A country-wide survey of knowledge and practice regarding prevention, snake identification and pre-hospital management of children with snakebites amongst Public Health Midwives in Sri Lanka

PLOS Neglected Tropical Diseases

Dear Dr. Dayasiri,

Thank you for submitting your manuscript to PLOS Neglected Tropical Diseases. After careful consideration, we feel that it has merit but does not fully meet PLOS Neglected Tropical Diseases'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.

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We look forward to receiving your revised manuscript.

Kind regards,

Wuelton Monteiro, Ph.D.

Section Editor

PLOS Neglected Tropical Diseases

Wuelton Monteiro

Section Editor

PLOS Neglected Tropical Diseases

Shaden Kamhawi

co-Editor-in-Chief

PLOS Neglected Tropical Diseases

orcid.org/0000-0003-4304-636XX

Paul Brindley

co-Editor-in-Chief

PLOS Neglected Tropical Diseases

orcid.org/0000-0003-1765-0002

Journal Requirements:

If the reviewer comments include a recommendation to cite specific previously published works, please review and evaluate these publications to determine whether they are relevant and should be cited. There is no requirement to cite these works unless the editor has indicated otherwise.

1) Please ensure that the CRediT author contributions listed for every co-author are completed accurately and in full.

At this stage, the following Authors/Authors require contributions: Kavinda Chandimal Dayasiri. Please ensure that the full contributions of each author are acknowledged in the "Add/Edit/Remove Authors" section of our submission form.

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3) Please amend your detailed Financial Disclosure statement. This is published with the article. It must therefore be completed in full sentences and contain the exact wording you wish to be published.

1) 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."

2) If any authors received a salary from any of your funders, please state which authors and which funders..

If you did not receive any funding for this study, please simply state: u201cThe authors received no specific funding for this work.u201d

Reviewers' Comments:

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

Reviewer #2: -Are the objectives of the study clearly articulated with a clear testable hypothesis stated?

-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 but further explanation f qualitative methods needed

-Are there concerns about ethical or regulatory requirements being met? No concerns

Reviewer #3: The objectives are articulated with clear hypothesis and the study design is appropriate. A sample size calculation was not included. Although the size attained seemed reasonable. The statistical analysis, and conclusions are appropriate and there were no concerns regarding ethical standards

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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: Yes

Reviewer #2: -Does the analysis presented match the analysis plan? Yes

-Are the results clearly and completely presented? Yes but need direct quotes or more evidence for the qualitative findings

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

Reviewer #3: The analysis presented matches the plan and the results in the prose are clearly stated. The tables however are not very clear, specifllcally table 2. This has the question in the questionaire with the answer in bracket. It is difficult to follow. Perhaps sumarizing this as a figure with the actions instead being the subject of the question rather than the entire question.. to make this clearer to the reader. There are 8 tables which are cumbersome to read and could be converted to figures for ease of understanding

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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: Yes

Reviewer #2: -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

-Is public health relevance addressed? Yes

Reviewer #3: The conclusions are supported by the data and the limitations described. They do discuss how these data is helpful and public health relevance is adressed

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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: yes

Reviewer #2: (No Response)

Reviewer #3: I think a minor revision is needed

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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: 1. This study utilized an online questionnaire that respondents completed themselves. The data may be subject to social desirability bias, despite the authors' efforts to minimize it. Additionally, the study does not measure actual practices in the field.

2. The conclusions drawn are strong, but the suggestions for "structured training" and "curriculum integration" are quite typical. The Discussion section could explore more innovative, system-level, or technology-based solutions to the ongoing challenges noted, such as strong traditional beliefs and transportation issues.

3. The term "adequate knowledge" is defined as being in the 75th percentile of the composite score, which is a somewhat technical measure. Providing the raw score range or more context in the Results section could help non-technical readers understand this better.

4. It is suggested to refer from the paper: "Blockchain-Enabled Healthcare Optimization: Enhancing Security and Decision-Making Using the Mother Optimization Algorithm". This reference discusses blockchain in healthcare and improved decision-making. It supports the need for better awareness of national guidelines and emergency contact services by suggesting a secure and efficient data-sharing platform for public health management Suggested insertion: Conclusion/Future Work

5. The Discussion acknowledges barriers such as transportation challenges and traditional beliefs. It would be helpful to connect these barriers to technology-driven solutions suggested in other references, such as mobile education tools, visual aids, and secure data sharing. This would change the recommendation from general "training" to "structured training with technology and community involvement".

6. The Discussion section successfully explains the results and places them within the context of other countries facing similar challenges.

7. The point about cognitive dissonance, where knowledge clashes with harmful practices, is noteworthy and deserves further exploration. This could suggest the need for a behavioral or psychological aspect in the required training.

Reviewer #2: (No Response)

Reviewer #3: Overall a well done study on an important topic which is underreported, would commend the others for this study.

Comments

1. Although the sample size is large, perhaps having a justification of the sample size with a power calculation

2. Tables are difficult to follow. Suggest editing these and/or changing a few to figures to enhance readibility. Specifllcally tables 2 and 6. These have the questions used in the questionnaire with the answer in brackets. It is difficult to follow. Perhaps sumarizing this as a figure with the actions instead being the subject of the question rather than the entire question.. to make this clearer to the reader.

3. There are a few grammatical errors that need correction

4. For table 3: Chi square test is a measure of association, therefore the term "Deteminant" may not be an accurate term, rather associations in the bivariate analysis

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If you choose “no”, your identity will remain anonymous but your review may still be made public.

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Reviewer #1: No

Reviewer #2: No

Reviewer #3: No

Figure resubmission:

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Dear Dr. Dayasiri,

We are pleased to inform you that your manuscript 'A country-wide survey of knowledge and practice regarding prevention, snake identification and pre-hospital management of children with snakebites amongst Public Health Midwives in Sri Lanka' 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,

Wuelton Monteiro, Ph.D.

Section Editor

PLOS Neglected Tropical Diseases

Wuelton Monteiro

Section Editor

PLOS Neglected Tropical Diseases

Shaden Kamhawi

co-Editor-in-Chief

PLOS Neglected Tropical Diseases

orcid.org/0000-0003-4304-636XX

Paul Brindley

co-Editor-in-Chief

PLOS Neglected Tropical Diseases

orcid.org/0000-0003-1765-0002

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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: I recommend accepting the manuscript. The authors have addressed all points raised by the reviewers. The revised manuscript is clearer and better organized than the original. Given these significant improvements and the relevance of the findings.

1. The authors responded to all reviewer concerns, especially clarifying the quantitative methods and removing any confusion between qualitative and quantitative data.

2. The results section is better organized, with complex tables changed into more understandable figures and the text simplified for easier reading.

3. The study's technical quality has improved with a detailed sample size and power calculation, confirming that the final sample of 1,706 participants provides enough statistical power for the analysis.

4. This study offers important new insights into neglected tropical diseases by presenting the first nationwide assessment of Public Health Midwives' knowledge gaps about pediatric snakebites in Sri Lanka.

5. The analysis uses clearer statistical terms, such as changing "determinants" to "associations," which accurately reflects the type of analysis performed.

6. The overall presentation has improved through careful editing, and the discussion now includes new, technology-based solutions for healthcare challenges at the community level.

Reviewer #3: This is okay

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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: Good

Reviewer #3: These are better

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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: Good

Reviewer #3: Conclusions have improved

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Editorial and Data Presentation Modifications?

<br/>

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: Good

Reviewer #3: (No Response)

**********

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: Good

Reviewer #3: (No Response)

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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 #3: No