PONE-D-20-36566

An ethnographic study of how health system, socio-cultural and individual factors influence uptake of intermittent preventive treatment of malaria in pregnancy with sulfadoxine-pyrimethamine in a Ghanaian context

PLOS ONE

Dear Dr. Aberese-Ako,

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 Jun 10 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,

R Matthew Chico, MPH, PhD

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 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.

3. Please state in your methods section whether you obtained consent from parents or guardians of the minors included in the study or whether the research ethics committee or IRB approved the lack of parent or guardian consent.

4. Please ensure that your recent study (Aberese-Ako, Matilda, et al. "Managing intermittent preventive treatment of malaria in pregnancy challenges: an ethnographic study of two Ghanaian administrative regions." Malaria journal 19.1 (2020): 1-17.) is mentioned  in the Introduction and in the Discussion, and that you have adequately discussed the relationship between the two studies.

5. Please provide additional details regarding participant consent. In the ethics statement in the Methods and online submission information, please ensure that you have specified how verbal consent was documented and witnessed.

6. When reporting the results of qualitative research, we suggest consulting the COREQ guidelines: http://intqhc.oxfordjournals.org/content/19/6/349. In this case, please consider including more information on the number of interviewers, their training and characteristics. Moreover, please provide the interview guide used as a Supplementary file.

7. 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.

8. Please include captions for your Supporting Information files at the end of your manuscript, and update any in-text citations to match accordingly. Please see our Supporting Information guidelines for more information: http://journals.plos.org/plosone/s/supporting-information

9. Your ethics statement should only appear in the Methods section of your manuscript. If your ethics statement is written in any section besides the Methods, please delete it from any other section.

[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: N/A

Reviewer #2: N/A

**********

3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

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: This is a very interesting and well written study, drawing upon a rich data source to explore reasons behind uptake or lack of uptake of IPTp-SP in Ghana. A few specific comments are provided below:

Background

• Lines 82-83: It seems unfair to say the findings were inconclusive because they were based on reported data – we rely on this type of data for many studies. It does of course have limitations in comparison to observations – suggest rephrasing along those lines and use this to emphasise the importance and value added of your study.

Methods

• Lines 127-128: perhaps add something about the addition of this HF leading to the total of 5 districts (rather than 2+2 as suggested by stage I of the four-stage selection process.

• It would be useful to describe how IDIs differ from conversations. Were conversations recorded and transcribed? Or did the RAs take notes that were used for the analysis?

• Are the case studies in table 2 the ANC attendants randomly selected and accompanied through the ANC process (lines 189-190)? If so, would be useful to state that in the main text.

Results

• How did you identify the number of doses of IPTp-SP that women received? Did you stratify the analysis by women with/without 5 doses?

• As this was a longitudinal study, did you observe/interview the same women or other participants more than once?

• Line 273: how did the HWs keep a record of who was due to have IPTp-SP on a given day (you may mention it elsewhere)? This seems useful information for achieving high coverage.

• Line 442: advise not advice

Discussion

• Lines 574-576: this sentence sounds out of place in the first paragraph (especially as overall this does not seem to be one of the more important influences on lower uptake). I suggest you remove it from here as you discuss it further down in the discussion.

• Line 589:”Others found the contrary was true” is a bit misleading – I think you mean that other studies found that lack of supervision resulted in low uptake (rather than other studies finding that DOT resulted in low uptake). Both support the same point that the current successful focus on DOT should be continued.

• Line 591-592: The finding form study #41 needs expanding slightly – what were the factors that meant delivery of IPTp through ANC in this setting was ineffective?

• Line 593: “The finding suggests…” Which finding are you referring to? Something from your study?

• Overall, your results section suggests that health system factors were generally positive in terms of uptake or IPT-SP, with the exception of stock outs of SP. In fact, even the lack of information did not seem to be a barrier to most women (the exception perhaps being teachers, or other more highly educated women?) – if they were told to take the SP then they took it. Your discussion of this and the role that health workers play in providing an enabling environment is well made. Trust of health providers is crucial as you discuss and it seems that your study area is leading the way on these measures compared to other studies on IPTp uptake. I note that you commend this in the conclusion which is good to see.

• However, as you say – attitudes that led to late attendance had a big impact on achieving higher number of doses. Is it information about malaria and IPTp that will lead to early attendance? Or perhaps other messaging or interventions (such as having adolescent specific days, encouragement from husbands/family members/community leaders) could effectively encourage early attendance and the uptake of IPTp would follow (health system factors permitting)

• Line 639: duplication of “which contributed”

• Lines 662-663: what were the information sources discouraging IPTp? Was it social media? Could expand on this slightly as these channels could potentially be used to deliver positive messages.

• Lines 671-676: these sentences on late attendance seem out of place with the rest of this paragraph which is discussion the potential link between higher education levels and refusal to take IPTp-SP.

Conclusion

• You make a clear summary of your findings and there are some interesting and practical recommendations. However, mention of encouraging early attendance is missing. Encouraging early attendance is critical to ensuring the full number of IPTp-SP doses are taken – I suggest including this in your conclusion, along with potential ways to do this.

Reviewer #2: I read with great interest this study entitled “An ethnographic study of how health system, socio-cultural and individual factors influence uptake of intermittent preventive treatment of malaria in pregnancy with sulfadoxine-pyrimethamine in a Ghanaian context”. Acknowledging the well-known gap between ANC attendance and IPTp coverage, this paper assesses the multiple factors influencing IPTp-SP uptake in 2 regions in Ghana. Based on ethnography, the manuscript reports relevant information on the social component of antenatal care that, ultimately, could be of great interest when designing interventions aiming at improving access to maternal health services.

Overall, the study identifies an important topic to address in public health interventions and, indeed, this is a nice piece of example showing how anthropological approaches can contribute to the body of knowledge related to malaria in pregnancy.

However, there are some aspects I would like the authors to consider in order to improve manuscript before publication.

General comments:

The manuscript is well-written, well performed in terms of methodology, easy to read and clear results and discussion sections. The topic of the study is of highly relevance and, while the study appears to be sound, I would suggest the authors to stress the rational of the study in the Background section, given the quite extensive literature existing on determinants of IPTp uptake or ANC attendance.

Moreover, the objective of the study, as it is stated in the text (lines 106-108) seems to directly refer to the identified factors, which seems a bit confusing: If the aim of the study was to explore “how health system, individual and socio-cultural factors influenced IPTp-SP uptake”, were, then, these categories previously identified? I would recommend the authors to either rephrase or to clarify the objective.

I would like to remark the efforts of the authors to describe the methodological procedures and the decisions made by the research team, including community entry activities. I appreciate the inclusion of the observation checklist and interview guides as additional material. However, I advise the authors to clearly describe how the urban/rural criteria to select the settings were defined, in order to clarify what contextual characteristics were taken into consideration. Finally, I would only recommend to rephrase the Data collection techniques subsection, so that the reader could easily understand what techniques were used and what group of people they were targeting (and information that it is already presented in table 2).

I would suggest the authors to structure the results section, by adding subheadings, following the 3 categories of analysis. It would be helpful for the reader to understand how the researchers relate the subcategories to the broader categories of analysis (health system, individual and socio-cultural factors). For instance, the subsection called “Women knowledge…” is not clear whether it is part of the health system or individual factor (which, to me, would have made more sense, but it seems a category that appears later in the section).

I would like to emphasize the particular value of providing pieces from observation notes, together with the quotations. In this respect I would require the authors to revise the identification of the quotations presented throughout the text, since there is missing information in some cases (e.g. type of technique or the respondent profile). It would also be helpful to specify how the health facility pseudonym will be presented (providing an example in line 226 could be an option).

In the discussion section, I have the impression that authors present some findings that are not included in the results, for example what is presented in page 31 (lines 593-595, about the type of information provided to pregnant women). I would ask the authors to revise this aspect.

I would have appreciated a more nuanced discussion of the results. I think that the discussion section does not only needs to present how previous works support (or not) the results but, rather, it allows for going one-step beyond in the interpretation of data. Thus, I encourage the authors to expand the discussion section in order to provide a rich dialogue between the findings of the study, previous works and broader topics or other public health interventions. For instance, trust on health providers could be an element for further discussion, since it is an aspect which has deserved much attention in other studies related to other type of interventions (such us community engagement approaches). In the same vein, results related to interpersonal factors could also be discussed within the frame of gender roles, female decision-making processes and/or the role of community-shared meanings, values and norms.

Finally, including a paragraph on possible limitations of the study, could be an asset.

Specific comments:

Abstract

• Line 39: Revise the year and the WHO recommendation, which seems incorrect (see comment bellow)

Background:

• Lines 75-78: The year when the WHO recommendation is announced is missing in the text (but it is the abstract). However, I would ask the authors to revise it. As far as I know since 2012, WHO has recommended IPTp at each scheduled antenatal care clinic visit starting in the second trimester of gestation, with the objective of ensuring the uptake of at least three IPTp administrations of SP. The references provided to support that the recommendation is to provide a minimum of 5 doses are not from WHO but, rather, other papers. I would ask to revise if this is a National Policy in Ghana, and change it accordingly.

Methods

• Line 115: I advise to elaborate the relation with the reference provided about the Hawthorne effect.

• Line 117: There’s a typo (informal conversions, which should be conversations)

• Table 2: I would spell out DHD officials, as a footnote on the table.

Results:

• Lines 293-294: there’s a repeated sentence (Health workers reported that education was critical for adherence)

• Lines 350-354: I’m not sure if these 2 quotes presented exemplify the previous statement.

• Lines 432-438: How the information provided in this paragraph correlates with the issue of SP stock-outs

• Line 453: “Interpersonal and socio-cultural factors also influenced uptake of IPTp-SP” is a sentence that already appears at the beginning of the subsection.

• Lines 482-484: I don’t understand how this relates to socio-cultural factors.

• Lines 539-544: I wonder to which extend this finding may not be related with sociocultural factors.

• Line 567: Specify from where this information comes from (and IDI? Conversation?).

Discussion

• Line 625: There a single square bracket. I don’t know if this is a typo or the authors have forgotten to include a reference.

• Lines 638-639: Does “Some women…” refer to the study participants?

• Lines 639-640: “which contributed” appears twice.

I hope that above comments would help the authors to improve the manuscript. I am so looking forward to read the article once published.

Kind Regards.

**********

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. 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.

PONE-D-20-36566R1

An ethnographic study of how health system, socio-cultural and individual factors influence uptake of intermittent preventive treatment of malaria in pregnancy with sulfadoxine-pyrimethamine in a Ghanaian context

PLOS ONE

Dear Dr. Aberese-Ako,

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 19 August 2021. 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,

R Matthew Chico, MPH, 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: All comments have been addressed

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Yes

**********

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

Reviewer #1: N/A

Reviewer #2: N/A

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: No

Reviewer #2: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: The authors have done a thorough job of addressing all reviewer comments and I recommend that this paper is accepted. My only minor point of note is to have one last check for typos in the new text (I noticed some in the track changes version but these may have been corrected in the clean version)

Reviewer #2: I read with great interest the revision of this manuscript.

Either the background and the rationale of the study are more contextualized now.

The inclusion of headings and subheadings make the results section clearer to the reader, and facilitates the understanding of the analytical categories identified and used by the researchers. I would only recommend to simplify subheadings, by using more synthetic concepts (e.g. the one used in lines 574-576 is too long).

The discussion section shows a deeper interpretation of the results, and includes more complex dialogues with previous studies, with makes the manuscript analytically richer.

Corrections (such the year of the WHO recommendation, and its adaptation in Ghana) and specifications on settings identifiers and data collection techniques have also been introduced.

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

Reviewer #2: No

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

An ethnographic study of how health system, socio-cultural and individual factors influence uptake of intermittent preventive treatment of malaria in pregnancy with sulfadoxine-pyrimethamine in a Ghanaian context

PONE-D-20-36566R2

Dear Dr. Aberese-Ako,

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,

Marianne Clemence, Staff Editor, PLOS ONE, on behalf of

Matthew Chico

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments: