PONE-D-23-11475Developing a context-relevant psychosocial stimulation intervention to promote cognitive development of children with severe acute malnutrition in Mwanza, TanzaniaPLOS ONE

Dear Dr. Olsen,

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Engelbert A. Nonterah, MD, PhD

Academic Editor

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: No

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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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: No

Reviewer #2: Yes

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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

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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: The topic of this study is highly significant at both local and global levels. Investment in promoting early childhood development can yield substantial health, social, and economic benefits for society as a whole. There is a dearth of psychosocial stimulation programs designed for children facing adversities in resource-constrained settings. However, the study could have several flaws, leading to limited results. No results on the barriers and facilitators at the child, community, healthcare providers, and the healthcare system levels were reported.

Below are my suggestions:

1. Avoid excessive use of acronyms.

2. Introduction: Provide a comprehensive explanation of psychosocial stimulation, both in general and specific to Severe Acute Malnutrition (SAM). Detail the WHO guidelines for inpatient SAM treatment and recommendations for psychosocial stimulation.

3. Methods: Provide a more detailed description of the design of the qualitative formative research in the "Study Design and Setting" section. Explain the rationale behind the chosen qualitative methods and the theoretical framework guiding the study.

4. Clarify whether the psychosocial interventions studied were intended for inpatient treatment in hospitals or community management of SAM.

5. Describe the process of selecting professionals for the study.

6. Specify the number of participants who declined to participate and their reasons for refusal.

7. Elaborate on the process of deciding to stop conducting interviews based on data saturation. Explain who made this decision and how.

8. Detail the development and pilot testing of the interview guides.

9. Address the limitations of the study's results, particularly their focus on barriers and facilitators at the family level.

Reviewer #2: This is a timely and insightful research related to child development and malnutrition particularly in low and middle income countries. It unearths key findings that are useful for interventions in similar context. It also provides nuanced information given the paucity of qualitative studies on the subject matter. While this is a well written manuscript, some aspects of the paper require revision.

The introductory information that builds up argument for the study appear limited. For instance, what is severe acute malnutrition (SAM)?, What does psychosocial stimulation entail and/or what are its components?. The introduction section can improve with a bit more information to better ground the study.

The study was guided by the nurturing care framework (NCF) by the WHO. Data was organized and synthesized using this framework. However, the framework has only been summarized without being thoroughly reviewed. For instance, what are its strengths or otherwise?, why was it the best option for this study and not some other framework out there?

Then again, what do the five components of the NCF mean. When you refer to ‘good health’ or ‘adequate nutrition’ etc , what does this mean for your study. In effect, if the framework was thoroughly reviewed, it will clear all doubts and help one see if findings reflect what you set out to do.

You state how caregivers were sampled (purposively). How were professionals sampled? How did you decide which professional to interview or were all professionals within the context of interest interviewed?

Under the results section, on page 10 you provide a quote from a professional on the wellbeing of the caretaker. Linking this to the comment above about how dearth the explanation of the NCF framework is , it becomes unclear exactly who the focus of the component of ‘good health’ is for. If the components are well explained, then it will be easier to link or see the barriers to promoting PS for children in SAM.

On the component of ‘security and safety’ on page 15, it is stated that there was limited discussion on psychological stress. Can a brief reason be given since the study’s focus is on PS?

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Reviewer #1: No

Reviewer #2: No

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PONE-D-23-11475R1Developing a context-relevant psychosocial stimulation intervention to promote cognitive development of children with severe acute malnutrition in Mwanza, TanzaniaPLOS ONE

Dear Dr. Olsen,

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.

Kindly review your manuscript based on the comments of the reviewer and return your manuscript within two weeks to facilitate further processing of same.

Please submit your revised manuscript by May 10 2024 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,

Engelbert A. Nonterah, MD, PhD

Academic Editor

PLOS ONE

Journal Requirements:

Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

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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 #2: All comments have been addressed

Reviewer #3: (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 #2: Yes

Reviewer #3: Yes

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

Reviewer #2: N/A

Reviewer #3: Yes

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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 #2: Yes

Reviewer #3: No

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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 #2: Yes

Reviewer #3: 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 #2: The paper makes a valuable contribution to global health research and provides nuanced insights into using psychosocial stimulations to improve the well being and health outcomes of children in poor resourced countries.

The introduction of the paper has been restructured making it clearer and concise. There is less use of acronyms and this has boosted clarity.

The methods used have now been clearly explained and details the framework (NCF) that was used to analyze the data. Also good to see some reflexivity on the part of authors and research participants, as this allows for transparency.

There is also an insightful engagement with the findings in addition to providing contextual information removing any ambiguities. An outline of limitations has made the paper more focused. Bar one or two grammatical omissions, the paper is robust enough to be published.

Reviewer #3: Manuscript title: Developing a context-relevant psychosocial stimulation intervention to promote cognitive development of children with severe acute malnutrition in Mwanza, Tanzania

COMMENTS

I read the manuscript with keen interest. Overall, it is of relevance and well written. It also followed a scientific structure. Data management and analysis was done appropriately. Verbatim translation of recordings was done and this would ensure originality of contents. The coding process as described was thorough and the application of thematic content analysis was appropriate. A reliable tool (Dedoose) was used for the data processing/analysis. However, the authors’ statement on data availability gives an indication that access to data to supplement the manuscript is highly restrictive.

The framework used has to be illustrated clearly to relate well with the results and discussions. The results should be clearly presented to reflect the framework. The discussions should also reflect same. For instance, it was surprising that the authors mentioned “social”, “environmental” and “familial" factors in their discussion. These were not indicated anywhere in the results and methods section where the framework was mentioned.

Below are some other comments for consideration.

Study design and setting

• A brief description of the ‘BrightSAM (Brain development, growth and health in children with SAM) trial development study’ would help. Otherwise, it could be cited that this has been described elsewhere (e.g. reports, protocol, etc.).

• Sentence construction in line 135: It should be “exploring the views and experiences of a range "of" caregivers. The second "of" is missing.

• The framework used (Nurturing Care Framework) should be elaborated further to illustrate how the barriers and facilitators interact with the five components (good health, adequate nutrition, responsive caregiving, opportunities for early learning, and security and safety). Also, I suggest the framework is given a section/sub-section with a clear heading to make it more visible in the manuscript.

• In terms of flow, the description of the study setting as in line 149-160 could be moved to the beginning of the sub-section (study design and setting).

Participant selection and data collection

• The authors mentioned that “sampling was done with assistance from healthcare staff from the nutrition unit at BMC”. It would be clearer if this is elaborated a little further. How did the health staff help? What role did they play? Did they play a role in recruitment of the participants? If they played a role in recruitment, this could have influenced caregivers’ responses to questions relating to the health facility and caregiver. In that case, using the healthcare staff to recruit participants could introduce response biases which could be a limitation of the study. Such a limitation is worth mentioning in the manuscript.

• The number of interviews by category should be indicated. Also, an explanation of how such numbers were arrived at would be useful.

Results

• Is it possible to know how many participants were from the NGO and how many were healthcare workers? This should have also been addressed in the participant selection section.

• From the way the results are presented, the perspectives on suggestions and recommendations do not clearly standout. They are mixed with issues that came up in the perspectives on barriers and facilitators making it difficult for a reader to follow. Perhaps a separate heading could be created for suggestions and recommendations.

• In the summary (as indicated in the framework), it is not clear whether all the recommendations were perspectives of the study participants or they were based on the authors’ objectivity based on their analysis.

Discussions

• Line 436-468: the authors said “Our results demonstrate social, environmental and familial factors….”. From the results section, which of the factors are categorized as social, environmental and familial factors? This should be made clear either in the results section or in the discussion.

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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: Aaron Kampim

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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.

Developing a context-relevant psychosocial stimulation intervention to promote cognitive development of children with severe acute malnutrition in Mwanza, Tanzania

PONE-D-23-11475R2

Dear Dr. Mette F Olsen,

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.

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Kind regards,

Engelbert A. Nonterah, MD, PhD

Academic Editor

PLOS ONE

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