Changes in care-seeking for common childhood illnesses in the context of Integrated Community Case Management (iCCM) program implementation in Benishangul Gumuz region of Ethiopia

Samson Gebremedhin; Ayalew Astatkie; Hajira M. Amin; Abebe Teshome; Abebe Gebremariam

doi:10.1371/journal.pone.0242451

Peer Review History

Original SubmissionAugust 22, 2020
21 Sep 2020 Decision Letter - Khin Thet Wai, Editor PONE-D-20-26348 Changes in care-seeking for common childhood illnesses in the context of Integrated Community Case Management (iCCM) implementation in an emerging region of Ethiopia PLOS ONE Dear Dr. Gebremedhin, 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 by="" manuscript="" revised="" submit="" your=""> Please include the following items when submitting your revised manuscript:</please> 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 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 https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and https://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, 1)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, and 2) whether the questionnaire has been previously validated. 3. We note that you have indicated that data from this study are available upon request. PLOS only allows data to be available upon request if there are legal or ethical restrictions on sharing data publicly. For information on unacceptable data access restrictions, please see http://journals.plos.org/plosone/s/data-availability#loc-unacceptable-data-access-restrictions. In your revised cover letter, please address the following prompts: a) If there are ethical or legal restrictions on sharing a de-identified data set, please explain them in detail (e.g., data contain potentially identifying or sensitive patient information) and who has imposed them (e.g., an ethics committee). Please also provide contact information for a data access committee, ethics committee, or other institutional body to which data requests may be sent. b) If there are no restrictions, please upload the minimal anonymized data set necessary to replicate your study findings as either Supporting Information files or to a stable, public repository and provide us with the relevant URLs, DOIs, or accession numbers. Please see http://www.bmj.com/content/340/bmj.c181.long for guidelines on how to de-identify and prepare clinical data for publication. For a list of acceptable repositories, please see http://journals.plos.org/plosone/s/data-availability#loc-recommended-repositories. We will update your Data Availability statement on your behalf to reflect the information you provide. 4. Thank you for stating the following in the Competing Interests section: "HMA, AT and AH worked at Emory University (Ethiopia) that implemented the iCCM program. SG and AY received consultancy fees for evaluating the implementation of the program." Please confirm that this does not alter your adherence to all PLOS ONE policies on sharing data and materials, by including the following statement: "This does not alter our adherence to PLOS ONE policies on sharing data and materials.” (as detailed online in our guide for authors http://journals.plos.org/plosone/s/competing-interests). If there are restrictions on sharing of data and/or materials, please state these. Please note that we cannot proceed with consideration of your article until this information has been declared. Please include your updated Competing Interests statement in your cover letter; we will change the online submission form on your behalf. Please know it is PLOS ONE policy for corresponding authors to declare, on behalf of all authors, all potential competing interests for the purposes of transparency. PLOS defines a competing interest as anything that interferes with, or could reasonably be perceived as interfering with, the full and objective presentation, peer review, editorial decision-making, or publication of research or non-research articles submitted to one of the journals. Competing interests can be financial or non-financial, professional, or personal. Competing interests can arise in relationship to an organization or another person. Please follow this link to our website for more details on competing interests: http://journals.plos.org/plosone/s/competing-interests Additional Editor Comments (if provided): This article highlights the role of trained health workers in improved community care seeking. Following issues are to be considered to strengthen readability and scientific integrity of the manuscript: (1) It is essential to correct grammatical errors and typos. (2) To clarify whether the same households in kebeles selected/recruited in three rounds of surveys and whether there was any replacement strategy used for vacant households. (3) The authors need not change the use of verbal consent to written informed consent as suggested by the reviewer. Oral informed consent is acceptable for those with low literacy. (4) In the discussion section, the possible impact of demand creation activities and uninterrupted medical supplies system should be added with appropriate citation rather than included in the results section as indicated by the reviewer: " It will be good to give comparison of change of IEC activities before and after the programme, the medicine supply chain". (5) If the positive findings are likely to be due to " maturation effect" please rewrite the conclusion. [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 Reviewer #2: Yes ******** 2. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: No Reviewer #2: Yes ****** 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: 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: The authors have addressed an important issue of access to care near hone where referral is not possible . There are few issue which need attention. Title: It is unclear why the authors have used the word ‘emerging” for region. There is no mention about registry of the trial , hope it has been registered . Background : The ICCM programme was implemented in Ethopia in 2012 , but it is unclear what was the implementation status before the research team implemented the programme . Methods : Authors have used a pre and post design and the aim is to evaluate the change in care seeking behaviours after implementation of the programme not the associations ?the objectives need to be clearly stated . Intervention: The authors need to describe the intervention in more details , what was missing , what was put in place by the research team . How was health system strengthening done . IEC : what IEC activities were done specific to ICCM programme , its frequency.. Supervision: More details about the supervision , what was done , what was the rate of retention of skills will be valuable to add Sampling procedure : It is unclear how the households were selected for the three surveys , were the same kebeles selected . Ethical consideration : Although the ethics committee has cleared the project , a witnessed written informed consent could have been obtained Data Analysis: The rationale of selecting variables for adjustment has not been described . The authors need to give definition of the wealth index if that is consistent with the definition used in national surveys . Tables and Results : It will be good to give a trial profile of the exclusions , the authors have not mentioned children with what illness were selected . Table ! there is typographical error endline survey has been labelled as midline . The programme was implemented for 2-59 months , however the mean age of children who were included in survey is 27 months, it is unclear whether the younger children did not participate or did not have any illness . It will be good to give comparison of change of IEC activities before and after the programme, the medicine supply chain Reviewer #2: The objective of this study is of great relevance to health of under 5 years old children residing in areas with limited access to facility-based health care provider. The paper is well-written and use appropriate study design and procedure. As the author mentioned, the major limitation is that there is no control arm in the study that could affect the empirical evidence of the effectiveness of intervention. There are only few comments which are shown below. Line 84: There may be a typographical error, “A multicountry study that included ……” Line 91: What is meaning of “revitalized the iCCM program …”? Is there previous history of implementing iCCM in the area? If yes, how is it different from previous iCCM program? Line 148 & 150:What are references for design effect 1.5 and intra-cluster correlation 2%? Line 168: The author mentioned that care-seeking was defined as any of the individual conditions the child had during two weeks. But did not explain clearly how to determine when two or more signs and symptoms (e.g. fever with cough and diarrhea) were occurred in the single time of illness. In my opinion, the definition of care-seeking practice should be whether they visited to health facility or health post for every single time of illness. Reporting number of care seeking practice based on individual signs and symptoms (S & S) would lead estimation bias because one or more S & S can be occurred during single time of illness. Line 182: How the care-seeking practice was assessed? Is it record review or reported care-seeking practice by asking questionnaire? Line 191: What is reference for 13 danger signs? In Table 1, the 4th column heading should be “Endline”. There is same typographical error in the paragraph interpreting table 4 and footnote of table 4, which should be “one way walking distance…”. Overall, the results of this study will contribute towards increasing the access to treatment needs in under 5 years old children residing in areas with limited access to facility-based health care provider. I am grateful for being considered to review this manuscript and would gladly review any updated versions in the future. ****** 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.] 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. 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Revision 1
27 Sep 2020 Author Response Thank you for both of the reviewers and the editor for raising all these important points. We have tried our best to accommodate all of them. Journal Requirements: Comment 1: When submitting your revision, you need you to address these additional requirements on file naming. Response: Done. Comment 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, 1)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, and 2) whether the questionnaire has been previously validated. Response: The data collection tool is now given as the supporting table. Please note that the tool had not been validated before and we have stated the same in the “Data collection” sub-section. Comment 3: We note that you have indicated that data from this study are available upon request. PLOS only allows data to be available upon request if there are legal or ethical restrictions on sharing data publicly. If there are no restrictions, please upload the minimal anonymized data set necessary to replicate your study findings as either Supporting Information files or to a stable, public repository and provide us with the relevant URLs, DOIs, or accession numbers. Response: We have now uploaded the minimal anonymized data as a supporting table. Comment 4: Thank you for stating the following in the Competing Interests section: "HMA, AT and AH worked at Emory University (Ethiopia) that implemented the iCCM program. SG and AY received consultancy fees for evaluating the implementation of the program." Please confirm that this does not alter your adherence to all PLOS ONE policies on sharing data and materials, by including the following statement: "This does not alter our adherence to PLOS ONE policies on sharing data and materials.” Response: We declare that the conflict of interest declared did not alter our adherence to all PLOS one policies. Additional Editor Comments: Comment 1: It is essential to correct grammatical errors and typos. Response: Done Comment 2: To clarify whether the same households in kebeles selected/recruited in three rounds of surveys and whether there was any replacement strategy used for vacant households. Response: The information is now provided in the “sampling procedure” sub-section (Page 10) Comment 3: The authors need not change the use of verbal consent to written informed consent as suggested by the reviewer. Oral informed consent is acceptable for those with low literacy. Response: OK Comment 4: In the discussion section, the possible impact of demand creation activities and uninterrupted medical supplies system should be added with appropriate citation rather than included in the results section as indicated by the reviewer: Response: Corrected (Page 22, Paragraph 2) Comment 5: " It will be good to give comparison of change of IEC activities before and after the programme, the medicine supply chain". Response: It is true that comparison of changes in IEC activities and medical supply would be interesting and add value to the study. Unfortunately, we did not collect quantitative data on these parameters. Comment 6: If the positive findings are likely to be due to " maturation effect" please rewrite the conclusion. Response: As the study is not a controlled trial, the changes in care seeking might also be explained by “Maturation effect”. The same is now stated in the Discussion and Conclusion sections. Reviewers' comments: Reviewer I Comment 1: Title: It is unclear why the authors have used the word ‘emerging” for region. Response: In Ethiopia context, regions are broadly classified: as emerging and major regions. Emerging regions have relatively lower economic status and limited access to social services. In order to clarify the issue further for international readers, we have added few sentences under the sub-section “study setting” (Page 7). Comment 2: There is no mention about registry of the trial, hope it has been registered. Response: In fact, the study was a program evaluation, not a trial. It has not been registered. Comment 3: Background: The ICCM programme was implemented in Ethiopia in 2012, but it is unclear what was the implementation status before the research team implemented the programme. Response: the following sentence “Even though the iCCM program started to be implemented in Ethiopia earlier, the program was rudimentary in Benishangul Gumuz region until 2017.” Is now added in the “Background” section, Paragraph 6 (Page 5). Comment 4: Methods: Authors have used a pre and post design and the aim is to evaluate the change in care seeking behaviours after implementation of the programme not the associations? the objectives need to be clearly stated. Response: The objective is now restated (Page 7). Comment 5: Intervention: The authors need to describe the intervention in more details, what was missing, what was put in place by the research team. How was health system strengthening done. Response: The required information is now given under the sub-section “Description of the intervention” (Page 8). Comment 6: IEC: what IEC activities were done specific to ICCM programme, its frequency. Response: Further clarification is now given under the sub-section “Description of the intervention” (Page 8). Comment 7: Supervision: More details about the supervision, what was done, what was the rate of retention of skills will be valuable to add. Response: The point raised by the reviewer is important. Unfortunately, we did not measure the rate of retention of skills. Comment 8: Sampling procedure: It is unclear how the households were selected for the three surveys, were the same kebeles selected. Response: Once the village was selected, a rapid listing of all eligible children in the village was made, and eligible children were selected randomly. Please note that at the final sampling stage we selected, eligible children, not households. Household selection was not made to reduce the number of sampling stages. During each survey round, the same kebele and village were studied; however, study subjects were selected independently. We have now added further clarification to this section (Page 10). Comment 9: Ethical consideration: Although the ethics committee has cleared the project, a witnessed written informed consent could have been obtained. Response: Yes, it is true but it depends on the decision of the IRB. The IRB sometimes may recommend for such arrangements. But in our case, in line with the direction of the IRB that approved the proposal, independent verbal consent was secured. Comment 10: Data Analysis: The rationale of selecting variables for adjustment has not been described. The authors need to give definition of the wealth index if that is consistent with the definition used in national surveys. Response: The required information is now given in the data analysis section (Page 12). Comment 11: Tables and Results: It will be good to give a trial profile of the exclusions, the authors have not mentioned children with what illness were selected. Response: A section on “Morbidity pattern” and a new table (Table 2) are now added (Page 16). Comment 12: Table ! there is typographical error endline survey has been labelled as midline. Response: Sorry for this silly error. Corrected. Comment 13: The programme was implemented for 2-59 months, however the mean age of children who were included in survey is 27 months, it is unclear whether the younger children did not participate or did not have any illness. Response: As shown in Table 1, children 2-11 months were underrepresented, contributing only to about 5% of the total sample size. This was because, infants 0-11 months were selected for another parallel “Community-based newborn “(CBNC)” survey. This may limit the generalizability of the findings to infants. The same is now stated among the limitation of the study (Last paragraph of the Discussion section, Page 24). Comment 14: It will be good to give comparison of change of IEC activities before and after the programme, the medicine supply chain. Response: The comments of the reviewer are valid. However, we did not collect quantitative data on these parameters. Reviewer #2 Comment 1: Line 84: There may be a typographical error, “A multicountry study that included ……” Response: Thank you. Corrected. Comment 2: Line 91: What is meaning of “revitalized the iCCM program …”? Is there previous history of implementing iCCM in the area? If yes, how is it different from previous iCCM program? Response: The required information is now provided under the section “Description of the intervention”. The implementation of the iCCM program was started in Benishangul Gumuz region in 2014. However, the earlier program was rudimentary and did not bring meaningful change at the group level due to multiple problems including weak health extension program, limited coverage, shortage of human resources for health and turnover of trained health workers. The current program implemented the program according to the national iCCM protocol but included system strengthening and stronger community mobilisation components. Comment 3: Line 148 & 150: What are references for design effect 1.5 and intra-cluster correlation 2%? The DEFF of 1.5 was calculated using standard formula using ICC of 2%. The reference for the ICC of 2% is now added (Reference # 30). Comment 4: Comment 4: Line 168: The author mentioned that care-seeking was defined as any of the individual conditions the child had during two weeks. But did not explain clearly how to determine when two or more signs and symptoms (e.g. fever with cough and diarrhea) were occurred in the single time of illness. In my opinion, the definition of care-seeking practice should be whether they visited to health facility or health post for every single time of illness. Reporting number of care seeking practice based on individual signs and symptoms (S & S) would lead estimation bias because one or more S & S can be occurred during single time of illness. Response: The point raised by the reviewer is correct. When the children had two distinct illness in the refence period (as judged by the caregiver) both conditions were considered as different illnesses. However, as the reviewer noted, when the child had multiple symptoms of the same illness, we only considered the chief complaint of the mother. Clarification is now given under the section “Variables of the study” (Page 10). Comment 5: Line 182: How the care-seeking practice was assessed? Is it record review or reported care-seeking practice by asking questionnaire? Response: Care-seeking practice was assessed based on the reports of the caregiver without reviewing any formal medical records. The same is now stated under the “Data collection” sub-section (Page 11). Comment 6: Line 191: What is reference for 13 danger signs? Response: Reference # 31 is now added. Comment 7: In Table 1, the 4th column heading should be “Endline”. Response: Corrected. Comment 8: There is same typographical error in the paragraph interpreting table 4 and footnote of table 4, which should be “one way walking distance…”. Response: Sorry for the silly error. Corrected. Attachments Attachment Submitted filename: Point by point response.docx https://doi.org/10.1371/journal.pone.0242451.r002
15 Oct 2020 Decision Letter - Khin Thet Wai, Editor PONE-D-20-26348R1 Changes in care-seeking for common childhood illnesses in the context of Integrated Community Case Management (iCCM) implementation in an emerging region of Ethiopia PLOS ONE Dear Dr. Gebremedhin, 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 by="" manuscript="" revised="" submit="" your=""> Please include the following items when submitting your revised manuscript:</please> 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): English language correction is deemed necessary. [Note: HTML markup is below. Please do not edit.] 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: (No Response) ******** 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 ****** 3. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: Yes ****** 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: 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: No ****** 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: All the comments have not been adequately addressed Previous Comment 1: The authors have explained the meaning of émerging’ but the ‘word’ does not make sense in the title. Previous Comment 2: Unsure if Ethiopia system does not need the observational studies to be registered. For most registries all types of research need to be registered. Previous Comment 5 Description of the intervention has been added still unclear what support other than medicines and improving linkages was done by research team It is unclear if was supervision was by the health system. Previous Comment 7 Has this been added as the limitation of the trial. Previous Comment 8 Is there a possibly if the same child could have been selected in all 3 surveys. If yes, would that primed the caregivers with the responses to be given. Previous Comment 11 Trial profile is still missing. Previous Comment 13 Not added in limitation as mentioned by author. Previous Comment 14 Should add as a limitation. ****** 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 [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. https://doi.org/10.1371/journal.pone.0242451.r003
Revision 2
24 Oct 2020 Author Response Comment from the editor: English language correction is deemed necessary. The manuscript is now edited further. Comments of Reviewer 1 Comment 1: The authors have not fully made all data underlying the findings. Response: We disagree with the evaluation of the reviewer. We have already made our data available as a supporting table (S2 table). Comment 2: Previous Comment 1: The authors have explained the meaning of ‘emerging’ but the ‘word’ does not make sense in the title. Response: The title is now modified accordingly. Comment 3: Previous Comment 2: Unsure if Ethiopia system does not need the observational studies to be registered. For most registries all types of research need to be registered. Response: As the reviewer mentioned, observational studies can also be registered but we don’t think that’s mandatory. That’s why the study was not registered. Comment 4: Previous Comment 5: Description of the intervention has been added still unclear what support other than medicines and improving linkages was done by research team It is unclear if was supervision was by the health system. Response: Please note that this is an observational study so that the researchers were not directly involved in the implementation of the program. But if the concern of the reviewer is on the role Emory University in the implementation of iCCM program, the following activities were implemented by Emory University: training of frontline health workers, consolidating referral linkage between health posts and health centers, instating quality improvement framework at various levels of the system, provision of supervisory skill training for health extension worker supervisors, joint supportive supervision and monthly couching of health extension workers. We have now made some correction on the section “Description of the intervention” to make the issue clear for readers. Comment 5: Previous Comment 7: Has this been added as the limitation of the trial. Response: this is now listed as the limitation in the last paragraph of the discussion section (Page 24) Comment 6: Previous Comment 8: Is there a possibly if the same child could have been selected in all 3 surveys. If yes, would that primed the caregivers with the responses to be given. Response: It would be very unlikely for a child to be included in multiple surveys for two reasons: (1) the chance a child would be sick during two or more survey rounds is obviously low, (2) in each survey round a random and independent sample of children were selected. So we don’t think the concern of the reviewer is a major concern in our study Comment 7: Previous Comment 11: Trial profile is still missing. Response: It would be more interesting to have a flow chart that describe the characteristics of the study subjects excluded from the study, unfortunately we did not collect data on subjects excluded from the study. Comment 8: Previous Comment 13: Not added in limitation as mentioned by author. Response: We disagree with the evaluation reviewer. As you may read from the last paragraph of the discussion section, we have discussed the issue as a limitation “Furthermore, infants 2-11 months were underrepresented (contributed to only 5-6% of the total children enrolled) which may limit the generalizability of the findings of the study.” Comment 9: Previous Comment 14: Should add as a limitation. Response: We have now stated this as a limitation in the last sentence of the discussion section (Page 24). Attachments Attachment Submitted filename: Point by point PLOS.docx https://doi.org/10.1371/journal.pone.0242451.r004
3 Nov 2020 Decision Letter - Khin Thet Wai, Editor Changes in care-seeking for common childhood illnesses in the context of Integrated Community Case Management (iCCM) program implementation in Benishangul Gumuz region of Ethiopia PONE-D-20-26348R2 Dear Dr. Gebremedhin, 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. Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication. An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. 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 help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- 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. Kind regards, Khin Thet Wai, MBBS, MPH, MA (Population & Family Planning Resear Academic Editor PLOS ONE Additional Editor Comments (optional): All comments of reviewers are fully addressed. Reviewers' comments: https://doi.org/10.1371/journal.pone.0242451.r005
Formally Accepted
5 Nov 2020 Acceptance Letter - Khin Thet Wai, Editor PONE-D-20-26348R2 Changes in care-seeking for common childhood illnesses in the context of Integrated Community Case Management (iCCM) program implementation in Benishangul Gumuz region of Ethiopia Dear Dr. Gebremedhin: I'm 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 let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, 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. If we can help with anything else, please email us at plosone@plos.org. Thank you for submitting your work to PLOS ONE and supporting open access. Kind regards, PLOS ONE Editorial Office Staff on behalf of Dr. Khin Thet Wai Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0242451.r006

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