PONE-D-21-29137

Preferences for accessing sexual and reproductive health services among adolescents and young adults living with HIV/AIDs in Western Kenya: A qualitative study.

PLOS ONE

Dear Dr. Adhiambo,

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.

While the reviewers agree that this is an important topic, there are some issues with the paper in its current form that need to be addressed. Notably, the reviewers question issues of confidentiality in your supplemental documents. In addition to addressing all other reviewer comments, please also address how the confidentiality of participants is protected. Please provide information on ethics board approval as well. Ensure that there are NO confidentiality breaches in any of the information provided within the document or in the supplemental contents (see reviewer #1 comments for an example of potentially identifiable information) as this paper cannot be published with ethical violations.

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PLOS ONE

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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: Partly

Reviewer #2: Yes

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

Reviewer #1: N/A

Reviewer #2: Yes

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Reviewer #1: No

Reviewer #2: Yes

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

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Reviewer #1: No

Reviewer #2: Yes

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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: Apologies to focus on the negatives, there was clearly good and necessary research in this document, but my comments are below. My biggest concerns are CONFIDENTIALITY BREACHES OF PEOPLE LIVING WITH HIV IN THE SUPPLEMENT document.

Ethics:

Two major points of concern:

1. The information in the supplementary information is inappropriate. I only read a tiny bit of it and already had a young person’s town, school name, their age, school year, employment, sex, and their intentions to go to university. IT IS THEREFORE POTENTIALLY ENTIRELY IDENTIFIABLE to anyone who knows these young people. This error makes me question data governance in this project. In my opinion, local actions need to be taken to investigate this confidentiality breach. The interview transcripts should never in my opinion be published in their current form. A suitable alternative would be to append the interview and focus group discussion topic guides.

I think that the interview and focus group topic guides should be appended rather than the interviews themselves in the form that they are in.

2. Why were healthcare workers and caregivers asked if they were sexually active? This does not seem an appropriate question as the study was NOT about their sexual behaviour. Was the ethics team aware that this would be asked of these groups of people? In my country this would be inappropriate data to obtain in this context, as it does not relate to the research question. Again, I question whether training on data governance needs to be strengthened in the reporting team.

General feedback:

The use of the word "facility" throughout this piece had me confused and needs some clarity.

I would want the interview and FG topic guides as appendices (and not the transcripts, for reasons above)

Abstract:

“AYAs generally preferred receiving SRH services from the health facilities offered and served by trained healthcare providers.” – having read the whole paper, I am not sure I have seen evidence of the “trained healthcare providers” bit of this statement? I think maybe the abstract should just say that AYAs generally preferred SRH services to be co-situated with clinical facilities? Your data seems to support the idea that healthcare providers feel that training is important.

Introduction:

A Key issue: I think for me the article would be a bit easier to understand if a bit more of the context was given about the presence of PEPFAR and its projects and centres for AYA living with HIV, their relationship to state-provided healthcare, and therefore the policy need for research of this type.

“Like many countries in SSA, Kenya still grapples with challenges in improving the utilization of adolescent sexual reproductive health services that urgently need focus” – Is focus a big issue for healthcare providers? I think this needs to be made clearer

The other clear difference between AYAs living with and living without HIV is that the latter group is already in regular contact with healthcare professionals for their HIV. In many countries these professionals would feel confident in advising the AYA about SRH needs, certainly in giving out condoms, or signposting them to SRH-specialist services. The challenges here are that some services may have known the AYA since they were a child, and then the child feels that they cannot discuss their sexuality with them, and that the HIV team will have an interest in discussing disclosure with the AYA. A fresh or unknown staff member from an SRH team can be helpful in these situations. I didn’t hear much about this angle from the introduction and would like to know how things are in Kenya and why the patients’ own HIV teams aren’t able to cover their SRH needs. Or are they? Are they meant to? It would be really useful background information to have, as then the other questions and statements would make more sense.

Methods:

Unclear how patients were consented, especially regarding the language they were consented in, language of consent form, and were the participants clear that participation didn’t affect the care they were receiving, as PLWHIV? I note some people had only “some primary” education – were measures put in place to support those who were illiterate?

Data security of recordings etc is not mentioned?

Unclear in methods section why broad code groups were given in this section– would usually be in results section unless the codes were a priori codes, furthermore, it is not clear if these codes were a priori codes or not and this needs to be clarified.

Did the interviewer sex match the participant’s? what training had the research assistants had? Abstract mentions they were trained and experienced but this isn’t in the text, which is a bit unusual as typically there shouldn’t be anything in the abstract that isn’t inside the main article. Training is especially important as discussing sex with very young people.

Also, how old were the interviewers, given your research’s findings that young people prefer to talk to younger staff?

Were the FGDs held with boys and girls together – if so, it would be interesting to know what drove this decision?

Where were interviews held? What efforts were made to keep the conversations from being heard? Was anyone else present or allowed to be present when the IDIs were held? Were parents informed of the interviews? how were issues such as school attendance navigated for these interviews, to encourage participation and minimise impact on life?

Were there any pilots performed? If so, should be mentioned.

What proportion of those approached agreed to participate, if known? If the number of people invited is unknown, this should be stated, and why it is unknown.

I am not clear whether the AYAs and the carers were known to each other or not, ie. were the carers picked because they cared for the specific AYA being interviewed?

How were carers and healthcare workers approached to be in the study, I couldn’t see this?

How was the number 30 chosen? I am not clear at what point saturation was found – was it after all 30 had been interviewed or before then? The wording isn’t quite clear. It reads more like 30 was chosen as it was expected that by this point saturation would have been reached, which is not quite the same thing as reaching thematic saturation.

Were all 3 FGDs asking the same questions, or was each group tackling different questions? Also, how many people were in each FGD?

Results -

What groups were the healthcare workers from? Eg. what proportion was nursing, doctors, etc. what proportion of the patients were living with HIV? And what proportion of the patients participated in group discussions? Did all the AYAs have IDIs and FGDs?

At least one male in the staff group seems to have (perhaps understandably as presumably he was indicating that he is a father) said that he was previously pregnant/expectant – this raises questions about whether the question was relayed to all participants in the same way? It is probably worth unpicking from your data and commenting to explain how this happened (or changing the way the question is described in the table).

I would have liked a general paragraph in the results to outline how the FGDs had been – was there discord? How much did people disclose? Did boys or girls, older or younger people dominate discussions in the FGD for AYAs? Were staff in general agreement or were there differences eg. based on rank or location of their work? Was there a lot of difference in the views raised at the 3 groups? Were the caregivers able to give many opinions? What were the main concerns within the 3 groups of people?

Why are the IDIs so under represented in your quotes? It seems a shame that you did ?30 IDIs and they only get 2 quotes.

Preferences sections:

Were the locations discussed (schools, hotels, pharmacies etc) prompted from a list/interview or FG prompt or spontaneously mentioned by the participants in the different groups?

“If you access those other things, maybe there are not good places you can get from them. But here, they will tell you the good ones and the bad ones (IDI #2 at KCH)” I think this quote needs some extra words in square brackets to help it make sense as at the moment I don’t understand it, even within the context given in the text.

“I feel that it would be beneficial because I have seen community health volunteers who talk to children, and they open up. I think the issue of age makes them have confidence in you (FGD on 23 August 2019” – this quote needs to say which of the 3 FGD groups this quote came from

“Others were inclined to have a trained professional go to schools on specific days to provide SRH services and offer psychosocial advice. However, other participants had a contrary opinion arguing that if teachers were to be assigned to provide the services, they would be judgmental and deny AYAs services with the reasoning that they are young and they should not be accessing such services.” - I do not find these two statements contradictory unless one assumes that the trained professional going to the schools is a teacher (and I don’t know why they would necessarily be?). there is also quite a lot of duplication of this paragraph in the following quotation so it could be trimmed.

“elderly” doesn’t really feel like the correct word, I think, where you have used it. Perhaps just “older” would be better?

Throughout the section on preferences of counsellors I wasn’t getting a very good idea of which groups of people were thinking what in terms of the preferences. This needs a bit more clarity (even if they were all in agreement, for example).

“receiving services at the facility” – this could be clearer eg. by stating “within a hospital building” (as to me, facility could mean anything including a school for example). I think this terminology is in the abstract as well, and would just be clearer if it used more precise language.

Key point: Did the IDIs concur up with the FGDs on your key findings (ie. preferred gender and age of care provider for girls and boys, and preference for SRH services co-situated at a venue like a clinic or hospital)? Did the different FGDs generally concur with this or were some more in agreement with your conclusion and others less so? I think this needs a bit more fleshing out as it is interesting if there are trends (rather than just the odd quote).

Discussion:

I don’t feel from reading your results that there was a strong prefererence for hospital or clinic co-situated SRH facilities, among the AYAs; rather that there was a large mix of views and maybe the predominant view was one of reference for co-situated SRH services (the word you use is “many”). I feel the discussion and abstract implies there was a fairly clear preference for healthcare co-situated SRH services. Therefore I suggest that either the results section needs to justify the conclusion that there was an overall preference (eg. by stating that a majority of participants said it (please also see above note about showing more clearly if it was in FGD or in IDIs that this conclusion was most evident; AYAs or staff/caregivers)), or the discussion/abstract need to decrease the weight currently placed on preference for SRH being co-situated with healthcare (eg by saying “the most commonly voiced preference by AYAs in ___(FGD/IDIs) was x”).

“AYAs generally preferred receiving SRH services from the health facilities offered and served by trained healthcare providers.” – having read the whole paper, I am not sure I have seen evidence of the “trained healthcare providers” bit of this statement? I think maybe the abstract should just say that AYAs generally preferred SRH services to be co-situated with clinical facilities? Your data seems to support the idea that healthcare providers feel that training is important.

“One of our main findings was the need to design SRH interventions that ensure all services the AYAs require are “under one roof."” . This may be true but you don’t evidence it much if it is a main finding. For example, there are no quotes from AYAs illustrating this (the quote that mentions parents not knowing what services are being sought does not illustrate the desire for a “one stop shop” with multiple services for the AYA, merely the fact that a health facility masks the SRH activity by also offering non-SRH activity that the person does not intend to use).

The sentences about the youth centres are interesting, but I don’t really see how they link in with the “under one roof” idea very clearly – are they co-sited with hiv clinical teams? This needs greater clarity.

I’m not sure what a “stigmatizing outburst” is – needs greater clarity/rephrasing.

“These findings highlight the importance of having a ‘safe space’ environment for the provision of SRH services within our health facilities and interventions that will improve access to the existing SRH service provided to adolescents living with HIV/AIDs at the adolescent centers.” Who does “our” refer to? And where would the safe spaces be? Within PEPFAR or within the health centres?

It would be interesting to hear why you think that girls preferred younger, and men older, healthcare professionals – is there any theory you can link with?

Typos:

AYA, SRH, SSA, IDI, FGD – define when first mentioned, not later in the document

“20 million girls aged (15-19 years)” should be “girls (aged 15-19)”

“if they were aged 14-24, living with HIV and on care at the two facilities” [should read IN care]

I can see that orphan/total orphan is a recognised term but it is a bit confusing – suggest it might help readability to change to “one/both parents deceased”

“This ensured that participants were free to discuss sensitive issues” – suggest you might mean “felt comfortable”?

Not sure if a typo – what are “health families” p.15 on my document?

“This study explored the perspectives of adolescents, caregivers, and health care providers on improved access to sexual and reproductive health services of AYAs living within western Kenya.” Currently this reads as though the services are already improved and people are being asked about them – I’m not sure this is what you mean though.

“horrible staff attitude” – suggest you mean “disrespectful staff attitudes” or something similar. “Horrible” is not an appropriate word for a journal, unless a quotation.

“In as much as AYAs in our study had a strong preference for receiving their SRH services at health facilities, some preferred other outlets like retail pharmacies” – this doesn’t make sense to me linguistically and I think you mean

“Although most of the AYAs in our study had a strong preference for receiving their SRH services at health facilities, some preferred other outlets like retail pharmacies”.

Reviewer #2: Well written and excellent manuscript of an important issue around AYA. The introduction however needs to be revised on various aspects- grammar, references and literature. The factors outlined as contributing to inadequate access to SRH do not only apply to ALHIV but to all adolescents in general. The distinction between these two groups and the differences need to be outlines as well as the possible reasons. More literature is needed in the background regarding preferences of healthcare providers and caregiver. More results could be included as well. Also in the discussion comparison with other studies could be made stronger.

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Reviewer #1: No

Reviewer #2: No

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PONE-D-21-29137R1Preferences for accessing sexual and reproductive health services among adolescents and young adults living with HIV/AIDs in Western Kenya: A qualitative study.PLOS ONE

Dear Dr. Adhiambo,

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. The reviewer(s) note significant improvement in the manuscript but have detailed some additional minor changes that need to be made to further improve the paper. Please respond appropriately to each of these requested changes.

Please submit your revised manuscript by Dec 03 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.

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We look forward to receiving your revised manuscript.

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Bettye A. Apenteng

Academic Editor

PLOS ONE

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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.

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: (No Response)

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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

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

Reviewer #1: N/A

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

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

Reviewer #1: Yes

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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

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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: This is a big improvement, thank you for putting in the time! I especially found the topic guides were helpful, and the additional quotes really brought the topic alive. My only comments are (and apology that they are not in the same order as the issues come up in the text):

1. Table 1 shows a total of 9 female healthcare workers, and also says that 10 healthcare workers had ever been pregnant/expecting - perhaps if the question was "whether you or a partner had ever been pregnant" (is this what you mean by the question "ever been pregnant/expecting"?) was what was interpreted of this question by participants? It's not the biggest point, but your paper will appear more reliable if it doesn't seem to be saying that men were saying they had been pregnant (I'm assuming no transgendered individuals here).

2. As I suggested, please include age characteristics of interviewers in the article text (apologies if I missed it).

3. Please make explicit, as you said to me in response to my comments, that the FGDs and the IDIs concurred with each other around your overall conclusions, and that you did not see any significant differences between the AYAs/caregivers/healthcare workers on where SRH services were best provided. This is an important finding.

4. line 250 - the quote following this sentence about AYAs' expressed preferences seems in fact to have been from an adult, so it doesn't illustrate the expressed preference, only another person's assertion as to their preferences (minor point).

5. Darting back to the methods section, i think that what you told me about how you conducted interviews in school break times to accommodate the AYAs' other needs and to aid their ability to participate is something I would suggest including in the text. This demonstrates good practice for other research groups (I couldn't see it - apologies if it is there).

6. I would like to see your hypotheses for why adolescent boys like getting SRH care from older men and adolescent girls from younger women explored in the document - you have fed back some ideas to me, but not put them as hypotheses in the discussion as far as I can see (apologies if I missed it). Cite evidence where you can, but ultimately this is a potentially interesting avenue for future research, which you should point out. Your standpoint within a similar cultural millieu of the AYAs means that your interpretation is far better than, say, mine would be, and it is interesting and useful!

7. Darting to the interview and FGD guides - were all questions used for all interviews and all FDGs, or did you only say focus on one or two areas for each FDG, say? it seems like a lot of quesitons to get through in quite a short time. Please outline whether all question areas were covered in all interviews and FGDs, or whether the FGDs and interviews tended to pick up on just a few areas. To my mind it doesn't matter which is true, but i think it needs to be stated.

Thank you again, these are my only thoughts now and they are quite minor, great job!

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Reviewer #1: No

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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.

Preferences for accessing sexual and reproductive health services among adolescents and young adults living with HIV/AIDs in Western Kenya: A qualitative study.

PONE-D-21-29137R2

Dear Dr. Adhiambo,

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.

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Kind regards,

Bettye A. Apenteng

Academic Editor

PLOS ONE

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