PONE-D-21-32084ACCEPTABILITY OF THE WULIRA APP IN ASSESSING OCCUPATIONAL HEARING LOSS AMONG INDUSTRIAL WORKERS.PLOS ONE

Dear Dr. twinamasiko,

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 Jan 27 2022 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: https://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,

Mohammad Hossein Ebrahimi

Academic Editor

PLOS ONE

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When submitting your revision, we need you to address these additional requirements.

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https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf

2. Thank you for stating the following in the Acknowledgments Section of your manuscript:

“AWS and MN are research fellows of the MakNCD program supported by the Fogarty International Centre of the National Institutes of Health under Award Number D43TW011401.”

We note that you have provided additional information within the Acknowledgements Section that is not currently declared in your Funding Statement. Please note that funding information should not appear in the Acknowledgments section or other areas of your manuscript. We will only publish funding information present in the Funding Statement section of the online submission form.

Please remove any funding-related text from the manuscript and let us know how you would like to update your Funding Statement. Currently, your Funding Statement reads as follows:

“This study was funded by the Government of Uganda through the Research and Innovation Fund Makerere University, Fund no. MAKRIF/ DVCFA/ 026/ 20. The content is solely the responsibility of the authors and does not necessarily represent the official views of the Research and Innovation Fund.

IA was the grant recipient.

The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.”

Please include your amended statements within your cover letter; we will change the online submission form on your behalf.

3. Thank you for stating the following in the Competing Interests section:

“I have read the journal's policy and the authors of this manuscript have the following competing interests: Dr. Charles Batte is part of the team that developed the Wulira App. Dr. Charles Batte and Dr. Andrew Weil Semulimi are directors at Wulira Health Limited that owns the Wulira App. The other authors have no conflict of interest to declare.”

Please confirm that this does not alter your adherence to all PLOS ONE policies on sharing data and materials, by including the following statement: "This does not alter our adherence to  PLOS ONE policies on sharing data and materials.” (as detailed online in our guide for authors http://journals.plos.org/plosone/s/competing-interests).  If there are restrictions on sharing of data and/or materials, please state these. Please note that we cannot proceed with consideration of your article until this information has been declared.

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Reviewers' comments:

<ul><li>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

Reviewer #3: Yes

**********

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

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: 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

Reviewer #3: 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

Reviewer #3: 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: Dear authors thank you for your research:

-I preferred to mention the detailed of the Sekhon’s framework of Acceptability tool of data collection in the method section.

-regarding the sample size: could you please give some information about data saturation principle.

2you mention many limitations for the study that affect the validity of your results; what did you conduct to decrease the effect of them on your study results?

and you didn't ; why?

Reviewer #2: General comments:

- Please avoid starting a sentence as "There is/was/are/were" in scientific writing.

- Do not use the full stop after the title of the section.

Abstract:

- Please say when and where the study was done.

- It is not clear which were the inclusion/exclusion criteria.

- It is not clear what was tested with the FGDs.

- The results are not specific (e.g., how many are considered friendly or cheap; what time-saving means, etc.)

Introduction:

- "has increased the risk of developing hearing loss" how considerable the risk is?

- Please also report the 95% confidence interval associated with Se and Sp.

- "Previous studies" to which populations were these previously study conducted?

- "phone ownership is still low due to the cost" how low and how much does it cost relative to the income of persons who work in industries where hearing loss occurs?

- "Literature on the acceptability of mobile audiometry for monitoring purposes in Africa and Uganda is scarce" Briefly present these studies and their results.

- It is not clear which is hearing loss among industrial workers in the target population.

- End this section with the aim of your study.

Methods:

- It is not clear when the study was conducted.

- "industrial workers at a steel and iron manufacturing industry" Are the steel and iron manufacturing industry the most prevalent industry where hearing loss can occur?

- Why was this particular city and industry was chosen?

- The inclusion criteria are not sufficiently presented (e.g., how many years were they working in that industry, had the family history of hearing loss? etc.).

- It is not clear how the participant was recruited and how the participants were decided.

- Define "most active participants".

- Is there any reason why the participants were not evaluated for hearing loss by gold standard procedure?

- It is not clear which questions were in the interviews.

- It is not clear if the participants used the App on their own phones or not.

- It is not clear if the participants were or not with phone/smartphone skiled.

Results:

- Put the results either in text or in Tables. Do not duplicate the results in text and tables/figures.

- Do not include in the body of the table the units of measurements (e.g. %).

- "The results from the IDI and FGDs revealed themes that are presented using Sekhon’s framework to understand the acceptability of the hearing assessment using the Wulira app" this information is duplicated; please delete it.

- It is not clear how many participants agreed with the features presented in Table 2 as facilitator/barrier.

Discussion:

- Do not duplicate information (the aim of the study is already known).

- It is useful to begin the discussion by briefly summarizing the main findings and explore possible mechanisms or explanations for these findings.

- Emphasize the new and important aspects of your study and put your findings in the context of the totality of the relevant evidence. State the limitations of your study, and explore the implications of your findings for future research and for clinical practice or policy.

- "Our results revealed that Wulira App’s compatibility with only smartphones will be a major barrier for individuals in rural areas or with no smart devices" a possible solution to this barrier is that the employer to provide the possibility to test personal hearing on a stand-alone smartphone on which the application is installed and why not with a supervision of a technology skilled person to assist individual persons.

- The main limitation of your study is the absence of performance evaluation of the used App since the respondent was disease-free and no standard gold diagnosis was made.

Conclusions:

- Not all sentences presented here are conclusions (e.g., 453-457).

- Please provide the date for ethics approval.

Reviewer #3: The reviewed article presents a qualitative evaluation of the acceptability of the Wulira App in assessing hearing loss among industrial workers in Kampala, Uganda.

Overall, this qualitative investigation produced a useful insight into both facilitating and hindering factors experienced by a sample of industrial workers after their hearing has been assessed using the evaluated App.

The evaluation involved 4 focus group discussions (FGD) with 8 participants per FGD and 12 in-depth interviews (IDI), conducted after all industrial workers were first tested for hearing loss using the evaluated App.

None of the investigated workers has been found to be suffering from hearing loss.

In this reviewer’s opinion, this might have influenced the participants’ optimism and perceptions, when being later asked to describe their experience and their perceived acceptability of the App.

Unless the audiometric test results were not communicated to participants until after their participation in the FGDs and IDIs (an aspect that should be clearly mentioned in the article), this represents a limitation that should also be mentioned by the authors, and which should be addressed by future studies, by including a larger number of participants which may ensure not only the qualitative-data saturation (which dictated sample size in this study), but also a reasonable number of participants with hearing problems to be detected by the App (thereby reflecting the prevalence of hearing loss in the targeted population of industrial workers).

Despite the major conflict of interest that has been declared by 3 of the authors (who own, direct and/or have participated in the development of the evaluated App), other than this possibly important limitation of the study (which needs to be clarified or stated along with those already underlined in the Limitations section), the scientific approach appears to have been conducted using fairly objective methods (as described in the Methods part of the study and as reported in accordance to the COREQ guidelines).

Also, lacking other evidence, the authors needed to rely on their own previous works when making accuracy/ sensitivity/ specificity claims about the investigated App. Given the aforementioned conflicts of interest, encouraging future independent studies of diagnostic accuracy and acceptability of the evaluated App would be desirable.

Further improvements of the article manuscript may also be achieved by addressing the following issues:

Lines 73-75: please specify the gold standard against which the authors have determined the Se and Sp of the evaluated App in their previous work. Also, please specify the sample size and the 95% CI for Se and Sp.

Lines 129-130: please detail what “most active participants” means, since this may have been a highly subjective choice, leading to the selection of the most optimistic and favorably-oriented participants towards the evaluated App.

Lines 143-144: this reviewer suggests replacing “Before start of each FGD, moderator shared” with “Before the start of each FGD, the moderator shared”.

Line 150: this reviewer suggests replacing “moderator noted” with “the moderator noted”.

Line 172: this reviewer suggests replacing “FGD findings were ratified and triangulated themes got from IDI” with “The FGD findings were ratified and triangulated with themes got from IDI”.

Line 174: please specify which open code software was used to perform the analysis.

Line 190: this reviewer suggests replacing “majority” with “the majority”.

Line 192: this reviewer suggests replacing “majority” with “a majority of them”.

Line 233: this reviewer suggests replacing “working high noise environments” with “working in high noise environments”.

Line 235: there is an unlikely omission of a sense-giving verb in the verbatim transcription of Interviewee 10: “You never what result I would get.”

Line 290: this reviewer suggests replacing “prevented some of them for accessing” with “prevented some of them from accessing”.

Lines 382-383: this reviewer suggests replacing “ranges from everyone month to once a year” with “ranges from once a month to once a year”.

Line 398: this reviewer suggests replacing “Study done” with “A study done”.

Lines 401-402: Once again, please specify the gold standard against which the Se and Sp of the App and of PTA have been determined, in order to reach a conclusion of “similarity” between the App and conventional PTA. Also, even if Se and Sp were indeed similar between the App and conventional PTA, it is not clear how that would influence or even “explain its acceptability”.

Lines 406-407: this reviewer suggests replacing “Study done” with “A study performed”.

Line 420: this reviewer suggests replacing “to separate individuals with potential hearing disorder from those who don’t” with “to separate individuals who have a potential hearing disorder from those who don’t”.

Line 424: this reviewer suggests replacing “in possession with these phones” with “in possession of these phones”.

Line 435: please resolve the doubling in “would would”.

Lines 476-478 and 480: There are several abbreviations in the list which do not appear in the text of this article: YLD, OHL, NIHL, MDR-TB. Those abbreviations might have been useful in previous publications of the authors, but should be removed from this article.

**********

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Reviewer #1: No

Reviewer #2: No

Reviewer #3: 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.

==============================</li></ul>

PONE-D-21-32084R1ACCEPTABILITY OF THE WULIRA APP IN ASSESSING OCCUPATIONAL HEARING LOSS AMONG WORKERS IN A STEEL AND IRON MANUFACTURING INDUSTRY.PLOS ONE

Dear Dr. twinamasiko,

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 14 2022 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: https://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,

Mohammad Hossein Ebrahimi

Academic Editor

PLOS ONE

Comments to the Author

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

N/A

2. 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.

No

3. 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.

No

Generally the authord appropriated response to my comments and suggestions. However, some chnages are needed before publication:

- I am not a native English speaker bu I belive that your manuscript could benefit by English language professional service.

- Write the aim of the study at past tense.

- Some duplicated text exist in the revised manuscript (e.g. Affective attitude).

- Line 230-231 belongs to the methods section.

- Do not start a sentence with a number.

- Please avoid starting a sentence as "There is/was/are/were" in scientific writing.

- Do not use the full stop after the title of the section.

Abstract:

- Please say when and where the study was done.

- It is not clear which were the inclusion/exclusion criteria.

- It is not clear what was tested with the FGDs.

- The results are not specific (e.g., how many are considered friendly or cheap; what time-saving means, etc.)

Introduction:

- "has increased the risk of developing hearing loss" how considerable the risk is?

- Please also report the 95% confidence interval associated with Se and Sp.

- "Previous studies" to which populations were these previously study conducted?

- "phone ownership is still low due to the cost" how low and how much does it cost relative to the income of persons who work in industries where hearing loss occurs?

- "Literature on the acceptability of mobile audiometry for monitoring purposes in Africa and Uganda is scarce" Briefly present these studies and their results.

- It is not clear which is hearing loss among industrial workers in the target population.

- End this section with the aim of your study.

Methods:

- It is not clear when the study was conducted.

- "industrial workers at a steel and iron manufacturing industry" Are the steel and iron manufacturing industry the most prevalent industry where hearing loss can occur?

- Why was this particular city and industry was chosen?

- The inclusion criteria are not sufficiently presented (e.g., how many years were they working in that industry, had the family history of hearing loss? etc.).

- It is not clear how the participant was recruited and how the participants were decided.

- Define "most active participants".

- Is there any reason why the participants were not evaluated for hearing loss by gold standard procedure?

- It is not clear which questions were in the interviews.

- It is not clear if the participants used the App on their own phones or not.

- It is not clear if the participants were or not with phone/smartphone skiled.

Results:

- Put the results either in text or in Tables. Do not duplicate the results in text and tables/figures.

- Do not include in the body of the table the units of measurements (e.g. %).

- "The results from the IDI and FGDs revealed themes that are presented using Sekhon’s framework to understand the acceptability of the hearing assessment using the Wulira app" this information is duplicated; please delete it.

- It is not clear how many participants agreed with the features presented in Table 2 as facilitator/barrier.

Discussion:

- Do not duplicate information (the aim of the study is already known).

- It is useful to begin the discussion by briefly summarizing the main findings and explore possible mechanisms or explanations for these findings.

- Emphasize the new and important aspects of your study and put your findings in the context of the totality of the relevant evidence. State the limitations of your study, and explore the implications of your findings for future research and for clinical practice or policy.

- "Our results revealed that Wulira App’s compatibility with only smartphones will be a major barrier for individuals in rural areas or with no smart devices" a possible solution to this barrier is that the employer to provide the possibility to test personal hearing on a stand-alone smartphone on which the application is installed and why not with a supervision of a technology skilled person to assist individual persons.

- The main limitation of your study is the absence of performance evaluation of the used App since the respondent was disease-free and no standard gold diagnosis was made.

Conclusions:

- Not all sentences presented here are conclusions (e.g., 453-457).

- Please provide the date for ethics approval.

PONE-D-21-32084R2ACCEPTABILITY OF THE WULIRA APP IN ASSESSING OCCUPATIONAL HEARING LOSS AMONG WORKERS IN A STEEL AND IRON MANUFACTURING INDUSTRY.PLOS ONE

Dear Dr. twinamasiko,

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 29 2022 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: https://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,

Mohammad Hossein Ebrahimi

Academic Editor

PLOS ONE

Journal Requirements:

Reviewers' comments:

[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.

ACCEPTABILITY OF THE WULIRA APP IN ASSESSING OCCUPATIONAL HEARING LOSS AMONG WORKERS IN A STEEL AND IRON MANUFACTURING INDUSTRY.

PONE-D-21-32084R3

Dear Dr. twinamasiko,

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,

Mohammad Hossein Ebrahimi

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments: