National TB program shortages as potential factor for poor-quality TB care cascade: Healthcare workers’ perspective from Beira, Mozambique

Miguelhete Lisboa; Inês Fronteira; Paul H. Mason; Maria do Rosário O. Martins

doi:10.1371/journal.pone.0228927

Peer Review History

Original SubmissionAugust 10, 2019
26 Nov 2019 Decision Letter - Frederick Quinn, Editor PONE-D-19-22633 National TB program shortages as potential factor for poor-quality TB care cascade: healthcare workers’ perspective from Beira, Mozambique PLOS ONE Dear Dr. Lisboa, Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’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. We would appreciate receiving your revised manuscript. When you are ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file. If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. 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Reviewer #1: Yes Reviewer #2: Yes ******** 2. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: N/A Reviewer #2: N/A ****** 3. Have the authors made all data underlying the findings in their manuscript fully available? The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified. Reviewer #1: No Reviewer #2: Yes ****** 4. Is the manuscript presented in an intelligible fashion and written in standard English? PLOS ONE 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: No ****** 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: Authors should address these minor comments ABSTRACT: (a) In the background it is not very clear what you intend to communicate. Please rephrase for clarity. (b) The last part of the "Objective) i.e. "---to overcome them toward to the TB elimination" should be revisited. (c) Line 67 and throughout the manuscript: Write "lab" in full i.e. "laboratory" INTRODUCTION: Lines 121-123 should be rewritten for clarity. MATERIALS and METHODS: (a) Line 127: Should be "This was a cross-sectional qualitative study(13) conducted from January to February 2019". (b) Lines 135-138: Please provide the total number of health workers in the Beira Central Hospital against the indicated health categories i.e. nurses, medical doctors etc. (c) Lines 141-142: For an average reader, please describe where Beira city is located within Mozambique i.e. northern, central, eastern etc. (d) Line 152: Should be "FGD were used to assess a broad range of views about --------" (e) Line 159-160: Should be "We conducted fifteen IDI with five medical doctors, seven managers and three hospital decision-makers" (f) Lines 161-164: Although the consent procedure is mentioned, please mention whether the study obtained ethics approval from an ethics committee? RESULTS: (a) Line 265: Correct the typo i.e. should be "resource" (b) Line 292: Fear of contamination is frequently mentioned in the text but what do you mean exactly? Do you mean contamination of TB cultures or health workers getting infected by TB (as the context of lines 292-298 suggest?). Clarify. Reviewer #2: The authors target the programmatic manageable shortages, specifically the task shifting inefficiency of TB services, that persist in regions with poor quality of TB management. The authors seek to understand the root causes of poor implementation of task shifting strategy and draw a conclusion from narrative survey-based data. The overall logic is sound, scientifically. However, given that only healthcare workers, who have been implementing guided TB services and strategies, were included the in this study, how do you justify the insight of the interviewees? Or is there any evidence suggesting the identified factors extracted from the interviews are the ones playing the most crucial role in the quality of TB services? In addition, please monitor the writing throughout the manuscript. There are typos and confusing sentences in the manuscript. For example, line 55, line 77-78, line 101-104, Table 1 Percentage "51, 9" or "51.9", line 319. ****** 6. 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: 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 to be viewed.] 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. Registration is free. 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. Please note that Supporting Information files do not need this step. https://doi.org/10.1371/journal.pone.0228927.r001
Revision 1
8 Jan 2020 Author Response Reviewers’ comments and authors’ responses to each point raised by the reviewers Responses to reviewer #1 ABSTRACT: (a) In the background it is not very clear what you intend to communicate. Please rephrase for clarity. The content of the background (under abstract section) was revised and now is written as following: Mozambique is one of the countries with the deadly implementation gaps in the tuberculosis (TB) care and services delivery. In-hospital delays in TB diagnosis and treatment, transmission and mortality still persist, in part, due to poor-quality of TB care cascade. (b) The last part of the "Objective) i.e. "---to overcome them toward to the TB elimination" should be revisited. The content of the objective (under abstract section) was rewritten as following: We aimed to assess, from the healthcare workers’ (HCW) perspective, factors associated with poor-quality TB care cascade and explore local sustainable suggestions to improve in-hospital TB care and services delivery. (c) Line 67 and throughout the manuscript: Write "lab" in full i.e. "laboratory" Thanks for the excellent comment. The word was revised on every single page of the document and now is written in full “laboratory” instead of lab INTRODUCTION: Lines 121-123 should be rewritten for clarity. The content of the lines (under introduction section) were rewritten as following: This study was carried out to assess, from the healthcare workers’ perspective, the factors associated with in-hospital poor-quality TB care cascade and explore local sustainable suggestions to improve in-hospital TB care services. MATERIALS and METHODS: (a) Line 127: Should be "This was a cross-sectional qualitative study (13) conducted from January to February 2019". This sentence was corrected as recommended. “This was a cross-sectional qualitative study (13) conducted from January to February 2019” (b) Lines 135-138: Please provide the total number of health workers in the Beira Central Hospital against the indicated health categories i.e. nurses, medical doctors etc. Under the study design, population and sample section, is rewritten as: The target population was the health staff from the Beira Central Hospital dealing with TB matters. Therefore, there were a total of 71 healthcare workers including managers and decision-makers. Among them, there were 11 medical doctors, 16 nurses, 13 laboratory technicians and 31 hospital auxiliary workers. We used a convenience sampling approach to select our sample(13). The selected categories of health workers represent the full range of healthcare staff with different levels of training and experience in relation to TB. They also had different responsibilities and possibly had different perceptions and practices related to TB diagnosis, treatment and infection control measures within the central hospital. Our sample was purposively only made of staff working in the medical wards and TB laboratory, hence, 20 hospital auxiliary workers, 10 nurses, 5 medical doctors, 9 TB laboratory technicians. Additionally, 7 managers and 3 hospital decision-makers were also selected and asked to participate in the focus group discussions (FGD) and individual in-depth interviews (IDI). (c) Lines 141-142: For an average reader, please describe where Beira city is located within Mozambique i.e. northern, central, eastern etc. Under the study setting section, the paragraph was rewritten as: The study was carried out in Hospital Central da Beira. Beira city (the capital of Sofala province) is located in the central region of Mozambique (about 1,200 km northern of Maputo, the capital city of Mozambique). Beira is the second largest city in Mozambique with a population estimated in about 463,442 inhabitants in 2017. The TB incidence rate (659/100,000 inhabitants) and TB/HIV co-infection rate (about 63%) in Beira city are above the national average(14). (d) Line 152: Should be "FGD were used to assess a broad range of views about -----" This sentence was corrected as recommended. “FGD were used to assess a broad range of views about TB within medical wards from auxiliary workers, nurses and TB laboratory technicians” (e) Line 159-160: Should be "We conducted fifteen IDI with five medical doctors, seven managers and three hospital decision-makers" This sentence was corrected as recommended. “We conducted fifteen IDI with five medical doctors, seven managers and three hospital decision-makers” (f) Lines 161-164: Although the consent procedure is mentioned, please mention whether the study obtained ethics approval from an ethics committee? The authors have included an ethical statement (under “methods and material” section – on page 08) as following: “The study protocol was approved by the Institutional Bioethics Committee for Health of the National Institute of Health of Mozambique and by WHO Ethics Review Committee. The Mozambique Ministry of Health, the Sofala Provincial Health and Beira Central Hospital authorities provided administrative approval. After an introduction of the participants, researchers and the objectives of the study, written informed consent procedures were ensured. Therefore, all participants signed an informed consent form. Participants were allowed to decline to take part of the FGD or IDI. To ensure that every healthcare worker had the opportunity to contribute freely in the FGD, the groups were homogeneous in terms of responsibilities. The anonymity of the participants was guaranteed by their identification with the initial letters of their professional category followed by the numeral, according to the chronological order of the interviews or sitting position during the focus discussion groups, for example, MD1 (Medical Doctor 1), DM3 (Decision-Maker 3), AW5 (Auxiliary Worker 5), M3 (Manager 3), LT9 (Laboratory Technicians 9), and so on.” RESULTS: (a) Line 265: Correct the typo i.e. should be "resource" The typo was corrected. Now is written “resource” (b) Line 292: Fear of contamination is frequently mentioned in the text but what do you mean exactly? Do you mean contamination of TB cultures or health workers getting infected by TB (as the context of lines 292-298 suggest?). Clarify. Thanks for the excellent comment. The sentence was revised on every single page of the document and now is clear that we’re referring to: “fear of healthcare workers getting infected by TB” Responses to reviewer #2 The authors target the programmatic manageable shortages, specifically the task shifting inefficiency of TB services, that persist in regions with poor quality of TB management. The authors seek to understand the root causes of poor implementation of task shifting strategy and draw a conclusion from narrative survey-based data. The overall logic is sound, scientifically. However, given that only healthcare workers, who have been implementing guided TB services and strategies, were included the in this study, how do you justify the insight of the interviewees? Or is there any evidence suggesting the identified factors extracted from the interviews are the ones playing the most crucial role in the quality of TB services? Thank you very much for this comment. As we stated in the paper, the aim of this study was to understand, from the healthcare workers’ perspective, the cause of causes of poor quality of TB care cascade within the hospital environment. As described by Patton, M. (1990) purposeful typical case sampling - interviewing key-healthcare cadres who are dealing with, are knowledgeable and have experience on TB care and services delivery and management - can help identify what are and not typical concerns, rather than general healthcare workers or patients. Therefore, we do believe that the factors extracted from the interviews are the ones playing the most crucial role in the quality of TB services, at least at the Beira Central Hospital. However, we are keeping in mind that the purpose of typical cases is to describe and illustrate what is and not typical to those unfamiliar with the program, and not to make generalized statements about the experiences of all participants. In addition, please monitor the writing throughout the manuscript. There are typos and confusing sentences in the manuscript. For example: line 55, - the background of the abstract was revised and rewritten as: In-hospital tuberculosis (TB) delays, transmission and mortality persists in Mozambique, in part, due to poor-quality of TB care cascade. Little is known about the local factors associated with the deadly implementation gaps in the TB care and services delivery. line 77-78, - the conclusion of the abstract was revised and was rewritten as: Shortage of resources within the national TB control programme is one of the potential factors for poor-quality of the TB care cascade. Task shifting of TB care and services delivery to lower HCW, decentralization of the molecular TB diagnostic tools, and regular provision of N95 respiratory masks should contribute not just to reduce the impact of resource scarceness, but also to ensure proper TB diagnosis and treatment to both sensitive and MDR TB. line 101-104, - the content of the lines (under introduction section) was revised and rewritten as: In-hospital delays of TB diagnosis and treatment, transmission and mortality persist around the country, in part, due to poor-quality of TB care cascade (7-9). Shortage of resources seems to hinder the local authority commitment on reduction of delays in TB diagnosis and treatment, morbidity and mortality (8-10). Table 1 Percentage "51, 9" or "51.9", The table content and typos were revised and can be found on the page 9 of the doc in track changes. line 319. - the content of the sentence (under discussion section) was revised and rewritten: In addition, task shifting was mentioned from the TB management perspective, meaning to higher professionals to lower healthcare workers. Attachments Attachment Submitted filename: Responses to Reviewers 08_Dec_2019.docx https://doi.org/10.1371/journal.pone.0228927.r002
28 Jan 2020 Decision Letter - Frederick Quinn, Editor National TB program shortages as potential factor for poor-quality TB care cascade: healthcare workers’ perspective from Beira, Mozambique PONE-D-19-22633R1 Dear Dr. Lisboa, We are pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it complies with all outstanding technical requirements. Within one week, you will receive an e-mail containing information on the amendments required prior to publication. When all required modifications have been addressed, you will receive a formal acceptance letter and your manuscript will proceed to our production department and be scheduled for publication. Shortly after the formal acceptance letter is sent, an invoice for payment will follow. 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With kind regards, Frederick Quinn Academic Editor PLOS ONE Additional Editor Comments (optional): Reviewers' comments: Reviewer's Responses to Questions Comments to the Author 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 #1: All comments have been addressed Reviewer #2: All comments have been addressed ******** 2. Is the manuscript technically sound, and do the data support the conclusions? The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented. Reviewer #1: Yes Reviewer #2: Yes ****** 3. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: N/A Reviewer #2: N/A ****** 4. Have the authors made all data underlying the findings in their manuscript fully available? The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified. Reviewer #1: Yes Reviewer #2: Yes ****** 5. Is the manuscript presented in an intelligible fashion and written in standard English? PLOS ONE 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 ****** 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 #1: Authors have satisfactorily responded to all my comments. I recommend publication of this manuscript without further revisions. Reviewer #2: The authors have addressed all the comments properly. The structure of the manuscript, the introduction of the study goal, the data presentation, the insight have been polished to a publication quality. ****** 7. 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: Yes: David Patrick Kateete Reviewer #2: No https://doi.org/10.1371/journal.pone.0228927.r003
Formally Accepted
30 Jan 2020 Acceptance Letter - Frederick Quinn, Editor PONE-D-19-22633R1 National TB program shortages as potential factor for poor-quality TB care cascade: healthcare workers’ perspective from Beira, Mozambique Dear Dr. Lisboa: I am pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department. If your institution or institutions have a press office, please notify them about your upcoming paper at this point, to enable them to help maximize its impact. If they will be preparing press materials for this manuscript, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org. For any other questions or concerns, please email plosone@plos.org. Thank you for submitting your work to PLOS ONE. With kind regards, PLOS ONE Editorial Office Staff on behalf of Dr. Frederick Quinn Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0228927.r004

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