PONE-D-20-01768

Health system actors’ perspectives of prescribing practices in public health facilities in Eswatini: A Qualitative Study

PLOS ONE

Dear Mrs Ncube,

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.

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We look forward to receiving your revised manuscript.

Kind regards,

Khin Thet Wai, MBBS, MPH, MA (Population & Family Planning Resear

Academic Editor

PLOS ONE

Additional Editor Comments:

This article addresses the factors influencing rational prescribing practice for quality medicine by application of Social Practice Theory. In general, authors should follow the submission guidelines in preparing the abstract, text structure and the citation style.

To further improve scientific integrity, authors need to pay attention to the following:

1. To add one key reference on qualitative research reporting guidelines.

2. To check and revise throughout in line with COREQ 32 item checklist for qualitative studies.

3. To reorganize the sequence of Results section in line with key themes emanated [LINES: 188-190].

Journal requirements:

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2. Please ensure you have thoroughly discussed any potential limitations of this study within the Discussion section.

3. Please include additional information regarding the interview guide used in the study and ensure that you have provided sufficient details that others could replicate the analyses.

For instance, if you developed a guide 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.

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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

Reviewer #2: Yes

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2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: N/A

Reviewer #2: Yes

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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

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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: Yes

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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: This paper reports on qualitative research conducted in Eswatini to investigate perspectives of key health system actors on prescribing practices and factors influencing these.

I have reviewed this with a particular focus on the description of methods, and reporting of qualitative data throughout the paper. Please see feedback on recommended revisions below.

Introduction

It is not clear how the Social Practice Theory developed in this section informed the method section. It seems as you used elements of the SPT to develop your interview guide.

I would rather suggest that the authors develop a sub-section on “Conceptual framework” under the methods section.

Methods

Study design:

This should provide a clear statement on the study design, with appropriate definition and referencing. The authors state that this is an ‘qualitative exploratory study design’. This will need defining and referencing.

The authors should describe how this study is embedded in the larger intervention study, in term of research questions, methodology, ….. How are they complementary?

The sampling requires a clear summary about the people who were interviewed, especially frontline managers. How they were sampled, and how they were recruited. In addition, how the balance between urban/rural settings, public/private health facilities was ensured.

I would propose that the following information is covered:

- a sentence stating how these were sampled, including a definition of this sampling strategy, an explanation about why this sampling strategy was used, and a recognisable reference to support these ideas

- a table to clearly outline and summarize the sample, including information on number of participants, district participants, settings, level of care, owner of the facility (public/private).

- A very transparent explanation about how these participants were recruited into the study (how were they identified, how were they invited into the study, who invited them into the study etc).

- A statement on whether they were reimbursed/incentivised.

Data collection

The data collection subsection should include a clear account of the following issues:

- Why a semi-structured interview was chosen, with a reference to literature

- How long interviews lasted

- What language they were conducted in

Data Analysis

The analysis process needs to be clearly described, and referenced to a recognisable analysis process. This section lacks convincing or transparent explanation. Please clarify so there are clear statements on:

- the analysis process used, with reference to a systematic analysis process

- a step by step explanation about how the analysis was conducted, including an explanation of which analysis approach and technique (again with references) were used in this study.

Results

Lines 186-188 should do under methods section

The reference for each quote needs to be done in a systematic fashion, to provide sufficient information linking the quote back to the sample. I propose that the authors include ‘role, level of work, district interviewee is from’. These need to link back clearly to the sample section of the methods, and to the table summarizing the sample, so readers are clear who is quoted. At the moment, we have no idea how many of the interviewees are represented in the quotes selected, and how representative of the sample these selected quotes are.

Discussion

The authors should discuss the study limitation: methods and results

- The limitation is applying the Social Practice Theory

- The limitation in utilising the adapted model of practice (SPT)

- The study limitations section needs to include statements on the ‘reliability’ and ‘rigour’ of the study design. Explanations of these are given in any good methods text book (e.g. Bryman, A. (2008). Social Research Methods. Oxford: Oxford University Press)

- In the study limitations, you will also need to account for the potential issues associated with rigour and integrity associated with using a number of different topic guides throughout the study, as it ‘thins’ the data collected (i.e. not all interviews were conducted in the same manner)

Reviewer #2: This is an important study and the findings are relevant to inform interventions to improve pharmaceutical care. I would like to also congratulate the authors for this piece of work. Below are my comments and suggestions for the authors.

General comment

The manuscript is generally well organized. However, I believe some sentences can be revised to bring more clarity.

Introduction

1. The authors need to provide more context on the Standard Treatment Guidelines (STGs) and the Essential Medicines List (EML). Are the medicines in these documents assigned specific levels of care? Are there key differences between the EML and STGs? For example, do these documents differ on how they assign/restrict medicines to levels of care? These are needed to put the findings from the study in context.

Methods

1. Under study setting, it would be helpful to also indicate which cadres of health workers are available at the various levels of care.

Results

1. The authors provided the range of the number of years of experience of the study respondents. It would be helpful to also provide the median number of years of experience.

2. It would be helpful to include the breakdown of the number of respondents (especially the 32 frontline health workers) by level of care or type of facility (clinics, health centers, hospitals etc.)

3. It is hard to believe the STG/EML were mainly tailored for primary health care as reported by the authors: “current STG/EML, which were mainly tailored for primary health care” (under the section titled “availability and use of STG/EML”). This may require further explanation. Does this mean the medicines in the EML for instance, are only medicines for primary care services? The comment that “Frontline healthcare providers highlighted the difficulty for them to adhere to treatment guidelines due to restrictions on availability of medicines at certain levels of care” (under the section titled “restriction of medicines by level of care”) indicates that the guidelines may not only tailored to primary care facilities

4. This finding/sentence may also need more clarification: “However, key informants highlighted that targeting the guidelines at primary level of care resulted in secondary and tertiary level facilities prescribing outside the guidelines”. What does “targeting guidelines” mean? Does it have to do with the content of the guidelines focusing on primary care or the promotion of the guidelines to primary care facilities?

5. Line 268 -269: Please provide specific examples of NCD medicines and antibiotics that are not available at primary health care facilities.

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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.]

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PONE-D-20-01768R1

Health system actors’ perspectives of prescribing practices in public health facilities in Eswatini: A Qualitative Study

PLOS ONE

Dear Dr. Ncube,

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.Please submit your revised manuscript by Jul 31 2020 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 plosone@plos.org. When you're 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.

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). You should upload this letter as a separate file labeled 'Response to Reviewers'.
• 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, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols

We look forward to receiving your revised manuscript.

Kind regards,

Khin Thet Wai, MBBS, MPH, MA (Population & Family Planning Resear

Academic Editor

PLOS ONE

Additional Editor Comments (if provided):

Please consider revising in accordance with the comments provided by the reviewer.

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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: (No Response)

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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: No

**********

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: (No Response)

Reviewer #2: I would like to congratulate the authors for taking time to carefully incorporate the comments from the reviewers and editors. The manuscript has substantially improved. I have only a few comments below.

Introduction

-The statement “In 2017, posts for pharmacy assistants in all levels of care, but mainly clinics, were approved” is not clear. I suggest the authors expand on this statement.

Methods

-I find it confusing that the “theory informed implementation intervention (the theoretical domains framework)” was introduced in the methods section (under the section titled, conceptual framework), even though this is not the theoretical framework used for this qualitative study. I agree it will be nice to have a subsection on the conceptual framework in the methods section. However, I believe this subsection should focus on the framework that is relevant for the methodology of this particular study. This will be a good place to discuss how the framework informed the design of interview guides etc.

-Data Management: I do not believe it is necessary to disclose what the codenames of the transcripts mean. A general statement that the data were anonymized, and stored securely should suffice.

-Data analysis: It seems the information in the second paragraph should come before the first paragraph.

-Study design and sampling: I do not believe it is necessary to talk about the sampling of prescriptions which was done in the larger study but irrelevant (and perhaps distracting) for this qualitative study. Since the qualitative interviews were with health facilities, the description on how these facilities were sampled should be enough.

Results

-Availability and use of STG/EML: The authors stated, “Information from key informants highlighted that public sector prescribing practices were influenced by the current STG/EML, which were mainly targeted at primary health care (though they can still be used at secondary and tertiary levels of healthcare)”.. the authors should revise the first sentence of this section which says that both the STG and the EML are focused on primary care.

-Restriction of medicines by level of care: The authors stated, “Frontline healthcare providers highlighted the difficulty for them to adhere to treatment guidelines due to restrictions on availability of medicines at certain levels of care. An example cited was the unavailability of ceftriaxone and azithromycin at primary healthcare levels yet the latest guidelines for managing sexually transmitted infections recommend these medicines as first line therapy and for them to be available at primary healthcare level.” This is one example where referring to the STGs and the EML as if they were one document could mask important findings that may have implications for the revision of these documents. As I stated in the introduction, the EML restricts medicines to specific levels of care while the STG does not. This should be made clear in the presentation of the findings in the above sentence. If I understand correctly, based on the EML, primary care level facilities are not allowed to stock certain medicines. However, the STGs expect these facilities to treat conditions that require the use of medicines the EML restricts to higher level facilities. So there is a discordance between the EML and the STGs which may be impacting rational use of medicines.

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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: 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.]

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 PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

Health system actors’ perspectives of prescribing practices in public health facilities in Eswatini: A Qualitative Study

PONE-D-20-01768R2

Dear Dr. Ncube,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

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Kind regards,

Khin Thet Wai, MBBS, MPH, MA (Population & Family Planning Resear

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments: