Knowledge, attitudes and practices regarding neonatal jaundice among caregivers in a tertiary health facility in Ghana

Solomon Mohammed Salia; Agani Afaya; Abubakari Wuni; Martin Amogre Ayanore; Emmanuel Salia; Doreen Dzidzor Kporvi; Peter Adatara; Vida Nyagre Yakong; Sean Augustine Eduah-Quansah; Shine Seyram Quarshie; Eric Kwame Dey; Dominic Amoah Akolga; Robert Kaba Alhassan

doi:10.1371/journal.pone.0251846

Peer Review History

Original SubmissionJune 26, 2020
27 Nov 2020 Decision Letter - Miquel Vall-llosera Camps, Editor PONE-D-20-19725 Determinants of Neonatal Jaundice Knowledge, Attitudes and Practice Among Caregivers in a Tertiary Health Facility in Ghana: Implications for Neonatal Care policy Reforms and Reducing Neonatal Mortality in a Low Resource Setting. PLOS ONE Dear Dr. Salia, 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. I would like to sincerely apologise for the delay you have incurred with your submission. It has been exceptionally difficult to secure reviewers to evaluate your study. We have now received two completed reviews; their comments are available below. 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(Please upload your review as an attachment if it exceeds 20,000 characters) Reviewer #1: Determinants of Neonatal Jaundice Knowledge, Attitudes and Practice among Caregivers in Ghana Introduction and Literature Review: Neonatal Jaundice is an important topic in the West African sub-region, the significance of jaundice being emphasized by the complications that attend uncontrolled rise in unconjugated hyperbilirubinaemia . Jaundice may progress to acute bilirubin encephalopathy with hearing loss and cerebral palsy or death besides lingering kernicterus spectrum disorder. The author needs to elaborate this outcome of jaundice because it is ruinous to families that become unfortunate to experience the disorder. Jaundice occurs in physiological or pathological forms. While the former is harmless the latter is deleterious. What is concerning is the pathological jaundice which may lead to neonatal mortality. Literature review however scanty it may be needs to cover the entire understanding of the subject matter as the KAP of parents may be influenced by this knowledge. Study Population: The study focused on the real fathers/mothers of the neonates excluding other significant patient relatives. In the study location of West Africa, a good number of caregivers are neither the real father/mother of the neonate. Very often the grandmother, aunt, sister or other significant relative play an important, sometimes dominant role in neonatal care. Thus excluding them from a study of this nature could mean a major information loss and interventions targeted at real mothers/fathers may fall short of success without them. In the author’s area of practice the grandmothers often overrule their daughters in child care practices irrespective of the daughter’s knowledge or educational background. Inclusion/Exclusion Criteria: The author excluded adolescent mothers/fathers from the study. In West Africa, teenage pregnancy and delivery is common. These mothers are inexperienced and therefore more likely to be ignorant of good child care practices. Studies of under-five mortality show that infants born to these teenagers succumb by far more than the experience mothers of older age group. This study would have been more revealing and perhaps more beneficial if adolescent mothers (12-18 years) were included in the study. Study Design: The study design was entirely quantitative but the issues were more dominantly qualitative. A study which set out to evaluate the KAP of respondents should have given them the opportunity to express themselves freely in order to optimize that information that the researcher may not have thought about. This is a major concern in this study. How can we be sure that the investigators captured the reflections of the respondents’ true inclination? Data Collection procedure: The sampling of study participants was by convenient method. How could this methodology have navigated around bias? The questionnaire was administered to two groups differently, to one group by self-administration while to the second group it was by interviewer administration. A number of the respondents had no formal education requiring interpretation of the questionnaire. How exactly was this bottle neck sorted out? Was translation into local languages carried out? Please specify the details. Assessment of Knowledge of mothers/caregivers on NJ: It is eminently observable that death as an outcome of untreated NJ was not evaluated in this study, neither as a complication nor as danger sign. Could knowledge of this adverse outcome influence respondents’ attitude and change their health seeking behavior? If this was evaluated, it would be important to analyze the data to enrich the present study. Treatment of NJ: Several treatment modalities were indicated by the authors in evaluating the KAP of the respondents. All modes of treatment were investigated individually. Were there respondents who practiced a combination of more than one mode of treatment of NJ in the study? Fifty-five respondents volunteered that they sought help by visiting “church” or by “fasting and praying”. How many of these respondents also visited the health facility for treatment of the NJ? It is possible to criminalize a respondent’s practice without fully exploring all the actions taken towards treatment of their neonates’ NJ. In West Africa usually a combination of approaches are resorted to in order to overcome health challenges. Attitude of Caregivers towards NJ: An overwhelming number of the respondents demonstrated the attitude of attending ANC and a large number of respondents showed awareness that NJ early in life can be treated in the hospital. However, the investigators did not evaluate how many of the respondents actually practiced taking their infants to the hospital for treatment of NJ. In West Africa most health care seekers would apply traditional methods of treatment of ailments and would also visit the hospital for treatment. Was it a deliberate action not to include this point or an omission? Confounding variables: KAP may be influenced by other considerations that may complicate the ones studied herein. Such other factors include health infrastructure and availability of equipment, economic realities, and distance to the health facility, availability of transportation and insecurity. How were these confounding variable eliminated so we can trust the validity of this study findings? Reviewer #2: Reviewer: Plos One Title: Determinants of Neonatal Jaundice Knowledge, Attitudes and Practice Among Caregivers in a Tertiary Health Facility in Ghana: Implications for Neonatal Care policy Reforms and Reducing Neonatal Mortality in a Low Resource Setting. Date: 26/11/2020 General comment: Thank you for allowing me to review this article by Salia, et al. The manuscript is about neonatal jaundice a common condition affecting newborns which can lead to disability and sometimes mortality. Generally, the manuscript reads well and is of relevance to those with an interest in the public health aspect of newborn care. However there are several abbreviations such as Neonatal Jaundice, neonatal mortality and postnatal which are simple words or phrases, that can be obtrusive to reading and a few other items that need to be corrected prior to publication. I have made some suggestions below: Major corrections • Page 1: Title: Suggest revision of title to: Knowledge, Attitudes and Practices Regarding Neonatal Jaundice Among Caregivers in a Tertiary Health Facility in Ghana. • This was what was done. The study is a small study and finding are not so different from what is already known or so novel to warrant a reform in policy. • Page 6 Sample size and sampling determination (change determination to methods) - it is not clear what sampling method was actually applied. While is says in this section that systematic sampling was done, on Page 8 line 10 it says ...caregivers were conveniently selected – this is in contrast with the assertion on page 6 that systematic sampling was used. Please clarify. • Page 6 Line 12 and 13: was selection of the first skip interval done by balloting or other random sampling method? How were the patients arranged ina row? Were they arranged according to time of arrival as one would imagine would be the same as the attendance records or in another way? This needs to be specified. • Page 2 abstract line 12 under methods: It does not say where the study was done and what data was collected. Minor essential corrections • Abstract • Page 2 line 23: suggest rephrase to “good attitude about neonatal jaundice” rather than “...attitude in jaundice”. • Page 2 line 29: suggest rephrase to “,,, will help reduce disability and deaths from neonatal jaundice.” Introduction • Page 3 line 14: it will be useful to also capture global targets (SDG) • Page 3 lines 9-11. Although neonatal jaundice affects a number of babies, many of them recover. A few may die from kernicterus or bilirubin encephalopathy however underlying causes such as neonatal sepsis are more often the cause of neonatal death in babies with jaundice. Nonetheless neonatal jaundice is a major cause of disability i.e. cerebral palsy and emphasis of this role is lacking. Thus need to rephrase to capture this. • Page 4 line 9: should read “...as a means of treatment” • Page 4 line 10 change “generations back” to “previous generations” • Page 4 line18 suggest rephrasing to read...serve as useful information Methods • Page 5 ethical approval: were the benefits and risks also explained to them? • Study area: Information on the delivery rate, presence of a newborn unit, its capacity, admission and neonatal mortality rates will be useful. • Page 5 line 17: ...the health facility serves as a major facility for neighbouring Togo residents – needs to be put in the right perspective as unintentional. • Page 5 line 17 bed capacity” remove approximately- be specific • Page 6 study design – reads better without the abbreviations. i.e. if they are written in full -. KAP and NJ • Page 6 line 20 - 21 Inclusion criteria- need to include the recruitment period • Page 7 line 1: rephrase to “...not the parents of the baby” rather than “...not the real father or mother” • Page 7 line 7 - no mention of northern tribes – they form a significant proportion of the Ghanaian population, were they few? • Page 7 line 12: Adequacy of antenatal visits is now pegged at 8 or more visits but 4 or more can still be used as information on this is more readily available for comparison. Need to mention • Page 7 line 15 -17. Add - these are captured in more details in the results section . • Page 8 line 17: “...further explanation” seems a more appropriate to understanding • Page 9 line 4 comment of significance of these coefficients. Results • Page 10. Table 1 title: choose caregivers or participants • Page 13: frequent ANC attendance alone will not prevent jaundice unless it provides education on prevention and recognition. Sentence should reflect this. • Page 13 Lines 4 and 5 only a few identified traditional practices as being wrong should be reflected in the discussion and conclusion • Page 10. Table 1 an unusually large number of caregivers with tertiary education needs an explanation and additional information on catchment area for hospital or was there a selection before the sampling method was applied • Page 13 Attitude questions seem like knowledge questions. • Page 13 last but one sentence spelling of colour –color • Page 17 last line & Table 7 suggests - factors associated rather than determinants Having one child was associated p-0.009 (with) ones practices, but not explained or discussed. • Conclusion poor knowledge regarding traditional treatments not mentioned • Discussion • Page 20 line 22: Is it possible that the reason for the disparity between your finding and Amegan-Aho et al‘s is because there were several caregivers with tertiary education in this study? • Page 21 line 6 suggest “...though in the minority...” • Page 21 line 8 suggest “... poor knowledge of (omit “a”)” • Page 21 line 14 suggest “... knowledge of... rather than “in”. • Page 21 last line: what is meant by “positive” knowledge? • Page 22 last but 3 line suggest removal of “will” to read who “offer” Discretionary corrections • Page 4 line 7 suggest revising “where” to read “because”. • Page 8 line 11: questions asked in the questionnaire –suggest rephrase • Page 20 Line 12: suggest revising “...where majority to “in which majority” • Page 21 line 17 suggest removal of “pre” before suggested ****** 6. 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Revision 1
6 Jan 2021 Author Response Dear editor, We appreciate your efforts in helping us to shape our manuscript to the required standard for publication in your reputable journal. We would like to thank the reviewer for the insightful comments on our manuscript. We are particularly grateful for the opportunity to resubmit the manuscript for another round of review. We find the comments very useful and have responded to them to the best of our knowledge. We acknowledge that the comments have no doubt helped improve the quality of our manuscript. We have therefore provided further details by showing point-by-point feedback on how each of the comments by the reviewer were addressed. For easy identification of our responses, the reviewers’ comments have been repeated while the Authors’ responses appear in BOLD text in the main manuscript. REVIEWER #1 Introduction and Literature Review: Neonatal Jaundice is an important topic in the West African sub-region, the significance of jaundice being emphasized by the complications that attend uncontrolled rise in unconjugated hyperbilirubinaemia. Jaundice may progress to acute bilirubin encephalopathy with hearing loss and cerebral palsy or death besides lingering kernicterus spectrum disorder. The author needs to elaborate this outcome of jaundice because it is ruinous to families that become unfortunate to experience the disorder. Jaundice occurs in physiological or pathological forms. While the former is harmless the latter is deleterious. What is concerning is the pathological jaundice which may lead to neonatal mortality. Literature review however scanty it may be needs to cover the entire understanding of the subject matter as the KAP of parents may be influenced by this knowledge. Authors response Page 3 line 76-91: The authors agreed that the above comment is relevant in the area of neonatal jaundice as it will reveal the deleterious effects of jaundice to the reader. Given this, the introduction section of the manuscript has been revised to address this comment. Study Population: The study focused on the real fathers/mothers of the neonates excluding other significant patient relatives. In the study location of West Africa, a good number of caregivers are neither the real father/mother of the neonate. Very often the grandmother, aunt, sister or other significant relative play an important, sometimes dominant role in neonatal care. Thus excluding them from a study of this nature could mean a major information loss and interventions targeted at real mothers/fathers may fall short of success without them. In the author’s area of practice the grandmothers often overrule their daughters in child care practices irrespective of the daughter’s knowledge or educational background. Authors response The authors appreciate the in-depth review carried out on the manuscript and the study subject by the reviewer in relation to the geographic area of the study. We acknowledged that the addition of these issues by the reviewer could by far improved the quality of the manuscript. However, these issues escaped us when we were designing the study and we have therefore included this comment as part of the limitations of the study. In subsequent related studies, we will take cognizance of these comments. Inclusion/Exclusion Criteria: The author excluded adolescent mothers/fathers from the study. In West Africa, teenage pregnancy and delivery is common. These mothers are inexperienced and therefore more likely to be ignorant of good child care practices. Studies of under-five mortality show that infants born to these teenagers succumb by far more than the experience mothers of older age group. This study would have been more revealing and perhaps more beneficial if adolescent mothers (12-18 years) were included in the study. Authors response We greatly agree with the reviewer on this comment that the inclusion of these groups of mothers could have brought out information/findings that would have contributed to policy reforms in the area of newborn care in Ghana. Despite the omission, we believe the study has revealed some key findings that will add to the body of knowledge and worthy of influencing newborn care positively in Ghana. We have therefore revised the manuscript to include this comment as part its limitation on page 25. Study Design: The study design was entirely quantitative but the issues were more dominantly qualitative. A study which set out to evaluate the KAP of respondents should have given them the opportunity to express themselves freely in order to optimize that information that the researcher may not have thought about. This is a major concern in this study. How can we be sure that the investigators captured the reflections of the respondents’ true inclination? Authors response The authors reviewed a wide range of relevant literature regarding this subject area which were equally done as quantitative studies and had included a wide range of relevant questions from literature and questions arising from discussions with some mothers. We however agree that allowing the mothers to express themselves freely on such an important topic would have revealed more information. We therefore believe that the questions asked in our study are by far the reflections of the caregivers’ true inclination. Subsequently, a mixed-method could be considered in related studies. Data Collection procedure: The sampling of study participants was by convenient method. How could this methodology have navigated around bias? The questionnaire was administered to two groups differently, to one group by self-administration while to the second group it was by interviewer administration. A number of the respondents had no formal education requiring interpretation of the questionnaire. How exactly was this bottle neck sorted out? Was translation into local languages carried out? Please specify the details. Authors response The method of sampling in this study was a systematic random sampling as found in the abstract and on page 2 line 52 of the manuscript. The manuscript has been revised to remove the convenient method from the manuscript as this was purely a mistake. The use of the systematic random sampling method eliminated any possibility of bias as a sampling interval was obtained to be (2). Participants were arranged to sit in rows and the first respondent who formed the starting point was selected by balloting. This is found on page 7 line 180-184. Respondents who were proficient in speaking and writing in the English language answered the questionnaires by themselves. For those who could neither read nor write in the English language were guided to complete the questionnaire. Four of the authors were native speakers of the “Ewe” language and three authors who could speak “Ewe”, “Twi” and other languages were used to orally translate the questionnaire into these local languages for the understanding of the caregivers. This has subsequently been included in the data collection procedure section of the manuscript on page 10 line 237-242. Assessment of Knowledge of mothers/caregivers on NJ: It is eminently observable that death as an outcome of untreated NJ was not evaluated in this study, neither as a complication nor as danger sign. Could knowledge of this adverse outcome influence respondents’ attitude and change their health seeking behavior? If this was evaluated, it would be important to analyze the data to enrich the present study. Authors response The authors find the comment very useful. Indeed, knowing that poor health seeking behaviour could lead to the death of a child could definitely influence caregivers attitude and their health-seeking behaviours. However, on page 15 (table 2: caregivers knowledge of neonatal jaundice) under the complication section, death has been captured where the majority (77.7%) of caregivers indicated that death could occur as a result of jaundice. We have further included this in the discussion section of the manuscript on page 24 line 422-424. Treatment of NJ: Several treatment modalities were indicated by the authors in evaluating the KAP of the respondents. All modes of treatment were investigated individually. Were there respondents who practiced a combination of more than one mode of treatment of NJ in the study? Fifty-five respondents volunteered that they sought help by visiting “church” or by “fasting and praying”. How many of these respondents also visited the health facility for treatment of the NJ? It is possible to criminalize a respondent’s practice without fully exploring all the actions taken towards treatment of their neonates’ NJ. In West Africa usually a combination of approaches are resorted to in order to overcome health challenges. Authors response We appreciate this comment. The authors allowed multiple responses from the caregivers. We therefore believed that the caregivers responded multiple times by choosing responses that applied to them. Attitude of Caregivers towards NJ: An overwhelming number of the respondents demonstrated the attitude of attending ANC and a large number of respondents showed awareness that NJ early in life can be treated in the hospital. However, the investigators did not evaluate how many of the respondents actually practiced taking their infants to the hospital for treatment of NJ. In West Africa most health care seekers would apply traditional methods of treatment of ailments and would also visit the hospital for treatment. Was it a deliberate action not to include this point or an omission? Authors response The authors agreed with the reviewer on this comment that most healthcare seekers would apply traditional methods of treatment of ailments and would also visit the hospital for treatment. However, it was purely an oversight on the part of the authors not to have included whether “caregivers actually took their infants to the hospital for treatment of neonatal jaundice” in our study. We appreciate that the addition of this to our study would have revealed more attitudes from the caregivers. Confounding variables: KAP may be influenced by other considerations that may complicate the ones studied herein. Such other factors include health infrastructure and availability of equipment, economic realities, and distance to the health facility, availability of transportation and insecurity. How were these confounding variables eliminated so we can trust the validity of this study findings? Authors response This study investigated knowledge, attitude and practice of neonatal jaundice among caregivers. The authors agreed that newborn care practices may be influenced by the factors stated in the reviewer’s comment. However, our questionnaire was designed based on the main aim of the study which was to evaluate caregivers knowledge, attitude and practice of neonatal jaundice. The questionnaire went through a thorough validity process where it was peer-reviewed by all the authors, nursing and medical specialists in related field to the study topic as well as piloting and pretesting. This made it possible that all questions included in the study were relevant and specific in achieving the intended purpose of the study. Also, the authors carried out multicollinearity diagnostics and found the Variance Inflation Factors (VIFs) were all below the 5-10 rule of thumb range, suggesting there is no collinearity among the independent variables to be fitted in the regression model! Indeed. REVIEWER #2 MAJOR CORRECTIONS Reviewer’s comment Page 1: Title: Suggest revision of title to: Knowledge, Attitudes and Practices Regarding Neonatal Jaundice Among Caregivers in a Tertiary Health Facility in Ghana. Authors response Page 1 line 2-3: We agree with the reviewer that the main outcome variables of this study were knowledge, attitude and practice and that the study size was small to influence policy. We have therefore revised the title of the manuscript to reflect the reviewer’s comment. Reviewer’s comment Page 6 Sample size and sampling determination (change determination to methods) - it is not clear what sampling method was actually applied. While it says in this section that systematic sampling was done, on Page 8 line 10 it says ...caregivers were conveniently selected – this is in contrast with the assertion on page 6 that systematic sampling was used. Please clarify. Authors response Page 7 line 175-178: The manuscript was formatted according to the journal specifications, however, because of the comment, “sampling determination” has been revised to “sampling method”. The sampling method for this study was systematic random sampling. Therefore, the manuscript was revised to remove “caregivers were conveniently selected” to reflect the correct sampling method as stated under sample size and sampling method. Reviewer’s comment Page 6 Line 12 and 13: was selection of the first skip interval done by balloting or other random sampling method? How were the patients arranged in a row? Were they arranged according to time of arrival as one would imagine would be the same as the attendance records or in another way? This needs to be specified. Authors response Page 7 line 170-184: The authors have revised this section of the manuscript to address these concerns. Reviewer’s comment Page 2 abstract line 12 under methods: It does not say where the study was done and what data was collected. Authors response Page 2 line 51-53: The method section of the abstract was revised to include where the study was done and the data collected. MINOR ESSENTIAL CORRECTIONS ABSTRACT Reviewer’s comment Page 2 line 23: suggest rephrase to “good attitude about neonatal jaundice” rather than “...attitude in jaundice”. Authors response Page 2 line 61-62: The authors revised the abstract to include the reviewer’s suggestion. Reviewer’s comment Page 2 line 29: suggest rephrase to “,,,will help reduce disability and deaths from neonatal jaundice.” Authors response Page 2 line 67-68: The abstract aspect of the manuscript has been revised to include the reviewer’s suggestion. INTRODUCTION Reviewer’s comment Page 3 line 14: it will be useful to also capture global targets (SDG) Authors response Page 5 line 104-107: The introduction section of the manuscript has been revised to include the global targets of reducing neonatal deaths Reviewer’s comment Page 3 lines 9-11. Although neonatal jaundice affects a number of babies, many of them recover. A few may die from kernicterus or bilirubin encephalopathy however underlying causes such as neonatal sepsis are more often the cause of neonatal death in babies with jaundice. Nonetheless neonatal jaundice is a major cause of disability i.e. cerebral palsy and emphasis of this role is lacking. Thus need to rephrase to capture this. Authors response Page3 line 92-96: The authors agreed that the above suggestion is relevant in the area of neonatal jaundice as it will reveal the deleterious effects of jaundice to the reader. Given this, the introduction section of the manuscript has been revised to capture this information. Reviewer’s comment Page 4 line 9: should read “...as a means of treatment” Authors response Page 5line 121-122: The manuscript has been revised to include this suggestion. Reviewer’s comment Page 4 line 10 change “generations back” to “previous generations” Authors response Page 5 line 126: The authors changed “generations back” to “previous generations”. Reviewer’s comment Page 4 line18 suggest rephrasing to read...serve as useful information Authors response Page 5 line 134: The manuscript was revised and the phrase “serve as a useful information” was changed to “serve as useful information”. METHODS Reviewer’s comment Page 5 ethical approval: were the benefits and risks also explained to them? Authors response Page 6 line 149-154: The authors at the point of data collection explained the ethical issues including benefits and risks to the caregivers. However, in the final write up of the manuscript, the benefits and risks aspects were not included in the ethical consideration as this was an oversight. We acknowledge the importance of benefits and risks to the participants. Because of the reviewer’s comments, the manuscript has been revised to include the benefits and risks. Reviewer’s comment Study area: Information on the delivery rate, presence of a newborn unit, its capacity, admission and neonatal mortality rates will be useful. Authors response Page 6-7 line 160-166: The manuscript was revised to include the above comment. Reviewer’s comment Page 5 line 17: ...the health facility serves as a major facility for neighbouring Togo residents – needs to be put in the right perspective as unintentional. Authors response Page 6: The authors revised the manuscript and have decided to remove this portion “the health facility serves as a major facility for neighbouring Togo residents” from the study area. Reviewer’s comment Page 6 line 17 bed capacity” remove approximately- be specific Authors response Page 6 line 160: The authors removed “approximately” from the study area section of the manuscript. Reviewer’s comment Page 6 study design – reads better without the abbreviations. i.e. if they are written in full -. KAP and NJ Authors response Page 7 line 172: The authors have revised the manuscript and KAP and NJ have been written in full as “knowledge, attitude and practice” and “neonatal jaundice”. Reviewer’s comment Page 6 line 20 - 21 Inclusion criteria- need to include the recruitment period Authors response Page 8 line 197: The manuscript was revised in the inclusion and exclusion section to include the recruitment period of the caregivers. Reviewer’s comment Page 7 line 1: rephrase to “...not the parents of the baby” rather than “...not the real father or mother” Authors response Page 8 line 196: In the inclusion and exclusion section, the phrase “not the real father or mother” was revised to “not the parents of the babies”. Reviewer’s comment Page 7 line 7 - no mention of northern tribes – they form a significant proportion of the Ghanaian population, were they few? Authors response From the 2010 national housing and population census, Ewes constituted the majority (73.8%) of the ethnic groups in Volta region, followed by Gurma (11.3%) and the Guan (8.1%). Specifically, the largest ethnic group in the Ho municipality where the study was conducted was Ewes (91.1%) followed by Akan (2.0) and the northern tribes (0.5%). However, the authors did not have any empirical data regarding the ethic stratification in the volta region and especially Ho at the time of designing the data collection instrument. Therefore, based on the statistics above, the authors decided to put all other tribes aside those mentioned in the study as “others ethnicity” which includes the northern tribes as contained on page 8 (study variables) and 12 (demographic characteristics). Ghana Statistical Service (2013). 2010 Population and Housing Census. Regional Analytical Report. GSS, Volta Region Reviewer’s comment Page 7 line 12: Adequacy of antenatal visits is now pegged at 8 or more visits but 4 or more can still be used as information on this is more readily available for comparison. Need to mention Authors response Page 9 line 208-210: The authors are grateful for this revelation on the adequacy of Antenatal Visit being pegged at 8 or more visits. We have therefore mentioned this in our manuscript but have maintained the 4 visits or more since the data was taken based on this. Reviewer’s comment Page 7 line 15 -17. Add - these are captured in more details in the results section. Authors response Page 9 line 215-216: The study variables section of the manuscript was revised to include the phrase “these are captured in more details in the results section” of the manuscript. Reviewer’s comment Page 8 line 17: “...further explanation” seems a more appropriate to understanding Authors response Page 10 line 243: The data collection section was revised where “further understanding” was replaced with “further explanation”. Reviewer’s comment Page 9 line 4 comment of significance of these coefficients. Authors response Page 11 line 253-260: The manuscript was revised to include the significance of the coefficient values. RESULTS Reviewer’s comment Page 10. Table 1 title: choose caregivers or participants Authors response The manuscript was revised replacing “participants” with “caregivers”. Reviewer’s comment Page 13: frequent ANC attendance alone will not prevent jaundice unless it provides education on prevention and recognition. Sentence should reflect this. Authors response Page 16: The authors largely agreed to the above comment and have therefore revised this item under the caregivers' attitude regarding neonatal jaundice. Reviewer’s comment Page 13 Lines 4 and 5 only a few identified traditional practices as being wrong should be reflected in the discussion and conclusion Authors response Page 26 line 454-459: The manuscript was revised in the discussion and conclusion sections to include the reviewer’s suggestion on. Reviewer’s comment Page 10. Table 1 an unusually large number of caregivers with tertiary education needs an explanation and additional information on catchment area for hospital or was there a selection before the sampling method was applied Authors response The Ho Teaching Hospital is located in the Ho municipality. The municipality is predominantly an urban area. Data from the Ghana Statistical Service (2013) showed that about 53.9% and 46.1% of women and men in the municipality are literate. Also, 30.8% of the women and 34.0% of men in the municipality can speak English and other languages. The increased number of caregivers with tertiary education in the current study could have been a coincidence since data collection was mainly through systematic random sampling. As a teaching hospital, many elite families who are highly educated would prefer to seek care there to receive the best care and this could have increased the number of caregivers with tertiary education. The authors employed the sampling strategy in selecting the caregivers, therefore, there was no selection of participants before applying the sampling strategy. Reviewer’s comment Page 13 Attitude questions seem like knowledge questions. Authors response Page 17: The attitude questions were revised in the main manuscript. Reviewer’s comment Page 13 last but one sentence spelling of colour –color Authors response The word “color” was revised to “colour” in the main manuscript. Reviewer’s comment Page 17 last line & Table 7 suggests - factors associated rather than determinants. Having one child was associated p-0.009 (with) ones practices, but not explained or discussed Authors response The authors have revised the results section of the manuscript to change “determinants” to “factors associated with” from page 17-22. Also, in the description section of the multivariate analysis of caregivers’ attitudes regarding neonatal jaundice, caregivers who had one child were 58% less likely to demonstrate a positive attitude of neonatal jaundice. This is captured on page 19 line 352-354 of the revised manuscript. Reviewer’s comment Conclusion poor knowledge regarding traditional treatments not mentioned Authors response Page 27 line 477-480: The conclusion section of the has been revised to include this comment. DISCUSSIONS Reviewer’s comment Page 20 line 22: Is it possible that the reason for the disparity between your finding and Amegan-Aho et al‘s is because there were several caregivers with tertiary education in this study? Authors response In our study, the majority of caregivers had tertiary education (45.0%) than Amegan-Aho et al (2019) but demonstrated poor knowledge (8.9%) compared to 76% good knowledge in Amegan-Aho et al with only 5.1% tertiary education. Ideally, one would have thought that a high level of tertiary education would be associated with a good knowledge in health-related issues as revealed by Greenaway et al (2012) and low level of education will lead to poor health-seeking behaviours including neonatal jaundice (Ogunlesi & Abdul, 2015). As revealed in our study on page 23 line 404-407, there was no association between caregivers’ educational status with knowledge on neonatal jaundice. Greenaway, E. S., Leon, J., & Baker, D. P. (2012). Understanding the association between maternal education and use of health services in Ghana: exploring the role of health knowledge. Journal of biosocial science, 44(6), 733. Ogunlesi, T. A., & Abdul, A. R. (2015). Maternal knowledge and care. Seeking behaviors for newborn jaundice in Sagamu, Southwest Nigeria. Nigerian journal of clinical practice, 18(1), 33-40. Reviewer’s comment Page 21 line 6 suggest “...though in the minority...” Authors response Page 24 line 415: The discussion section was revised to capture “though in the minority”. Reviewer’s comment Page 21 line 8 suggest “... poor knowledge of (omit “a”)” Authors response Page 24 line 417: The manuscript was revised in the discussion section to remove “a” and include “of” Reviewer’s comment Page 21 line 14 suggest “... knowledge of... rather than “in”. Authors response Page 24 line 417: The manuscript was revised in the discussion section to replace “in” with “of”. Reviewer’s comment Page 21 last line: what is meant by “positive” knowledge? Authors response Page 24 line 426: The intention was to indicate good knowledge and not positive knowledge. This has been revised as “good knowledge” and not “positive knowledge”. Reviewer’s comment Page 22 last but 3 line suggest removal of “will” to read who “offer” Authors response Page 26 line 463: The word “will” was removed from the sentence. DISCRETIONARY CORRECTIONS Reviewer’s comment Page 4 line 7 suggest revising “where” to read “because”. Authors response Page 5 line 123: Revision was made in which “where” was changed to “because”. Reviewer’s comment Page 8 line 11: questions asked in the questionnaire –suggest rephrase Authors response Questions in the questionnaire has been revised from 15-17. Reviewer’s comment Page 20 Line 12: suggest revising “...where majority to “in which majority” Authors response Page 23 line 396-397: Revision was made in the discussion section in which “where majority” was changed to “in which majority”. Reviewer’s comment Page 21 line 17 suggest removal of “pre” before suggested Authors response Page 25 line 429: Revision was made and “pre” was removed. Attachments Attachment Submitted filename: Response to Reviewers.docx https://doi.org/10.1371/journal.pone.0251846.r002
12 Mar 2021 Decision Letter - Bolajoko O. Olusanya, Editor PONE-D-20-19725R1 Manuscript title: Knowledge, Attitudes and Practices Regarding Neonatal Jaundice Among Caregivers in a Tertiary Health Facility in Ghana. PLOS ONE Dear Dr. Salia, 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 Apr 26 2021 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, Bolajoko O. Olusanya, MBBS, FMCPaed, FRCPCH, PhD Academic Editor PLOS ONE Journal Requirements: Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice. [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: All comments have been addressed Reviewer #2: (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 Reviewer #2: Yes ****** 3. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: Yes Reviewer #2: I Don't Know ****** 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 Response) ****** 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: The reviewer is satisfied by the responses given to questions raised towards the original MS contents. I believe the article is now in a better shape to be accepted for publication and so recommend same. Reviewer #2: General Comment. The manuscripts reads much better and most of my previous comments have been addressed. However, there are still some minor essential corrections and discretionary corrections that need to be addressed. Suggest further English language editing. Minor Essential Corrections Abstract Page 2 line 47: suggest changing “...of neonatal jaundice...” to “...regarding neonatal jaundice...” Page 2 line 52-53: suggest revision: “...sampling strategy. Quantitative data was collected using a questionnaire and analysed with STATA.... Page 2 line 54: the phrase “...neonatal jaundice knowledge...” does not seem right, kindly revise. Results Page 2 line 57 sentence beginning with “More than 50% (54.5%) and (52.5%) of caregivers...” is unclear, kindly revise Page 2 line 59: suggest revising “....knowledge in...” to “knowledge about...” Conclusion – needs to be more specific and focused on findings. Page 2 Line 65: suggest changing “...of jaundice...” to “...about jaundice...” Introduction Page 3 line 76-77: “Jaundice ...manifestation of a disease.” kindly add a reference. Page 3 line 99: reference 12: Reference from Graphic should be changed to a more appropriate source of data on prevalence of neonatal jaundice in Ghana. Page 3 line 101 suggest changing revealed to reported Materials and methods Page 6 line146: the word reinforced is unclear in this context. Page 6 line 153-154: invasive procedures are not the only sources of risk or discomfort so suggest you remove or revise the reference. The inconvenience of additional waiting to complete the questionnaire, though minimal may be seen as a source of discomfort to some. Page 6 line 157: study area you have described the neonatal unit however it is still not clear how neonatal services are delivered at the hospital as you have not described the postnatal ward in adequate detail. Page 7 line 172: remove capitalisation Page 7 line 175: Change methods to determination to meet journal specification Page 7 line 184: sentence “Balloting was done...”. needs to be re-sequenced as the skip interval is usually determine before the starting point. Page 9 line 208 to 2010: suggest revision- Although WHO has changed the minimum recommended antenatal visits from 4 to 8 visits, in this study we studied an attendance of 4 visits.[reference] No need to mention availability of information for comparison.. Page 9 line 218-219 remove capitalisation Page 10 line 238 remove” For” Results Format tables to fit with journals recommendations and also provide information on Total respondents Table1: Title - change caregiver to caregivers; Characteristics - Education received on neonatal jaundice and Child with a diagnosis of neonatal jaundice reads better (page 14) Table 2: title- suggest - Caregivers knowledge about neonatal jaundice; Prevention of neonatal jaundice: Neonatal jaundice is a common problem on newborns...so there is no need to prevent it reads better Table 5 and 6; more information needed on the logistic regression model. What aspects of the knowledge, attitudes, beliefs and practices and were examined? Page 19 line 354. There is no decimal place in the p-value. Conclusion: Does not provide a succinct summary of some of the good practices and gaps in knowledge. Lines 477-480 no need to bring in percentages. Discretionary corrections Page 2 line 42: suggest removing word “trends” Page 8 line 198; suggest removing “thus” References - Need to examine references again. Inconsistency in formatting noted,; date of accessing online publication omitted in some instances --------- ****** 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:** Stephen Oguche 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. https://doi.org/10.1371/journal.pone.0251846.r003
Revision 2
20 Apr 2021 Author Response Please see response to reviewers letter at the end of the PDF for review Attachments Attachment Submitted filename: Response to Reviewers.docx https://doi.org/10.1371/journal.pone.0251846.r004
29 Apr 2021 Decision Letter - Bolajoko O. Olusanya, Editor PONE-D-20-19725R2 Manuscript title: Knowledge, Attitudes and Practices Regarding Neonatal Jaundice Among Caregivers in a Tertiary Health Facility in Ghana. PLOS ONE Dear Dr. Salia, Thank you for submitting your revised manuscript to PLOS ONE. This current version is much improved but the key messages are still hazy and imprecise. At this stage I invite you to revise your abstract by addressing the following edits carefully to improve the clarity of your message to our audience. You will then need to amend your results and conclusions in line with the suggested changes in the abstract. 1. Abstract - Results DELETE: ‘Most of the caregivers demonstrated poor knowledge (54.5%) and attitude (52.5%) while 58.9% had good practices regarding neonatal jaundice’. REPLACE WITH: ‘Less than half of the caregivers demonstrated good knowledge (45.5%) and attitude (47.5%) but 58.9% had good practices regarding neonatal jaundice’. 2. Abstract Conclusion: DELETE: ‘Most of the caregivers demonstrated poor knowledge and attitude about jaundice while the majority demonstrated good practice. Healthcare professionals need to intensify education regarding jaundice among caregivers in low resource settings throughout antenatal and postnatal periods. Good knowledge may possibly lead to positive attitudes towards jaundice. Overall, improved knowledge and attitude improve maternal health-seeking behaviours which may help to reduce disabilities and deaths from neonatal jaundice’. REPLACE WITH: 'Less than two thirds of the caregivers demonstrated good practice with limited knowledge and poor attitude. Efforts to promote well informed and improved caregivers’ attitude will advance positive maternal health-seeking behaviour and reduce disabilities and death through early detection and intervention of infants with neonatal jaundice. Public awareness and education about neonatal jaundice especially among caregivers in the private sector should also be intensified'. 3. Reference 12 is incomplete without a URL. Please submit your revised manuscript by Jun 13 2021 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. Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols. We look forward to receiving your revised manuscript. Kind regards, Bolajoko O. Olusanya, MBBS, FMCPaed, FRCPCH, PhD Academic Editor PLOS ONE Journal Requirements: Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice. [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.0251846.r005
Revision 3
2 May 2021 Author Response Manuscript title: Knowledge, Attitudes and Practices Regarding Neonatal Jaundice Among Caregivers in a Tertiary Health Facility in Ghana Solomon Mohammed Salia1, Agani Afaya1,2, Abubakari Wuni3, Martin Ayanoore4, Emmanuel Salia5, Doreen Dzidzor Kporvi1, Peter Adatara1, Robert Kaba Alhassan6, Vida Nyagre Yakong7, Sean Augustine Eduah-Quansah1, Shine Seyram Quarshie1, Eric Kwame Dey1, Dominic Amoah Akolga1 Dear editor, We are very happy that you are giving us another chance to shape our manuscript to the required journal’s standard for publication. We would like to thank the reviewers for the thorough review and insightful comments on our manuscript. The comments though minor are very useful and we have responded to them to the best of our knowledge. We acknowledge that the comments have no doubt helped improve the quality of our manuscript. We have therefore provided further details by showing point-by-point feedback on how each of the comments was addressed. For easy identification of our responses, the comments have been repeated while the Authors’ responses appear in BOLD text in the main manuscript. Editor’s Comments Abstract - Results DELETE: ‘Most of the caregivers demonstrated poor knowledge (54.5%) and attitude (52.5%) while 58.9% had good practices regarding neonatal jaundice’. REPLACE WITH: ‘Less than half of the caregivers demonstrated good knowledge (45.5%) and attitude (47.5%) but 58.9% had good practices regarding neonatal jaundice’. Authors Response Page 2 line 60-61: The results section of the abstract was deleted and replaced with the suggested statement by the editor which adds more meaning to the results. Editor’s Comment 2. Abstract Conclusion: DELETE: ‘Most of the caregivers demonstrated poor knowledge and attitude about jaundice while the majority demonstrated good practice. Healthcare professionals need to intensify education regarding jaundice among caregivers in low resource settings throughout antenatal and postnatal periods. Good knowledge may possibly lead to positive attitudes towards jaundice. Overall, improved knowledge and attitude improve maternal health-seeking behaviours which may help to reduce disabilities and deaths from neonatal jaundice’. REPLACE WITH: 'Less than two thirds of the caregivers demonstrated good practice with limited knowledge and poor attitude. Efforts to promote well informed and improved caregivers’ attitude will advance positive maternal health-seeking behaviour and reduce disabilities and death through early detection and intervention of infants with neonatal jaundice. Public awareness and education about neonatal jaundice especially among caregivers in the private sector should also be intensified'. Authors Response Page 2 line 68-73: The authors have deleted the conclusion section of the abstract and have replaced it with the editor’s suggested phrase. This has made the understanding of the conclusion clearer. Editor’s Comment 3. Reference 12 is incomplete without a URL. Authors Response Reference to the second revision, the reviewer requested that we change the graphic Online source to a more appropriate reference. However, the authors have searched and have realized that the information used by graphic online was from the Ghana Health Service (GHS), but this information from the GHS was not published as at the time the authors used the information, and therefore, did not have a URL. Page 31 line 610-612: The authors have revised the reference and have added the URL Attachments Attachment Submitted filename: Response to Reviewers.docx* https://doi.org/10.1371/journal.pone.0251846.r006
5 May 2021 Decision Letter - Bolajoko O. Olusanya, Editor Manuscript title: Knowledge, Attitudes and Practices Regarding Neonatal Jaundice Among Caregivers in a Tertiary Health Facility in Ghana. PONE-D-20-19725R3 Dear Dr. Salia, 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, Bolajoko O. Olusanya, MBBS, FMCPaed, FRCPCH, PhD Academic Editor PLOS ONE Additional Editor Comments (optional): Reviewers' comments: https://doi.org/10.1371/journal.pone.0251846.r007
Formally Accepted
26 May 2021 Acceptance Letter - Bolajoko O. Olusanya, Editor PONE-D-20-19725R3 Knowledge, Attitudes and Practices Regarding Neonatal Jaundice Among Caregivers in a Tertiary Health Facility in Ghana. Dear Dr. Salia: 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. Bolajoko O. Olusanya Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0251846.r008

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