Incidence and determinants of Implanon discontinuation: Findings from a prospective cohort study in three health zones in Kinshasa, DRC

P. Z. Akilimali; Hernandez J.; Anglewicz P.; Kayembe K. P.; Bertrand J.

doi:10.1371/journal.pone.0232582

Peer Review History

Original SubmissionSeptember 9, 2019
21 Feb 2020 Decision Letter - Catherine S. Todd, Editor PONE-D-19-25274 Incidence and Determinants of Implanon Discontinuation: Findings from a Prospective Cohort Study in Three Health Zones in Kinshasa, DRC PLOS ONE Dear Dr Akilimali, 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 by Apr 06 2020 11:59PM. 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. To enhance the reproducibility of your results, we recommend that if applicable 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. For instructions see: http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols Please include the following items when submitting your revised manuscript: A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). This letter should be uploaded as separate file and labeled 'Response to Reviewers'. A marked-up copy of your manuscript that highlights changes made to the original version. This file should be uploaded as separate file and labeled 'Revised Manuscript with Track Changes'. An unmarked version of your revised paper without tracked changes. This file should be uploaded as separate file and labeled '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. We look forward to receiving your revised manuscript. Kind regards, Catherine S. Todd Academic Editor PLOS ONE Journal Requirements: When submitting your revision, we need you to address these additional requirements. 1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at http://www.journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and http://www.journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf 2. Please include additional information regarding the survey or questionnaire used in the study and ensure that you have provided sufficient details that others could replicate the analyses. For instance, if you developed a questionnaire as part of this study and it is not under a copyright more restrictive than CC-BY, please include a copy, in both the original language and English, as Supporting Information. Also, pre-testing of the questionnaire was mentioned but not on whom this pre-testing took place and how many participants were involved. Please update with this information as appropriate. Additional Editor Comments (if provided): This is a well-written manuscript regarding efforts to broaden access to long-acting reversible contraception in a context with a very low contraceptive prevalence rate. I agree with the reviewer that further information regarding context, sample selection, and results will enhance the manuscript and will be pleased to see a revised submission. [Note: HTML markup is below. Please do not edit.] Reviewers' comments: Reviewer's Responses to Questions Comments to the Author 1. 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 ******** 2. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: I Don't Know ****** 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: 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 ****** 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: Methodology: page 4 -perhaps use another word instead of "opted" rather use chose? to use Implanon. Can you comment on the experience of nursing students to provide the service. Did they provide a better service as they knew research would evaluate their service provision. What is meant by providing services at community level outreach event? was it a campaign to specifically target contraceptive uptake or the Implant? what other methods were available ? other helath services?Could they have got implanon at a local service nearby (for post insertion support) You say it was not possible to interview all 702, so what was the convenience sample limited to? those who agreed to stay? Why were the three districts chosen? noting one was very different? was there a programme that wanted to ensure IMplanaon wa smade available to the women in these areas? Did you collect data on who removed the implant? was it the same nurses and where did they go? The methodology says women were interviewed on the phone? on page 5 but a few sentance later it says women were asked to appear ? at a central community location. these two statements contradict each other. If many women lived in a military camp why did the study not ask for permission to interview them at the camp or did they also have to go to a community venue? again in analytic methods it says data was collected on a mobile phone? Did women get reimbursed for participation Results: Could you have tracked the LTFP via clinics in case they had the implant removed? Conclusions: The woman in military camps - were they working or just living with men employed by the military? if working perhaps the heavy bleeding impacted on their work or the camps had poor facilities? if they lack access to health facilities how did they get their implants removed? and if they all received equal conselling on a variety of methods why would they have less knowledge than other woman. Is it that the camps provide no Health facilities to their staff? Later in the conclusion it says the study was conducted in a community setting? rather enrollment was conducted in a community setting but interviews were on the phone? not in the community ? see earlier comments. ****** 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 [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.0232582.r001
Revision 1
15 Mar 2020 Author Response Comments from the reviewer are below in bold font, and our responses follow each comment in plain font Reviewer #1: Page 4 -perhaps use another word instead of "opted" rather use chose? to use Implanon. We agree and have updated accordingly. Can you comment on the experience of nursing students to provide the service. Did they provide a better service as they knew research would evaluate their service provision. We appreciate this comment. To address this issue, we have added the following text to the discussion section: “The authors acknowledge that the performance of the nursing students could have been influenced by their awareness of being evaluated. Yet this influence could operate in opposing directions. Whereas they could perform better under observation than otherwise, they might also performance less well from being nervous about the observation.” What is meant by providing services at community level outreach event? was it a campaign to specifically target contraceptive uptake or the Implant? what other methods were available ? other health services? Could they have got implanon at a local service nearby (for post insertion support) As part of their practical training, the students provided FP services at the community level: at outreach events (mini-campaigns) set up in a central location (e.g., near a referral health facility, beside a market), door-to-door, or from their own homes. Nursing students offered a range of five contraceptive methods: Implanon NXT, DMPA-SC, oral pills, condoms, and Cycle beads. Prospective clients often preferred these community services to fixed facilities in their neighborhoods, because they were less expensive and required less waiting time. You say it was not possible to interview all 702, so what was the convenience sample limited to? those who agreed to stay? In addition to “willingness to stay,” the respondent needed to provide consent for the interview. So, out of the 702 women who received Implanon NXT, 531 women aged 18 to 49 years old agreed to participate in the study and gave their informed consent to be interviewed at 6,12 and 24 months. Why were the three districts chosen? noting one was very different? was there a programme that wanted to ensure Implanon was made available to the women in these areas? The selection of zones took into account the proximity of the training institutes in which the students were trained. In addition, for logistical efficiency, we needed to limit that number of health zones to be covered and selected three with different characteristics to capture different types of clients (to increase the generalizability of the results). Did you collect data on who removed the implant? was it the same nurses and where did they go? Nursing students received training in the removal of Implanon NXT in the 4th year of nursing school. At the large majority of outreach events, a more experienced nurse handled the removal of implants (not the nursing students), and often the client was referred to the health facility near the outreach site for the removal. Our data show that among the 83 clients who had had an implant removed, 65% went to the Health center, 27% to the hospital and 8% in the resident of Nurse to remove the device. The methodology says women were interviewed on the phone? on page 5 but a few sentences later it says women were asked to appear ? at a central community location. these two statements contradict each other. If many women lived in a military camp why did the study not ask for permission to interview them at the camp or did they also have to go to a community venue? again in analytic methods it says data was collected on a mobile phone? During this study, trained interviewers used smart phone technology to collect data during a face-to-face interview. The use of mobile technology for data collection allowed interviewers to automatically upload data to a secure electronic server instead of having to code and enter data manually. Data was collected using interview face to face using mobile phone as tools ( SurveyCTO). These were not phone interviews. However women were re-contacted by phone to schedule the follow-up interviews. Did women get reimbursed for participation? Participants received U.S. $5.00 as reimbursement for transportation costs. Could you have tracked the LTFP via clinics in case they had the implant removed? Unfortunately, this is not possible. The client record system at these clinics would not have this type of information, nor is it clear that women using the community service would ever have registered with the nearby clinic. The woman in military camps - were they working or just living with men employed by the military? if working perhaps the heavy bleeding impacted on their work or the camps had poor facilities? if they lack access to health facilities how did they get their implants removed? and if they all received equal counselling on a variety of methods why would they have less knowledge than other woman. Is it that the camps provide no Health facilities to their staff? Most of the participants from Military camps were the wives of military personnel. Military camps are closed settings in which the health structures are less likely to receive technical and financial support from development partners. Also, results from a previous survey show that women in military camps have lower levels of knowledge and use of contraception than do their civilian counterparts. Because one of these development partners has begun supporting the military camp health facilities in recent years, Implant users have access to trained personnel who can remove implants. Later in the conclusion it says the study was conducted in a community setting? rather enrollment was conducted in a community setting but interviews were on the phone? not in the community? see earlier comments. The study was conducted in a community setting and participants were interviewed face to face using a questionnaire programmed on a mobile phone. During this study, trained interviewers used smart phone technology to collect data. The use of mobile technology for data collection allowed interviewers to automatically upload data to a secure electronic server instead of having to code and enter data manually. Data was collected during face to face interviews using mobile phone as tools ( SurveyCTO). This was not a phone survey. Attachments Attachment Submitted filename: Cover letter and response to reviewers.docx https://doi.org/10.1371/journal.pone.0232582.r002
10 Apr 2020 Decision Letter - Catherine S. Todd, Editor PONE-D-19-25274R1 Incidence and Determinants of Implanon Discontinuation: Findings from a Prospective Cohort Study in Three Health Zones in Kinshasa, DRC PLOS ONE Dear Dr Akilimali, 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 by May 25 2020 11:59PM. 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. To enhance the reproducibility of your results, we recommend that if applicable 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. For instructions see: http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols Please include the following items when submitting your revised manuscript: A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). This letter should be uploaded as separate file and labeled 'Response to Reviewers'. A marked-up copy of your manuscript that highlights changes made to the original version. This file should be uploaded as separate file and labeled 'Revised Manuscript with Track Changes'. An unmarked version of your revised paper without tracked changes. This file should be uploaded as separate file and labeled '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. We look forward to receiving your revised manuscript. Kind regards, Catherine S. Todd Academic Editor PLOS ONE Additional Editor Comments (if provided): This manuscript has largely responded to the queries raised by the prior reviewer. It will be suitable for publication once two minor changes are made: - Please add the description of the participants' context as military wives to the manuscript, ideally in the Introduction section. You identify the program as novel but do not mention the circumstances of the context where family planning services are traditionally limited and women less aware of contraceptive options. - Please add the reimbursement of travel expenses to the Methods section - this is a required feature to report. [Note: HTML markup is below. Please do not edit.] [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.0232582.r003
Revision 2
13 Apr 2020 Author Response April 14th, 2020 To: Catherine S. Todd Academic Editor PLOS ONE Re: Revised version manuscript PONE-D-19-25274 R2 Dear Editor, Thank you very much for the opportunity to revise and resubmit our manuscript. The comments we received helped to improve our research. Our revised submission includes the following documents: (1) the manuscript with changes tracked, (2) a clean revised manuscript including tables and (3) the rebuttal letter with our responses to each point raised by the editor and reviewers. Below is our reply to the comments and suggestions of the reviewers on a point-by-point basis. We would like to thank the referees for the valuable and constructive comments and suggestions. We are hoping that we have adequately dealt with the comments and suggestions, and that the revised version is to your satisfaction. Looking forward to hearing from you. Sincerely, Dr. Pierre Zalagile Akilimali Kinshasa School of Public Health University of Kinshasa Democratic Republic of Congo Reviewer’s Comments Please add the description of the participants' context as military wives to the manuscript, ideally in the Introduction section. Kokolo health zone consists of compounds that house military personnel and their families. Military compounds differs from other health zones in that they are a closed encampment within the city with their own health system, though often underfunded and affording less access to family planning than in the non-military population. We have added a statement about this on page 5 in Method section. You identify the program as novel but do not mention the circumstances of the context where family planning services are traditionally limited and women less aware of contraceptive options. Please add the reimbursement of travel expenses to the Methods section - this is a required feature to report. We have added the following statement “Participants received U.S. $5.00 as reimbursement for transportation costs per visit.” to page 7 of the manuscript. Attachments Attachment Submitted filename: Cover letter and response to reviewers.docx https://doi.org/10.1371/journal.pone.0232582.r004
20 Apr 2020 Decision Letter - Catherine S. Todd, Editor Incidence and Determinants of Implanon Discontinuation: Findings from a Prospective Cohort Study in Three Health Zones in Kinshasa, DRC PONE-D-19-25274R2 Dear Dr. Akilimali, 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. To ensure an efficient production and billing process, please log into Editorial Manager at https://www.editorialmanager.com/pone/, click the "Update My Information" link at the top of the page, and update your user information. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org. If your institution or institutions have a press office, please notify them about your upcoming paper to enable them to help maximize its impact. If they will be preparing press materials for this manuscript, you must inform our press team as soon as possible and no later than 48 hours after receiving the formal acceptance. 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. With kind regards, Catherine S. Todd Academic Editor PLOS ONE Additional Editor Comments (optional): Reviewers' comments: https://doi.org/10.1371/journal.pone.0232582.r005
Formally Accepted
28 Apr 2020 Acceptance Letter - Catherine S. Todd, Editor PONE-D-19-25274R2 Incidence and Determinants of Implanon Discontinuation: Findings from a Prospective Cohort Study in Three Health Zones in Kinshasa, DRC Dear Dr. Akilimali: 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. Catherine S. Todd Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0232582.r006

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