PNTD-D-25-00752

Effect of community engagement and enhanced health literacy on snakebite prevention and proper first aid practice: Outcome from a community trial in rural Bangladesh

PLOS Neglected Tropical Diseases

Dear Dr. Rahman,

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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Kind regards,

Eric Nyarko, BSc, MPhil, PhD, MPH

Academic Editor

PLOS Neglected Tropical Diseases

Victoria Brookes

Section Editor

PLOS Neglected Tropical Diseases

Shaden Kamhawi

co-Editor-in-Chief

PLOS Neglected Tropical Diseases

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

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co-Editor-in-Chief

PLOS Neglected Tropical Diseases

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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: AKM Fazlur Rahman, Chowdhury Farheen, Rumana Rashid, Farhana Jahan, Abdullah Abu Sayeed, Aniruddha Ghose, Abu Shahin Mohammed Mahbubur Rahman, F. M. Atiqur Rahaman, Chinmaya Howlader, Sayra Khan, Nusaer Chowdhury, Geeta Rani Debi, Md Robed Amin, Md. Shahidur Rahman, and M A Faiz. 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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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: 1. Please, in Figure 2, the population of the Two subdistricts (5,40,0000), intervention (1,98,000) and control area (3,30,0000) should be corrected by either removing the commas or by placing the commas at the desired places. That is either Two subdistricts (540,0000), intervention (198,000) and control area (3,300,000) or Two subdistricts (5400000), intervention (198000) and control area (3300000). In order way, the authors will be in a good position to address this mismatch better.

2. Please note that the selection of intervention and control areas was not truly random, but “purposive,” which could introduce bias. More detail is needed on how baseline comparability was ensured and how contamination between areas was minimized. Also, I noted in the write up that some terms like “design effect of 5.99” are mentioned without sufficient justification or explanation, which may confuse readers who are not versed in complex sampling strategies.

Reviewer #2: partly

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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: 1. Please, if possible conduct a statistical analysis on the most important features contributing to snake bite and discussion the impact of these features accordingly (either positive or negative). This can be done using the logistic regression algorithm which was adopted in the study. Also, figures and tables should be referenced more clearly in the text to guide the reader.

Reviewer #2: see my general comments

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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: 1. Please, the limitations section is brief and rather generic. A more thorough reflection on study limitations—such as the risk of reporting bias, the challenges of follow-up, the potential for recall bias in self-reported outcomes, and the limited generalizability due to the selection of only two subdistricts—would make the discussion more robust and trustworthy.

2. Please, the conclusion states that the intervention "should be implemented across Bangladesh and elsewhere," although it provides no discussion on the necessary practical procedures for scaling up, the requisite resources, or the policy consequences. What is required to implement such initiatives on a large scale, and what responsibilities should government, NGOs, or community leaders assume? This section might be enhanced with further actionable advice.

Reviewer #2: see my general comments

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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: N/A

Reviewer #2: see my general comments

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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 research addresses a critical public health concern as it evaluates the effectiveness of community engagement and enhanced health literacy for snakebite prevention and increased appropriate first aid practices utilizing existing health care systems in rural communities of Bangladesh.

1. Please, the introduction gives a good overview, but it does not clearly establish the novelty of the current study (what sets this study apart from similar interventions in the region or globally). Kindly consider stating the novelty more explicitly—what specific gaps in the literature does this study fill?. Likewise, consider highlighting how the approach employed in this study differs from past approaches in Bangladesh or other countries, which would make the paper’s novelty clearer to readers.

2. Please, the manuscript would benefit from a thorough language edit for clarity and flow. SSome sentences are quite long and complex, which makes them hard to follow. TThere are minor grammatical errors, repetitions, and awkward phrasing scattered throughout. For example, consider this sentence fragmentation and tense issues. “This community trial was conducted in two rural sub-districts of Bangladesh, randomly assigned one as intervention area and other remained control.”

Suggestion: “This community trial was conducted in two rural sub-districts of Bangladesh; one was randomly assigned as the intervention area and the other as the control.”

Reviewer #2: Thank you for giving me opportunity to review and below are my comments

1. title needs revision, at 1st say effect, then outcome, revise

2. line 34, …culturally tailored community engagement activities… , what does this mean?

3. Please provide the supplementary file of statistical analysis for transparency

4. Revise abstract to include only key contents

5. in the introduction community engagement and health literacy effect not adequately described, even health literacy not mentioned, is it similar with awareness, similar for community engagement, not described, what does it mean, levels of community engagement, link with citizen science as an approach, this issues should be clear

6. in sample size determination, what is the base for choosing mentioned effect size? also ICC? How clustering effect is controlled? why attrition rate not considered? how 500 is chosen? which software used to calculate?what is the sampling technique? it is not clear

7. the design of the study is not clear, why not RCT, justify? is it repeated crossectional or longitudinal? which is directly linked with statistical analysis you are going to perform? is base and endline population similar or different? clearly describe

8. include theory of change to show how changes come, assumptions with mediator and moderator variables

9. Figure 2 is not clear, do separately, also it is conceptual framework??

10. How fidelity, acceptability, of intervention determined?

11. How tailoring of IEC materials were produced and disseminated? who have done it

12. How data collection tool is developed its validity, reliability

13. Iam not convinced with statistical analysis applied, I think difference in difference is appropriate, are populatio

14. there is nothing said about community engagement in method also, which is boldy written on title, similar also for health literacy

15. I did not review result and discussion, because there are major issues with method

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Reviewer #1: No

Reviewer #2: No

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PNTD-D-25-00752R1

Effect of community engagement and enhanced health literacy on snakebite prevention and proper first aid practice: Outcome from a community trial in rural Bangladesh

PLOS Neglected Tropical Diseases

Dear Dr. Rahman,

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.

Please submit your revised manuscript within by Jan 13 2026 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 plosntds@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pntd/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

* A 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'. This file does not need to include responses to any formatting updates and technical items listed in the 'Journal Requirements' section below.

* 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'.

If you would like to make changes to your financial disclosure, competing interests statement, or data availability statement, please make these updates within the submission form at the time of resubmission. 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,

Annapaola Rizzoli

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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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: AKM Fazlur Rahman. Please ensure that the full contributions of each author are acknowledged in the "Add/Edit/Remove Authors" section of our submission form.

The list of CRediT author contributions may be found here: https://journals.plos.org/plosntds/s/authorship#loc-author-contributions

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Please respond directly to this email and provide any known details concerning your material's license terms and permissions required for reuse, even if you have not yet obtained copyright permissions or are unsure of your material's copyright compatibility. Once you have responded and addressed all other outstanding technical requirements, you may resubmit your manuscript within Editorial Manager.

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1. In a public repository

2. Within the manuscript itself

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.

6)  Please ensure that the files are uploaded in the online submission form in a correct numerical order.

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: The authors have addressed some of the significant comments raised in my previous review.

Reviewer #2: Revise title, is it effect or effectiveness?in discussion, you used impact of

please use appropriate which can contain community engagement and health literacy? through community engagement we can raise health literacy, it might be, Effectiveness of community engagement through on snakebite prevention and proper................

first aid practices: A community trial in rural Bangladesh

what does culturally tailored community engagement activities mean? use appropriate term

from the levels of community engagement from informing to empowering which is implemented in your study? clearly explain in methods the levels, how it was done, challenges encountered, limitations acknowledged,

in sample size what is the evidence to use 40%, is clustering not needed?

How you reach consensus on IEC development and then proceed to implementation, what representative population used in pretesting, where is the site of pretest, how you selected IEC materials,

how you measured health literacy?

The theory of change is not clear, what were the assumptions, the indicators, the chain of outcomes?, I don't see any community engagement concept in your study, ...

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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: The authors have addressed some of the significant comments raised in my previous review.

Reviewer #2: (No Response)

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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: The authors have addressed some of the significant comments raised in my previous review.

Reviewer #2: (No Response)

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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: (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: (No Response)

Reviewer #2: How incidence measured?

Major revisions

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Reviewer #1: No

Reviewer #2: Yes: Daba Abdissa

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To enhance the reproducibility of your results, we recommend that authors of applicable studies deposit 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

Dear Prof Rahman,

We are pleased to inform you that your manuscript 'Effect of community engagement and enhanced health literacy on snakebite prevention and proper first aid practice: Outcome from a community trial in rural Bangladesh' 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.

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

Best regards,

Dileepa Ediriweera

Section Editor

PLOS Neglected Tropical Diseases

Victoria Brookes

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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