Dear Dr Monteiro,

Thank you very much for submitting your manuscript "Building an explanatory model for snakebite envenoming care in the Brazilian Amazon from the indigenous caregivers’ perspective" 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. In light of the reviews (below this email), we would like to invite the resubmission of a significantly-revised version that takes into account the reviewers' comments.

We cannot make any decision about publication until we have seen the revised manuscript and your response to the reviewers' comments. Your revised manuscript is also likely to be sent to reviewers for further evaluation.

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

[1] A letter containing a detailed list of your responses to the 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.

Please prepare and submit your revised manuscript within 60 days. If you anticipate any delay, please let us know the expected resubmission date by replying to this email. Please note that revised manuscripts received after the 60-day due date may require evaluation and peer review similar to newly submitted manuscripts.

Thank you again for your submission. 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,

Abdulrazaq G. Habib

Academic Editor

PLOS Neglected Tropical Diseases

José María Gutiérrez

Section Editor

PLOS Neglected Tropical Diseases

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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? Since this is a qualitative study, sample size is adequate.

-Were correct statistical analysis used to support conclusions? No relevant

-Are there concerns about ethical or regulatory requirements being met? None

Reviewer #2: There was a clear study aim and specific objectives; the qualitative design is appropriate; the study population was clearly defined. Given one of the stated study limitations (difficulty achieving data saturation), the sample size is acceptable; the analysis and interpretation of the study results were appropriate. Ethical handling of the study was appropriate.

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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? Yes

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

Reviewer #2: The analysis presented matched the analysis plan; the results clearly and completely presented; The pictorial presentation results in the figures were beautiful.

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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? There is a comment on discussion. See the general comment.

-Is public health relevance addressed? Yes, with in the relevant geographical area

Reviewer #2: The conclusion was appropriate for the results obtained.

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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: (No Response)

Reviewer #2: I will recommend that you ACCEPT for publication in the present form.

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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: This paper describes the qualitative interview-based study on developing an explanatory model of indigenous healthcare communities for Snakebite envenoming patients from the perspective of indigenous caregivers in selected areas in Brazilian Amazon. The study has been conducted in a well-designed qualitative study method and the presentation of results are appropriate.

Major comments

More details of the study area: Include a map of the stud area indicating the locations of the caregivers were?

What is the basis of selecting these 8 caregivers and excluding others? Was it due to availability and accessibility or any other reason? Please include the basis of selecting the caregivers.

In what basis these questions were formulated? Describe the rationale of formulating these questions?

Under data analysis: Lines 225 to 229: “Interview data was analyzed to understand indigenous caregivers’ explanations in an analytical framework with three themes: i) Etiology; ii) Course of sickness (with three subthemes: onset of symptoms, pathophysiology, and severity and prognosis); and v) Treatment”

Describe how the data gathered from listed 20 questions was used to analyse under the above three themes?

Which questions were related to theme 1, 2 and 3?

Since this manuscript is going to read and refer by the scientists and researchers, highly recommend to include few paragraphs under the discussion to discuss the appropriateness and or inappropriateness of caregiver’s perspectives into western science and medical practices. Eg, use of tourniquet is a dangerous and unaccepted practice in western science and medicine. Likewise, there are many inappropriate and unaccepted practices and believes were explored in this paper. It would be really interesting to discuss these under the discussion. It is understandable and not possible to discuss every finding here. But at least the significant and important findings need to de discuss.

Other comments

Table 2: Details in the column ‘Presentation”: long descriptions of caregivers are not necessary. Recommend to reduce the word count and present in a point form avoiding sentences.

239: A total of eight indigenous caregivers were conducted. An important word of “interviews” is missing in this sentence. This has to be edited as “A total of eight interviews were conducted with indigenous caregivers.”

270: SBES: The last “S” should in lower case format. SBEs

263: Agents, should be change as species or snake

Throughout the manuscript: Word Envenoming and Envenomation have been used in different places. Suggest to use one terminology throughout the manuscript.

Reviewer #2: This is a well-written qualitative study, which tenaciously followed the 32-item COREQ checklist.

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Reviewer #1: Yes: Kalana Maduwage

Reviewer #2: Yes: Godpower Chinedu Michael

Figure Files:

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Reproducibility:

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Dear Dr Monteiro,

We are pleased to inform you that your manuscript 'Building an explanatory model for snakebite envenoming care in the Brazilian Amazon from the indigenous caregivers’ perspective' 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,

Abdulrazaq G. Habib

Academic Editor

PLOS Neglected Tropical Diseases

José María Gutiérrez

Section Editor

PLOS Neglected Tropical Diseases

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