such that it can be cited independently in the future. Additionally, PLOS ONE offers an option to publish peer-reviewed clinical study protocols. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols

References

Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article's retracted status in the References list and also include a citation and full reference for the retraction notice.

Attachments

Attachment

Submitted filename: Comments on PLOS Review.docx

Attachment

Submitted filename: PNTD-D-22-01081_reviewer October 2022.pdf

Dear Dr Rwamwejo,

Thank you very much for submitting your manuscript "Assessing the knowledge, attitudes, practices, and perspectives of stakeholders of the deworming program in rural Rwanda" for consideration at PLOS Neglected Tropical Diseases. As with all papers reviewed by the journal, your manuscript was reviewed by members of the editorial board and by several independent reviewers. The reviewers appreciated the attention to an important topic. Based on the reviews, we are likely to accept this manuscript for publication, providing that you modify the manuscript according to the review recommendations.

Please prepare and submit your revised manuscript within 30 days. If you anticipate any delay, please let us know the expected resubmission date by replying to this email.

When you are ready to resubmit, please upload the following:

[1] A letter containing a detailed list of your responses to all review comments, and a description of the changes you have made in the manuscript.

Please note while forming your response, if your article is accepted, you may have the opportunity to make the peer review history publicly available. The record will include editor decision letters (with reviews) and your responses to reviewer comments. If eligible, we will contact you to opt in or out

[2] Two versions of the revised manuscript: one with either highlights or tracked changes denoting where the text has been changed; the other a clean version (uploaded as the manuscript file).

Important additional instructions are given below your reviewer comments.

Thank you again for your submission to our journal. We hope that our editorial process has been constructive so far, and we welcome your feedback at any time. Please don't hesitate to contact us if you have any questions or comments.

Sincerely,

Alison Krentel

Academic Editor

PLOS Neglected Tropical Diseases

Francesca Tamarozzi

Section Editor

PLOS Neglected Tropical Diseases

***********************

Reviewer's Responses to Questions

Key Review Criteria Required for Acceptance?

As you describe the new analyses required for acceptance, please consider the following:

Methods

-Are the objectives of the study clearly articulated with a clear testable hypothesis stated?

-Is the study design appropriate to address the stated objectives?

-Is the population clearly described and appropriate for the hypothesis being tested?

-Is the sample size sufficient to ensure adequate power to address the hypothesis being tested?

-Were correct statistical analysis used to support conclusions?

-Are there concerns about ethical or regulatory requirements being met?

Reviewer #1: Yes, methods strong throughout the process.

Reviewer #2: The objectives of the study were clearly stated. The study design was found to be appropriate. The population was clearly stated but the study would have included school age children who are one of the critical stakeholders and beneficiaries of deworming Programme. Their insights and perspectives on deworming activities are equally needed and will make important contributions in the study of this kind. I think the sample size is adequate and equally addressed the hypothesis being tested.

Correct statistical analysis and variables were used to support the study.

There are no known ethical concerns as the study did not involve any invasive procedures.

--------------------

Results

-Does the analysis presented match the analysis plan?

-Are the results clearly and completely presented?

-Are the figures (Tables, Images) of sufficient quality for clarity?

Reviewer #1: Yes, changes were made to have the tables be a little clearer to read and understand.

Reviewer #2: The analysis presented matched the analysis plan. The results are clearly presented.

The figures and tables are of sufficient quality.

--------------------

Conclusions

-Are the conclusions supported by the data presented?

-Are the limitations of analysis clearly described?

-Do the authors discuss how these data can be helpful to advance our understanding of the topic under study?

-Is public health relevance addressed?

Reviewer #1: Yes, the conclusion is well written and clearly addresses limitations and use of these data for advancing the knowledge base.

Reviewer #2: The authors have to clearly describe and highlight the conclusions emanating from this study. They need to further describe the limitations of the analysis if any. I did not see in the manuscript, major recommendations and implications of the findings of the study to the National Deworming Programnme of Rwanda. By clearly describing how the outcomes of the study will impact on the Deworming Programme and may contribute to informed-decision making/policy change, this will bring to fore the public health relevance of the study.

--------------------

Editorial and Data Presentation Modifications?

Use this section for editorial suggestions as well as relatively minor modifications of existing data that would enhance clarity. If the only modifications needed are minor and/or editorial, you may wish to recommend “Minor Revision” or “Accept”.

Reviewer #1: All concerns and comments from the first submission have been satisfactorily addressed.

Reviewer #2: I recommend that the minor revision be done, and that the authors should carefully address the comments made in the draft manuscript.

--------------------

Summary and General Comments

Use this section to provide overall comments, discuss strengths/weaknesses of the study, novelty, significance, general execution and scholarship. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. If requesting major revision, please articulate the new experiments that are needed.

Reviewer #1: (No Response)

Reviewer #2: My overall comment is that the authors should address the gaps highlighted in the manuscript. One of the key beneficiaries of deworming Programme which are school age children were left out of this study. The authors should find away to interview them and incorporate their views and perspectives into the finding.

--------------------

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: No

Reviewer #2: Yes: Obiageli Josephine Nebe

Figure 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. 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 us at figures@plos.org.

Data Requirements:

Please note that, as a condition of publication, PLOS' data policy requires that you make available all data used to draw the conclusions outlined in your manuscript. Data must be deposited in an appropriate repository, included within the body of the manuscript, or uploaded as supporting information. This includes all numerical values that were used to generate graphs, histograms etc.. For an example see here: http://www.plosbiology.org/article/info%3Adoi%2F10.1371%2Fjournal.pbio.1001908#s5.

Reproducibility:

To enhance the reproducibility of your results, we recommend that you deposit your laboratory protocols in protocols.io, where a protocol can be assigned its own identifier (DOI) such that it can be cited independently in the future. Additionally, PLOS ONE offers an option to publish peer-reviewed clinical study protocols. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols

References

Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article's retracted status in the References list and also include a citation and full reference for the retraction notice.

Attachments

Attachment

Submitted filename: PNTD-D-22-01081_reviewer October 2022 REVIEWED FEB 2023.pdf

Dear Dr Rwamwejo,

We are pleased to inform you that your manuscript 'Assessing the knowledge, attitudes, practices, and perspectives of stakeholders of the deworming program in rural Rwanda' has been provisionally accepted for publication in PLOS Neglected Tropical Diseases.

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.

Should you, your institution's press office or the journal office choose to press release your paper, you will automatically be opted out of early publication. We ask that you notify us now if you or your institution is planning to press release the article. All press must be co-ordinated with PLOS.

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

Best regards,

Francesca Tamarozzi

Section Editor

PLOS Neglected Tropical Diseases

Francesca Tamarozzi

Section Editor

PLOS Neglected Tropical Diseases

***********************************************************

Reviewer's Responses to Questions

Key Review Criteria Required for Acceptance?

As you describe the new analyses required for acceptance, please consider the following:

Methods

-Are the objectives of the study clearly articulated with a clear testable hypothesis stated?

-Is the study design appropriate to address the stated objectives?

-Is the population clearly described and appropriate for the hypothesis being tested?

-Is the sample size sufficient to ensure adequate power to address the hypothesis being tested?

-Were correct statistical analysis used to support conclusions?

-Are there concerns about ethical or regulatory requirements being met?

Reviewer #2: The objectives of the study was clearly articulated with a clear testable hypothesis stated by the authors. The study design was quite appropriate and addressed the stated objectives. The use of phenomenological design to explore the stakeholders experiences and perspectives was aptly stated. The study population was clearly described and quite appropriate for the hypothesis tested. There is sufficient sample size, and ensure adequate power for the hypothesis tested. Correct statistical analysis were used to support the conclusion. The use of Karimollah formular for sample size estimation was good great and will be of interest to the scientific community. No ethical concerns whatso ever.

**********

Results

-Does the analysis presented match the analysis plan?

-Are the results clearly and completely presented?

-Are the figures (Tables, Images) of sufficient quality for clarity?

Reviewer #2: The analysis presented really match the analysis plan. The use of Karimollah formular for sample size estimation was good great and will be of interest to the scientific community. The results are clearly and completely presented. The tables are of sufficient quality for clarity.

**********

Conclusions

-Are the conclusions supported by the data presented?

-Are the limitations of analysis clearly described?

-Do the authors discuss how these data can be helpful to advance our understanding of the topic under study?

-Is public health relevance addressed?

Reviewer #2: The conclusions were supported by the data presented. The limitations were equally stated. The authors discussed how the data will help in advancing the understanding of the topic that was studied. Public health relevance was addressed.

**********

Editorial and Data Presentation Modifications?

Use this section for editorial suggestions as well as relatively minor modifications of existing data that would enhance clarity. If the only modifications needed are minor and/or editorial, you may wish to recommend “Minor Revision” or “Accept”.

Reviewer #2: I hereby recommend that the manuscript be accepted after minor revision as stated in the manuscript.

**********

Summary and General Comments

Use this section to provide overall comments, discuss strengths/weaknesses of the study, novelty, significance, general execution and scholarship. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. If requesting major revision, please articulate the new experiments that are needed.

Reviewer #2: The manuscript is well articulated, the study design- the use of cross-sectional quantitative and phenomenological design to explore the experiences and perspectives of stakeholders is quite significance. The data plan and analysis especially the use of Karimollah formular and details of the statistical formular for sample size estimation was great. No new experiment required. The research was conducted in accordance with the principles expressed in the Declaration of Helsinki. The manuscript was written in intelligible fashion and standard English. Accept the manuscript after minor revision.

**********

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 #2: Yes: Dr. Obiageli Josephine Nebe