https://orcid.org/0000-0002-4707-1282
Peer Review History
| Original SubmissionFebruary 2, 2021 |
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PONE-D-21-03659 Lived Experiences of Frontline Healthcare Providers offering Maternal and Newborn Services amidst the Corona virus Disease 19 Pandemic in Uganda: A Qualitative study PLOS ONE Dear Dr. Kayiga, 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. Thank you for this submission that includes important time-sensitive data. Both reviewers have provided detailed comments focusing on the introduction, methods, and discussion that give practical recommendations to improve the readability and length of the manuscript. Please address each reviewer's comment carefully. Please submit your revised manuscript by Jun 14 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:
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, Michelle L. Munro-Kramer, PhD, CNM, FNP-BC Academic Editor PLOS ONE Journal Requirements: When submitting your revision, we need you to address these additional requirements.
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Authors’ affiliations should reflect the institution where the work was done (if authors moved subsequently, you can also list the new affiliation stating “current affiliation:….” as necessary). 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: Partly ********** 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: No ********** 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: Thank you for the opportunity to review, “Lived Experiences of Frontline Healthcare Providers offering Maternal and Newborn Services amidst the Corona virus Disease 19 Pandemic in Uganda: A Qualitative study.” The paper is very interesting and highlights the complex environment in which MNCH providers have been operating with the COVID-19 pandemic. I believe this article will be very helpful to the readership of PLoS One and illuminate the challenged MNCH providers face. I only have two major comments for consideration and a few minor points. 1. While very interesting, the paper needs to be overall streamlined and synthesized. The quotes are helpful to understand the nuance, but each theme does not require 3-5 quotes. The authors should revise the paper and messaging to ensure readability, appropriate length, and synthesis. One potential approach to do this in the Methods is put the text description of the 8 hospitals in a table to streamline the text (i.e. remove lines 149-213). Similarly consider the quotes for each theme. 2. Depending on what was agreed to as part of the informed consent process and confidentiality agreement with the IRB and participants, the authors need to be very careful about identifiability of participants. Based on Table 1 alone, it is not unreasonable to expect that an individual clinician could be identified and the quote attribution. Given that the hospital is named and the cadre identified, it would be relatively easy to identify the interviewed person and potential put them at risk and violation of privacy/confidentiality. Further, since the authors described harassment of the providers by security forces, it would be even more important to protect participants from any retribution for speaking up. A few suggestions to remedy this: (a) Summarize Table 1 into descriptive categories of the 25 individuals (i.e. X were obstetricians, Y had Diplomas, Z were married); (b) Remove specific facility names and any names of persons (or identifiable traits) from the quotes, for example, “The Bishop of Namirembe Diocese managed to 659 get us some stickers. Maybe for your information, the Bishop is the patron for the 660 hospital. This is an Anglican founded hospital so that’s why the bishop had to come in.” (Line 658-660). MINOR 1. Can the authors describe the duration of lockdowns in Lines 90-95? 2. Please clarify in Line 88 is these are only COVID-19 tested and confirmed cases? Are there estimates of suspected case load that could be described? 3. Is there documentation of impact on MNCH attendance? 4. In the methods, then authors note this was part of a “bigger” study? Please clarify in the methods that this was an embedded qualitative study. Also, can the authors describe how they selected the 25 participants? 5. Was any software used for data analysis? Reviewer #2: 1. The manuscript is probably technically sound but clarifications are needed in the methods to confirm this statement. 3. The authors state that they have made all the data available but it is obvious that they have not nor could they do this. This is a textual data set consisting of direct transcripts of many hours of interviewing. Making it available would violate the subjects' confidentiality and privacy. Best to state this in the manuscript that saying that all the data have become available. 4. The results and discussion sections are presented in an intelligible fashion but the intro and methods are not. The reviewer suggests how to improve in the comments that follow. Additional comments by the reviewer are provided below: 1. The strength of the manuscript lies it its reported data. 2. Please, increase the readability of the data in two ways: a. Improve the quality of writing in the intro and methods so that the reader has stamina left to make it to the results. This reviewer suggests ways to do that in more detail further down in their review. b. Improve the readability of the results section by: i. Creating a table of contents of the themes and subthemes that emerged from the data; state in one sentence a summary of what was found in each theme or subtheme; and the page number where the theme or subtheme is described. You currently have over 13 different themes, with subthemes under some of the themes – it is impossible for the reader to follow. Please number all themes on this table and in the narrative. ii. Going over each theme and thinking of ways to shorten either the text or the length of the direct quote to convey only what is said in a unique way that the text has not said. Current length is over 23 pages – bring it down to 12 pages. 3. Safeguard the anonymity and confidentiality of the data by removing the names of Hospitals and the age of each discussant from Table 1. For the purposes of the publication, the categories that you mention of “two Private hospitals, three Private-Not-for Profit hospitals and three Public health facilities” are sufficient for the reader to understand the study context. Replace hospital name by Private hospital 1, Private hospital 2, Private not for Profit hospital 1, Private not for Profit hospital 2, and so on. You report the mean age and range in the text so no need to specify on the Table. Instead of nurse 1, nurse 2, report the number of nurses, admins, and other providers interviewed in each hospital on the Table. By doing these changes you also increase the readability of current Table 1. 4. Methods a. Describe all the teams that were involved in the study in one place. It looks like you had a data collection team, a data analysis team, and a team of external or independent (unclear) investigators that was checking the rigor. Like this: Team 1 had this and that investigator and did this; Team 2.. and so on. b. For rigor, you examined the credibility, confirmability, transferability and dependability of the data; also their congruency, triangulation and trustworthiness. These are all noble goals but your description of each is so confusing to any reader who might like to replicate your work at their hospitals, to the point of giving up reading the manuscript right there. You may clarify that these are related but slightly different aspects of data validity and you made sure to check for all of them by having a separate team constantly comparing the field notes, the transcripts, the codes, and their interpretation. Your manuscript does not describe any other evidence to compare your data with, neither do you ever mention that you took videos which brings on another layer of ethics and IRB approval issues. Please clean up and shorten that section. 5. I will now further elaborate the changes needed in the intro that I mention under comment 2.a. 1. Ref 1 – you need a HWO reference for this 2. Ref 2 – need full citation (page numbers, issue) 3. Ref 3 need the complete citation, weblink, and when it was accessed 4. Ref 4 , 5 – same 5. “with many vulnerable 90 populations, 1.4 million HIV positive patients, 800,000 diabetic patients and 100,000 TB sputum 91 patients, the President of Uganda, Yoweri Kaguta with his cabinet initially closed public 92 gatherings, shopping malls, and public domestic and international travels from the 18th March 93 2020.” a. The first part of this sentence belongs in the next paragraph on how the health care system in Uganda was already overwhelmed, and needs the citation of ref 9. The second part of this sentence doesn’t need the name of the President for a scientific publication but rather a reference from a government website. b. Use a better term for TB sputum patients 6. Ref 6 and 7. The reader needs to know the full citation. Is this a scientific journal? A newspaper? Provide the weblink and when it was accessed. 7. Ref 8 should be a ref on Uganda prior to the pandemic – this a WHO reference on the pandemic. Best to only refer to 9 there (line 100). Ref 8 is appropriate in line 107. 8. “The Ministry of Health in Uganda has already reported a decline in the current immunization coverage 104 though the overall impact of 105 COVID-19 on the immunization coverage is yet to be determined.” Need a citation or rephrase. 9. Ref 6 and 12 are the same. Streamline. 10. Ref 11. Need to know the type of document, weblink and date accessed. 11. Ref 13. The reader needs to know if this is a book, a journal, a report, the weblink and when it was accessed. 12. “In Uganda, 4,600 women deliver everyday” rephrase – perhaps you mean to say that there are xx deliveries per day. 13. “Interruption in access to quality maternal 108 and newborn health services could put over 10,000 lives of these women and their babies in 109 danger.” Show your calculations and define the time period. 14. “Due to shortages in the personal protective equipment in a number of health facilities, many 112 health workers offering maternal and newborn services fear for their lives.” This sentence already gives your study results away. It belongs to the results section. Delete from intro. Write it in the past tense in the results. 15. “some health workers can’t access their work stations easily 118 with the COVID-19 travel restrictions” This gives away the data – put in the results section. Use past tense in your writing throughout to avoid being outdated and to maintain tense sequence throughout the manuscript. 16. Format of ref 15 and 16 is good. Make all refs read like this. 17. “Some reports reveal health workers having been assaulted 119 by security personnel as they try to access or leave their work stations especially during curfew 120 hours [12, 15, 16]. “ Define security personnel. Do you mean police, hospital security, private firms? But this sentence also gives away your results – best to delete and let your data speak. Again, use past tense. 18. Ref 15 is about women in labour not health workers. Use an appropriate reference. 19. “some health workers have further have been deployed to manage the COVID-19 patients [9].” You cannot use a 2016 reference to substantiate a statement about 2020 or 2021. Also fix the grammar. 20. “with the aim of streamlining patient care in similar future disasters.” This is a good aim, but you also need an aim on streamlining patient care during the current disaster which still lingers in a big way. Edit abstract, intro and discussion on this. 6. Here I elaborate the changes needed in the methods under comment 2.a. 1. Reference the larger study, even if only manuscript in preparation 2. “phenomenological and inductive thematic approaches” Need a ref for phenomenological and for inductive. 3. ““Quality was determined through retrospective 136 review of hospital records on maternal and newborn services that included; hospital deliveries, 137 antenatal attendances, immunization coverage, family planning services offered, postnatal clinic 138 attendance, HIV care services six months before and during the COVID-19 pandemic. Using 139 interviewer-administered questionnaires; we also collected patient quantitative data to assess any 140 trends in the care offered during the COVID-19 pandemic.” You do not need this statement. It refers to a different study. Delete. 4. “We opted for in depth interviews 141 instead of focus group discussions to ensure social distancing and minimize spread of the 142 COVID-19.” There are certain strengths that focus groups have as a data collection method compared to in depth interviews, and vice versa. Say what you missed by not conducting focus groups due to the reasons that you cite and what you gained by conducting IDIs. The statement as is shows lack of understanding of focus groups as a qualitative research method. 5. “We conducted 50 in depth interviews. Twenty five among pregnant and 143 breastfeeding women to assess their lived experiences, perceptions about the quality of services 144 offered to them during the pandemic with the ultimate goal of identifying gaps and what their 145 level of satisfaction was as they sought care during the COVID-19 pandemic.“ This sentence does not belong to this manuscript. Here describe the methods you used only for this manuscript, i.e. the 25 interviews with health providers. 6. Ref 17 needs completion. I will now stop repeating this comment. Please check all refs and provide the weblink and when it was accessed. 7. Ref 18, 19, 22 and 24 are not needed. 8. “merging” you mean “emerging” 9. “The 261 interviews were tape recorded and transcribed verbatim” check and eliminate repetitions. This phrase appears under data collection, under quality control, and under data analysis. The recording should be mentioned under data collection only. The transcription under data analysis only. 10. “To ensure trustworthiness and credibility, two independent researchers read and reviewed the content (interview transcripts, 290 and field notes word-for-word, line-for291 line) several times. Field notes and interview transcripts from each of the interviews were 292 assessed individually and later integrated to strengthen the data analysis and dependability of the 293 study findings. “This is stated under data analysis but under Data collection it is also stated that “All of the interviews were tape recorded and 255 transcribed verbatim immediately thereafter. Transcription accuracy was ensured at the end of 256 the interviews by the Principal investigator and one Administrator. Field notes and the 257 transcription were compared for congruency.” Best to eliminate from both data analysis and data collection sections and describe in simple words as I suggest in 4.b under Rigor only. 11. “We 307 thereafter identified themes reflecting on the depth. We later compared with other classes so as to 308 delimit the theories and achieve conceptual congruency[31].” Explain to the reader what type of depth you reflected on, and what were these other classes and theories that you mention. Better yet, delete. 12. “We observed data credibility by 312 ensuring checks by two members of the research team to accept codes from the transcription” This you did for confirmability. The credibility was already established because you had the recordings to prove it. Delete and summarize as I suggest in 4.b. 13. “peer debriefing from the senior researchers” unclear what this did – probably transferability on whether the data from one hospital was similar for another hospital? Clarify or delete and summarize as I suggest in 4.b. 14. You mention an “external investigator” in line 324 and independent investigators” in line 327. Were these investigators different from the PI, and admin? Best to delete whole section and follow my suggestion under 4.a. 15. Results: Lines 330 to 333 are repetitive - delete. Start section by saying that Table 1 describes the types of cadres interviewed… and edit Table 1 according to my suggestion 3. 16. Results: “The participants 342 generally had a number of similar experiences in regards to maternal and newborn health service343 delivery irrespective of the nature of health facility they worked in.” Since you took such great efforts on rigor, it should have been those multiple checkers who said that the data were comparable among all hospitals in the study and that the participants had similar experiences which allowed for their collective reporting. State that in the results, with the exception of your first theme on preference for working in Private, not for Profit or public facility, where the lived experiences differed. END OF COMMENTS ********** 6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files. If you choose “no”, your identity will remain anonymous but your review may still be made public. Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy. Reviewer #1: No 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. |
| Revision 1 |
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PONE-D-21-03659R1 Lived Experiences of Frontline Healthcare Providers offering Maternal and Newborn Services amidst the Novel Corona virus Disease 19 Pandemic in Uganda: A Qualitative study PLOS ONE Dear Dr. Kayiga, 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. Thank you for this revision. Unfortunately there are still outstanding comments from the previous submission, as well as new comments from this revision. As suggested by Reviewer #2, please utilize a three column table and list out each reviewer comment in column one, your response in column two, and the page and line numbers where the change was made in column three. Please submit your revised manuscript by Sep 19 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:
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, Michelle L. Munro-Kramer, PhD, CNM, FNP-BC 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. Additional Editor Comments (if provided): I suggest paying careful attention to all three reviewers' comments, but would specifically like to highlight: 1) The need to use consistency in language (e.g., COVID, COVID-19, Corona Virus). After defining the Coronavirus disease (in the first paragraph of the introduction), please select one term and use consistently in the abstract and text. 2) The first two references are about the United States. Please ensure you are using appropriate global resources (ideally from the WHO) when describing the global pandemic. 3) It is not a journal requirement to include data (especially if potentially identifiable). I agree with Reviewer #2 that there are a number of factors that compromise the confidentiality of the sample (e.g., the raw data file, listing the hospital/health facility names and locations, specificity about participant characteristics per site). I would recommend removing Table 1 and summarizing characteristics of the type of facilities included (but not needing to name them). I would summarize Table 2 to list characteristics overall (e.g., number of males, females; range and mean for age, etc.) based on hospital type as recommended by Reviewer #4. Consider removing the individual names of hospitals and thanking the administrators more generally. Finally, it is not necessary to submit ethical approval forms, interview questions, and the raw data. I would consider removing these. 4) Please note the suggestions to the rigor section described by Reviewer #2. 5) Table 3 is an excellent addition to the manuscript. We look forward to receiving your revised submission. [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 #2: (No Response) Reviewer #3: (No Response) Reviewer #4: (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 #2: Partly Reviewer #3: Yes Reviewer #4: Yes ********** 3. Has the statistical analysis been performed appropriately and rigorously? Reviewer #2: N/A Reviewer #3: N/A Reviewer #4: 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 #2: Yes Reviewer #3: Yes Reviewer #4: No ********** 5. Is the manuscript presented in an intelligible fashion and written in standard English? PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here. Reviewer #2: Yes Reviewer #3: Yes Reviewer #4: 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 #2: 1. Many improvements evident throughout, most notably the addition of Table 3 2. Key words: suggest including "lived experiences" 3. Publication Ethics Table 1: by mentioning the names and identifying information of each study hospital continues to reveal who the study participants were and compromises their confidentiality. Please delete hospital names and identifying location information (highway or hill name, founding details, division name; does it matter in this case whether it was Anglican or Catholic?). Keep in minimal information that helps the reader understand what type of hospital with what type of capabilities and catchment was studied. 4. Publication Ethics: Same is true of the supporting information linked to the manuscript. Other than the participant interview guide, the documents contain hospital identifying information and therefore inappropriate to share with the journal’s readership. This includes: a. Clearance forms b. Protocol c. Consent form health workers d. Raw data set – every quote in the data set shows which hospital it came from; if you have to share, then all data should be de-identified, like you did in quotes used in the results section. This is a lot of work – I would rather you did not share due to data confidentiality issues. e. The other forms are not needed to be made public either and should be omitted from the supporting information. 5. The TASO IRB approval letter and the rstug UNCSTRefNumber do not contain identifying information but they are not needed by the readership either and should also be omitted as unnecessary. 6. “All participants were sanitized” A better way to say this for people is that they practiced a disinfection protocol prior to the interview and hopefully their interviewers did that as well. 7. “Team 3 was composed of two independent 161 researchers whose task was to read and review the content (interview transcripts, and field 162 notes word-for-word, line-for-line) several times for quality checks and triangulation.” Do you mean to review transcripts and notes compared to the recordings for transcription accuracy? Team 2 was already doing that. I suggest you rephrase the description of Team 3 to say that this team was checking rigor according to the Lincoln – Guba criteria and leave it at that because you explain those further down. What you say about triangulation fits better under rigor – move it there and say how team 3 was doing triangulation of the analysis findings comparing data from one hospital with another hospital (because I haven’t seen any other method used for triangulation). 8. “The research materials were kept under restricted access by only authorized staff for 182 patient confidentiality and privacy” There were no patients in the study. Please clarify that it was about the confidentiality of the participants, now violated by Table 1 and supporting documents. 9. “Participants were reimbursed for participating in the study in form of transport refunds and 190 refreshments.” Perhaps clarify that the refreshments were to take home? They were all in masks and PPE. 10. “The interviews were transcribed verbatim immediately. Transcription accuracy was ensured 198 at the end of the interviews by the Principal investigator and one Administrator. Field notes 199 and the transcription were compared for congruency. Data collection and analysis were 200 conducted concurrently until data saturation was achieved. This was done so that insights 201 from the data analysis could be used to make the required adjustments in the interview guide 202 and evaluate the credibility of the emerging themes in the subsequent interviews.” This was already stated under quality control. Delete the repetitions and merge the rest with that section. 11. “Data was 203 coded and analyzed manually using a framework matrix developed using an Excel workbook.” This statement implies that you developed the codes deductively and put them into a pre-designed framework. It is in contrast with the detailed description right below on how you developed inductive codes according to phenomenology. Did you perhaps built the framework matrix in excel after that detailed and careful process? State that and move that sentence after the description of the code development, to line 215. 12. “We ensured long term 220 involvement of the research team with the healthcare providers.” What rigor criterion does this fulfill? I suggest delete unless you use it to say that you are confident that you established good rapport with the participants. The authors did not follow my previous feedback on how to painlessly summarize rigor. I therefore provide feedback below on how to improve the accuracy and readability of the rigor section: 13. “Data dependability was 221 ensured by having team 3 that was devoted to continuous reading through of the transcripts to 222 ensure ongoing comparison of the key information generated during the data collection and 223 analysis processes.” This is about ensuring that the findings of the analysis were aligned with the data collected in the transcripts and is what you do for the credibility criterion. Please edit. 14. “Dependability was observed by the stringent coding procedure and inter 224 coder corroboration.” Here please add that you made sure to document what each code meant in detail as illustrated in Table 3, so that another researcher could replicate this coding under a similar context (dependability criterion). 15. “Data transferability was observed by ensuring that participants’225 statements were captured with barely any modifications made yet ensuring a rich, thick 226 description of the study process by the research team.” The first part of this sentence is about confirmability by capturing the statements of the participants without any modifications and use of quotes as you do in the results section. The second part of the sentence about the thick description of the study context is what you provide in the intro and tables 1 and 2 so the findings could be transferable by the reader to another context if it were similar to the one of the hospitals in Kampala (transferability criterion). Please edit so it is clear to the reader. 16. “Thorough checks of procedures and 227 results were emphasized to improve the dependability and transferability of the data [19].” This is good but if you clarify the sentences above it you don’t need to repeat. 17. “Confirmability was observed by comparing the results to other evidence and field notes by an 229 external investigator [34] who read and compared the study results with the field notes and 230 memos.” Comparing the results with other evidence is triangulation. Either say what other evidence you were comparing the results with or delete. The rest about comparing the results with field notes and memos is confirmability - merge with the other part on confirmability. But this is the first time you mention memos. Say under data analysis how you were also writing memos and for what purpose, or delete memos from the sentence. 18. “We ensured that the coordinators of the interviews or discussions didn’t participate in 231 the analysis but critiqued the results from the analysis and ensured that these results 232 conformed to their expectations from the discussions.” It is not a criterion of rigor that field researchers stay away from the analysis. What you did is “member checking”, i.e. another way of validating the findings. Please state. 19. “Field notes and transcripts, codes and 233 their interpretations were made by separate teams of investigators.” Again this is not a criterion of rigor. You can delete. Or merge under data analysis. 20. “More than 90% of the healthcare 239 providers…” You should not use percentages when the denominator is so small (n=25). Simply say the great majority of participants… 21. Publication Ethics Table 2: too much information that compromises the confidentiality of the participants and doesn’t improve the dependability and transferability of the results. Please look at my suggestions in the previous rounds on how to improve Table 2. You can collectively report average age and say that all had bachelors degrees and up. Why is marital status relevant here? Delete. 22. “The participants 242 generally had a number of similar experiences in regards to maternal and newborn health 243 service delivery irrespective of the nature of health facility they worked (Table 3).” Here is where you can say that your data comparisons during rigor analysis showed a number of similar experiences irrespective of the health facility. 23. Table 3 is very good and helps a lot. “Much stigma was associated with contracting COVID-19. This meant no working for more than 2 weeks for the infected healthcare providers.” This statement needs clarification. How could infected providers work for 2 weeks? 24. “A special773 vote of thanks goes to the Administrators of the eight health facilities namely; Kawempe774 National Referral hospital, Kawaala Health Centre III, China Uganda Friendship Hospital,775 Naguru (Naguru Hospital), St. Francis Hospital Nsambya, Lubaga Hospital, Mengo Hospital, 776 Kampala Hospital, and Case Hospital for all the support they gave us during the study period.” Here again you are compromising the confidentiality of your participants without improving dependability or transferability of the results. You can instead anonymously thank all the participating hospitals. 25. References 1 and 2 continue to be inappropriate. You can’t use studies from the US to support a statement of WHO. You need a WHO reference for that. 26. References 6, 7, 8, 10, 11, 14, 15, 37, 39, 40, 44, 49, 51 need a web link and date accessed 27. Reference 8 and 13 are the same reference. Eliminate one of the 2 and provide weblink and date accessed. 28. References 21-29 are not needed when you delete the hospital names. 29. References 38, 41, 50 missing volume issue page info. 30. A recommendation on how to best address the reviewers’ comments without missing any, is to create a two-column table where on the one side you list each comment and on the right side you insert your response and direct quote from the manuscript. END OF COMMENTS Reviewer #3: Thank you for submitting this revised paper. You have obviously undertaken extensive revissions. My comments are only minor. These include: a) Introduction: i) Good to benchmark the extensive lockdown and other measures in Uganda at the start of the pandemic to those seen in other Africa countries (Ogunleye OO et al. Response to the Novel Corona Virus Pandemic Across Africa: Successes, Challenges, and Implications for the Future. Frontiers in pharmacology. 2020;11:1205) helping to reduce mortality - certainly when compared to e.g. a number of Western European countries ii) Good to include more up-to-date figures for COVID-19 than late January. In addition % in WHO Africa vs. rest of the world (this builds on i) iii) Lines 84 - 85 - I assume you mean 'Uganda' by 'U'. In addition - I do believe Uganda was more prepared than a number of other countries including e.g. US iv) Line 91 - A similar situation on reduced routine vaccinations across Africa - please see Abbas K et al. Routine childhood immunisation during the COVID-19 pandemic in Africa: a benefit-risk analysis of health benefits versus excess risk of SARS-CoV-2 infection. The Lancet Global health. 2020;8(10):e1264-e72 v) Line 104 - avoid unscientific terms such as 'grossly' throughout the paper - better to say 'appreciably' than 'grossly' b) Discussion - I would concentrate on the key areas as well as say what the authorities in Uganda should now do as a result of your findings for this and future pandemic. This does not come through clearly enough. This does not mean adding to the Discussion - merely making it more focused. The same applies to the Conclusion. This would enhance the utility of the paper in Uganda, across Africa and across LMICs Reviewer #4: It is a pleasure to review the study entitled : “Lived Experiences of Frontline Healthcare Providers offering Maternal and Newborn Services amidst the Novel Corona virus Disease 19 Pandemic in Uganda: A Qualitative study”. This paper’s strength is in the richness of the data and the in-depth descriptions of the challenges faced by maternal and newborn healthcare providers in Uganda during the pandemic, and how that influenced care provision. The study is also a platform to raise healthcare providers’ voices about the horrible experiences and negative treatment that they received, and to share their opinions of recommendations to continue care provision during the pandemic and beyond. It is also difficult not to appreciate the rigorous research methodology that was applied. Despite the witnessed improvements in the structure of the manuscript after the first revision, there remained some issue that can be addressed before publication. My two main comments are: - Although I do believe that the rich and expressive quotes are a strength of the manuscript, they do tend to make the results’ section a lot longer than it can be. Some of them are particularly long and repetitive of the text summarizing the results and therefore can be either shortened or deleted altogether (for example the one in line 300 – 304 can be deleted). Perhaps keeping one quote per theme is sufficient, and the reader can always refer to the “raw data” supporting information for more. - The manuscript describes the lived experiences during the COVID-19 pandemic. Yet, as we all have witnessed, the pandemic has been ongoing for almost 16 months, and with varying levels of restrictions over time. In the manuscript, the time frame of the described “lived experience” is not clear: was it the early phase of the pandemic (first lockdown), or does it stretch to include the period of data collection? The authors can be more specific about the recall period. This can be very relevant especially considering the second lockdown that Uganda is recently going through, to see whether any of the lessons learned from the first lockdown have helped in managing the second response. Other minor comments are noted below, divided by section: Supporting information: - File called “Raw data” : suggestion to change the name of the file to : ”Detailed summary of the data by theme with quotes” since it is not possible to share the raw data (i.e. complete transcripts of interviews) due to issues of privacy and anonymity. Naming the file “Raw data” gives the false impression that the dull transcripts are actually published. - File called “Participant interview guide” : it seems that this file contains questions addressed to women who have sought care and not to healthcare providers, and the questions do not match those mentioned in the response to the reviewers. Suggestion to please revise and align. Abstract - Suggest to rephrase this sentence: “With the travel restrictions, social distancing associated with the containment of the virus, the maternal and newborn healthcare service in Uganda could be inaccessible, unaffordable, and unavailable to both the healthcare providers and many pregnant or laboring women.” It seems like the care is unaffordable and unavailable to healthcare providers - Is this intentional? – consider using the space in the abstract to focus mainly on the barriers faced by healthcare providers - This is a qualitative study and usually do not use terms such as “primary outcome” (which has more of a quantitative connotation). It is already clear in the objectives what the “outcome” of the study is. Suggestion to rephrase as: “the interview guide primarily explored xxxx” - The first sentence in the conclusion is probably correct but it is not a direct observation of this research. The conclusion can focus more on healthcare providers’ wellbeing and ability to provide care, and the need to respect and support them rather than about the service delivery Background: - Line 84-85: The COVID-19 pandemic took U by surprise[8, 10]. o Although I agree, it did take “me” and everyone by surprise, but I think the authors mean “took Uganda” o Suggest to move this sentence to the beginning of the paragraph - Line 93-96: “Interruption in access to quality maternal and newborn health services with the travel restrictions in place to curb the COVID-19, could put over 10,000 lives of both women and their babies in danger every single day of the COVID-19 pandemic.” o Please provide a reference to this estimate o This paragraph could use a bit more information about the MNH situation in Uganda before the pandemic: e.g. maternal mortality rate, skilled birth attendance, facility birth coverage, ANC coverage etc. how did these aspects evolve over time? And why is COVID-19 a particular threat to them, especially if it’s affecting healthcare providers. o The background is also missing information about the structure of the health system in Uganda before the pandemic – where do women usually seek care (hospitals, healthcare centres?) how is care covered? Public vs private sector role in the health system? And how are they similar/different to each other? etc. - Line 98: there is a “15” misplaced after December 2020. Also not clear what this sentence adds: “if it means that healthcare workers were infected with COVID-19”? Please clarify , with more details about the number of healthcare workers if that is possible. Methods: - Line 121: is this a public health facility? Not a hospital? - Table 1: o Suggest to present similar and complete information on all the hospitals ; e.g. why is number of deliveries per year available for Kawaala health centre and not others? If possible recommend to add for all o Suggestion to divide the “description” column into more structured columns, for example: level of care (primary, secondary, tertiary) ; some proxy of size of the health facility (e.g. number of maternity beds or number of deliveries in the past year – depending on which info is readily available); number of maternal and newborn healthcare providers (total or estimate); operating hours; free vs. paid services o An important characteristic to mention about the hospitals is whether or not they treated any pregnant women / women in labour who were suspected/confirmed with COVID-19 - Explain a bit more about the selection of the hospitals (purposive sampling of the biggest hospitals in Kampala, from three sectors public, private, private not-for-profit) - Line 121 – 123: “These eight facilities were the biggest service providers for public and private maternal and newborn health care in Kampala.” – why past tense here “were”? Suggest to change to present - Line 139: “All participants were sanitized”. Suggest to rephrase to : participants sanitized their hands or strict hand washing and sanitization were required from all participants… - It is important to mention where the interviews took place in the methods section: was it at the health facilities where participants worked? Or at the researchers office? - Line 155: “potential clients”. Suggest to rephrase to potential participants - Line 168: do the authors mean: no new emerging themes? - Quality control: what happened with the data from the pilot interviews? Was it included in the analysis? Please be clear about that and if yes why? If no why not? - Line 180: data were backed-up? Where and how? Results: - Title of the heading: please remove “baseline” - Table 2 is not completely showing on the page (please format and resize) - Please align the use of “obstetrician/gynecologist” vs. “medical doctor” when describing the cadres in the methods, results and table 2 - Suggestion for table 2: to switch the rows and the columns (the three types of facilities become columns, so that the categories of each variable are not repeated every time) Private Public Private not for profit Sex Male 2 2 2 female 4 8 7 Age 20-29 0 1 1 30-39 4 5 4 >40 2 4 4 - It is useful to know how many interviews were done per facility – perhaps could be added to table 1? - Table 3 – it is not clear for the reader why the page number is added to the table. Also keeping in mind that this might change when the paper is published, I suggest to remove this column. Or it can be used to indicate a reference to the “raw data” supplementary material if necessary - The authors indicate that HCP experienced a number of similar themes across the facilities, but did they note any discrepancies or similarities within the health facilities? E.g. differences between cadres who work at the same hospital? (just our of curiosity about dynamics between different cadres) - The perception that patient numbers increased is interesting- despite the fact that we could have assumed the opposite to happen (blocked roads/fear of healthcare seeking in facilities). - Comment/suggestion: try to avoid “quantitative” terms in the results (e.g. change “a significant number” on line 254 to something like “many/most” etc. - Line 258: exclamation mark after “gloves”. Suggest to remove to the keep the results description as objective as possible. - Suggestion to always refer to it as “COVID-19”. Sometimes COVID alone is used (it is ok if it’s in a quote, but not the main text). Line 451: suspected to have COVID-19 - Suggestion to spell out CME in-text (first occurrence line 529) Discussion - Line 650-651: specify which services exactly - Paragraph lines 685-697: recommendation about telemedicine should be considered with caution as it can lead to inequality in accessibility (poverty, illiteracy among women) and its impact on the quality of maternity care is not yet well understood. Suggest to revise the list of abbreviations and align with the updated version of the manuscript as some terms were deleted e.g. PMTCT ********** 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 #2: No Reviewer #3: Yes: Brian Godman Reviewer #4: 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. 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| Revision 2 |
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Lived Experiences of Frontline Healthcare Providers offering Maternal and Newborn Services amidst the Novel Corona virus Disease 19 Pandemic in Uganda: A Qualitative study PONE-D-21-03659R2 Dear Dr. Kayiga, 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, Michelle L. Munro-Kramer, PhD, CNM, FNP-BC Academic Editor PLOS ONE Additional Editor Comments (optional): Thank you for your careful attention to all reviewer comments. The manuscript has been substantially improved and I am happy to accept it for publication. |
| Formally Accepted |
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PONE-D-21-03659R2 Lived Experiences of Frontline Healthcare Providers offering Maternal and Newborn Services amidst the Novel Corona virus Disease 19 Pandemic in Uganda: A Qualitative study Dear Dr. Kayiga: 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. Michelle L. Munro-Kramer Academic Editor PLOS ONE |
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