Implementation of antimicrobial stewardship programs: A study of prescribers’ perspective of facilitators and barriers

Emelda E. Chukwu; Dennis Abuh; Ifeoma E. Idigbe; Kazeem A. Osuolale; Vivian Chuka-Ebene; Oluwatoyin Awoderu; Rosemary A. Audu; Folasade T. Ogunsola

doi:10.1371/journal.pone.0297472

Peer Review History

Original SubmissionSeptember 8, 2023
24 Oct 2023 Decision Letter - Mabel Kamweli Aworh, Editor PONE-D-23-27149Implementation of antimicrobial stewardship programs: a study of prescribers’ perspective of facilitators and barriersPLOS ONE Dear Dr. Chukwu, 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 Dec 08 2023 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, Mabel Kamweli Aworh, DVM, MPH, PhD. FCVSN Academic Editor PLOS ONE Journal Requirements: When submitting your revision, we need you to address these additional requirements. 1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. 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[Note: HTML markup is below. Please do not edit.] Reviewers' comments: Reviewer's Responses to Questions Comments to the Author 1. Is the manuscript technically sound, and do the data support the conclusions? The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented. Reviewer #1: Partly Reviewer #2: Partly ******** 2. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: No Reviewer #2: Yes ****** 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: 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: No 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: 1. General comment: This topic is key in the fight against AMR and the authors are commended for the efforts. However, I strongly suggest that the authors read through the entire manuscript for corrections of some grammatical errors. 2. Abstract a. In the methods, I suggest you use “focus group discussion” instead of “focused group discussion”. b. In the methods, no clear details on the analysis of the quantitative data. c. In the results, you may write “thirty” or “30” instead of “thirty (30)”. d. Regarding the means, having stated the mean and standard deviation, there may be no need to still state the range. Range is used as the measure of dispersion for skewed data while standard deviation is used as the measure of dispersion for data with normal distribution. e. The use of AMS in the results was not defined. The authors may have to write it out in full as was done in the conclusion. f. Having defined ASPs, there should be consistency in its use rather than writing in full as seen in the last sentence of the conclusion. 3. Introduction a. Define AMR in its first use before continuing with the abbreviation. b. Having defined ASPs, there should be consistency in its use rather than writing in full again. c. In page 3, LMICs should be stated in the first paragraph before its continuous use. 4. Methods a. In the methods, I suggest you use “focus group discussion” instead of “focused group discussion”. b. Under the “Study Design and Sampling Technique”, some details on the analysis of the qualitative data should be moved to the data analysis subsection of the methods. c. The authors stated in the results section that 20 participants were interviewed for the qualitative component of the study. Were these key informant interviews or FGDs? If they were FGDs, how many FGDs were conducted and what was the number of participants per FGD? Or were all 20 participants included in one FGD? 5. Results a. Take note of 2c and 2d above. b. The results should be reported in past tense. See example from the results section - “About one-half of the participants either do not have or are not sure if there exists an antimicrobial stewardship team in their facility while 28% were members of their facility stewardship team” 6. Discussion a. The authors made a good attempt to discuss their results. 7. References a. About half of the references are more than 5 years old. I recommend that the authors add more recent references (within the last 5 years). Reviewer #2: This work is so important, particularly as Nigeria is implementing NAP. The study will make a great contribution. However, there are issues that need to be considered and are highlighted below. There are valuable questions about the methods and results that need to be addressed to give this readers that insight that is required for this valuable study. Abstract…… programs and interventions in one sentence side-by-side …..creating awareness and training and inadequate personnel respectively “not clear”. OBSERVE PUNCTUATION MARKS. Which are the facilitators, and which are the barriers. That needs to clearly come out in your abstract. ……”resource-poor” and not resource poor Introduction ….”emergence and transmission of AMR in Nigeria” change to “transmission of AMR genes among disease pathogens”. Antimicrobial resistance doesn’t seem to be transmitted. It’s the genes that are the problem. Change ….”low-and-middle” to ….”low- and middle-income….” That isn’t one word Methods…. …..”antibiotic- related” change to antibiotic-related ….”faith- based” change to faith-based What ethical issues could be anticipated from this study and how were these issues addressed? How many FGDs were conducted and do the authors think the number of FGDs were sufficient? How about conducting In-depth interviews with these stakeholders? Could that had given better perspective to this study? What software was used for the qualitative coding and analysis? ……”SPSS version 26.0For…..” Change to ………….SPSS version 26.0. For…………. Results ……”About one-half”……..Correct to “About half” Is there anything like two-half??? 68% is about two-third and not about one-half, kindly correct!!! What the authors described as facilitators are suggested approaches to improve AMS rather than facilitators!! Correct the title to reflect appropriately what is reflected by the results!! The entire barrier section has not supporting quotes! Why?? What is the difference between the recommended strategies and facilitators as captured in the study?? ****** 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. Attachments Attachment Submitted filename: Comments for review AMS paper.docx https://doi.org/10.1371/journal.pone.0297472.r001
Revision 1
9 Nov 2023 Author Response Reviewer #1 S/N Reviewer’s comments Authors response 1 General comment: This topic is key in the fight against AMR and the authors are commended for the efforts. However, I strongly suggest that the authors read through the entire manuscript for corrections of some grammatical errors. Thank you for taking time out to review our manuscript. The authors have read through the manuscript and corrected grammatical errors 2 Abstract a. In the methods, I suggest you use “focus group discussion” instead of “focused group discussion”. b. In the methods, no clear details on the analysis of the quantitative data. c. In the results, you may write “thirty” or “30” instead of “thirty (30)”. d. Regarding the means, having stated the mean and standard deviation, there may be no need to still state the range. Range is used as the measure of dispersion for skewed data while standard deviation is used as the measure of dispersion for data with normal distribution. e. The use of AMS in the results was not defined. The authors may have to write it out in full as was done in the conclusion. f. Having defined ASPs, there should be consistency in its use rather than writing in full as seen in the last sentence of the conclusion. Done! A statement of the quantitative data analysis approach used has been added. Corrected This has been corrected as mean and standard deviation. This has now been written in full at its first appearance. Done! 3 3. Introduction a. Define AMR in its first use before continuing with the abbreviation. b. Having defined ASPs, there should be consistency in its use rather than writing in full again. c. In page 3, LMICs should be stated in the first paragraph before its continuous use. Done Done Done 4 4. Methods a. In the methods, I suggest you use “focus group discussion” instead of “focused group discussion”. b. Under the “Study Design and Sampling Technique”, some details on the analysis of the qualitative data should be moved to the data analysis subsection of the methods. c. The authors stated in the results section that 20 participants were interviewed for the qualitative component of the study. Were these key informant interviews or FGDs? If they were FGDs, how many FGDs were conducted and what was the number of participants per FGD? Or were all 20 participants included in one FGD? Corrected The analysis details have been moved to the data analysis section. 20 participants volunteered and participated in the focus group discussions. Two FDGs were conducted comprising of 10 participants each. This has been clarified 5 5. Results a. Take note of 2c and 2d above. b. The results should be reported in past tense. See example from the results section - “About one-half of the participants either do not have or are not sure if there exists an antimicrobial stewardship team in their facility while 28% were members of their facility stewardship team” Done Done 6 6. Discussion a. The authors made a good attempt to discuss their results. Thank you 7 7. References a. About half of the references are more than 5 years old. I recommend that the authors add more recent references (within the last 5 years). Some more recent references have been added Reviewer #2: This work is so important, particularly as Nigeria is implementing NAP. The study will make a great contribution. However, there are issues that need to be considered and are highlighted below. There are valuable questions about the methods and results that need to be addressed to give these readers that insight that is required for this valuable study. S/N Reviewer’s comments Authors response 1 Abstract…… programs and interventions in one sentence side-by-side …..creating awareness and training and inadequate personnel respectively “not clear”. OBSERVE PUNCTUATION MARKS. Which are the facilitators, and which are the barriers. That needs to clearly come out in your abstract. ……”resource-poor” and not resource poor Done. This has been rephrased for clarity. Done 2 Introduction ….”emergence and transmission of AMR in Nigeria” change to “transmission of AMR genes among disease pathogens”. Antimicrobial resistance doesn’t seem to be transmitted. It’s the genes that are the problem. Change ….”low-and-middle” to ….”low- and middle-income….” That isn’t one word Done Done 3 Methods…. …..”antibiotic- related” change to antibiotic-related ….”faith- based” change to faith-based What ethical issues could be anticipated from this study and how were these issues addressed? How many FGDs were conducted and do the authors think the number of FGDs were sufficient? How about conducting In-depth interviews with these stakeholders? Could that had given better perspective to this study? What software was used for the qualitative coding and analysis? ……”SPSS version 26.0For…..” Change to ………….SPSS version 26.0. For…………. Done Done Ethical clearance for human subject participation to conduct this study was obtained from the NIMR Institutional Review Board. However, participants were informed of their right to either participate or decline to participate in the study and only participants who gave their informed consent by signing the written consent form were included in the study. Two sets of FGDs were conducted with 10 participants in each set. One set was conducted with medical doctors and another set was conducted with pharmacists. Participation in the FGDs was voluntary. The FGDs had proper representation of participants based on demographics (Gender, age,) type of practice (public, private), range of experiences (early career, mid-career and advanced career clinicians and pharmacists) and the numbers of specialist in each group (10) providing unique and vast knowledge. The FGDs ended when the participants did not provide new or additional data as the same thematic areas were being re-emphasized and re-explained. This information has been included in the methods section (Focus Group Discussion) FGDs and In-depth interviews both offer unique advantages for qualitative research. However, for the purpose of this study, we aimed to gather individual stakeholders for a collaborative discussion on issues around implementing ASPs rather than individual perspective. In addition, participants were vocal, and understood the thematic focus and provided comprehensive discussions, rich understanding of the study context. Data analysis was done manually by a team of qualitative research experts and the processes has been explained in the data analysis section. Done 4 Results ……”About one-half”……..Correct to “About half” Is there anything like two-half??? 68% is about two-third and not about one-half, kindly correct!!! What the authors described as facilitators are suggested approaches to improve AMS rather than facilitators!! Correct the title to reflect appropriately what is reflected by the results!! The entire barrier section has not supporting quotes! Why?? What is the difference between the recommended strategies and facilitators as captured in the study?? Done Thank you, the participants responded based on the question asked about factors that could facilitate antimicrobial stewardship. The response documented were the first-hand accounts of what they believed were the factors that will motivate prescribers and healthcare facilities to engage in antimicrobial stewardship. However, we recognize that some participant-identified facilitators also featured/doubled as recommendations hence the implicated themes have now been moved to and discussed under recommendations. Supporting quotes have been added to this section. The respondents provided insights on the facilitators of AMS which are factors that the respondents believed would favour, motivate, or help individual prescribers as well as healthcare facilities to engage in a rational prescription of antibiotics while also recommending approaches for effective ASP implementation. Attachments Attachment Submitted filename: Response to reviewers.docx https://doi.org/10.1371/journal.pone.0297472.r002
29 Nov 2023 Decision Letter - Mabel Kamweli Aworh, Editor PONE-D-23-27149R1Implementation of antimicrobial stewardship programs: a study of prescribers’ perspective of facilitators and barriersPLOS ONE Dear Dr. Chukwu, 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 13 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, Mabel Kamweli Aworh, DVM, MPH, PhD. FCVSN 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: In response to the reviewer's comments kindly address the following issues; 1. Please provide additional quotes for facilitators of AMS. For each of the points raised, kindly provide at least two quotes from the FGD. Only one point "Having specialized and dedicated Teams" was supported by one quote. 2. Also provide at least two quotes for each barrier to the uptake of stewardship programs as provided by the respondents during the FGD. As it currently stands each point has one supporting quote. Kindly provide one additional quote to the one already provided for clarity and consistency please. 3. Once an acronym/abbreviation has been defined upon it's first use, it is expected that you use the acronym in the rest of the manuscript. For instance AMR has been defined previously so kindly correct page 22 line 3 "lack of data on antimicrobial resistance" to "lack of data on AMR". Please fix this issue wherever it occurs in the manuscript. Also check for consistency with other abbreviations used. This applies to AMS and antimicrobial stewardship. So kindly fix this as well all through the manuscript. [Note: HTML markup is below. Please do not edit.] Reviewers' comments: Reviewer's Responses to Questions Comments to the Author 1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation. Reviewer #1: All comments have been addressed Reviewer #2: All comments have been addressed ******** 2. Is the manuscript technically sound, and do the data support the conclusions? The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented. Reviewer #1: (No Response) Reviewer #2: Partly ****** 3. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: (No Response) Reviewer #2: No ****** 4. Have the authors made all data underlying the findings in their manuscript fully available? The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified. Reviewer #1: (No Response) Reviewer #2: 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 #1: (No Response) Reviewer #2: No ****** 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: (No Response) Reviewer #2: I still don't understand the reason for leaving out the quotes for some of the facilitation. The author(s) did not adequately address the issue of barriers. I have stated that the barriers identified by the author(s) did not align with the quotes and read more like suggestions to improvement. Again, I am wondering if the framework was used to develop a discussion guide because if you begin to ask questions until respondents began to repeat their responses then I wonder of there wad and FGD guide and if it was followed. Why did the authors decide to leave recommendations in table and the others in full writing? ****** 7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files. If you choose “no”, your identity will remain anonymous but your review may still be made public. Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy. Reviewer #1: No Reviewer #2: No ******** [NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.] While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step. https://doi.org/10.1371/journal.pone.0297472.r003
Revision 2
22 Dec 2023 Author Response S/N Editorial comments Author’s response 1. Please provide additional quotes for facilitators of AMS. For each of the points raised, kindly provide at least two quotes from the FGD. Only one point "Having specialized and dedicated Teams" was supported by one quote. Additional quotes have been provided for the facilitators with at least two quotes per listed facilitator Also provide at least two quotes for each barrier to the uptake of stewardship programs as provided by the respondents during the FGD. As it currently stands each point has one supporting quote. Kindly provide one additional quote to the one already provided for clarity and consistency please. One additional quote has been provided for the barriers with at least two quotes per listed barrier Once an acronym/abbreviation has been defined upon it's first use, it is expected that you use the acronym in the rest of the manuscript. For instance AMR has been defined previously so kindly correct page 22 line 3 "lack of data on antimicrobial resistance" to "lack of data on AMR". Please fix this issue wherever it occurs in the manuscript. Also check for consistency with other abbreviations used. This applies to AMS and antimicrobial stewardship. So kindly fix this as well all through the manuscript. Done! The defined terms have been replaced with acronyms all through the manuscript. Reviewer #2: . Thank you for your review comments I still don't understand the reason for leaving out the quotes for some of the facilitation Quotes have been provided for all the facilitators and barrier initially without quotes and additional quotes added to the existing with a target of two quotes per listed factor The author(s) did not adequately address the issue of barriers. I have stated that the barriers identified by the author(s) did not align with the quotes and read more like suggestions to improvement. The authors presented respondents identified barriers and perceived challenges to the effective implementation of ASP in their various facilities which was summarized under 5 themes. We have added additional quotes to provide more context to their stated barriers. We also want to mention that majority of the facilities (except one facility) did not have a standard antimicrobial stewardship program, rather had stewardship teams operating at various levels and the respondents discussed their perceived facilitators and barriers to implementation of a stewardship program in their facilities. Most of the responses were context specific for a resource poor setting. This has been stated in the limitation section Again, I am wondering if the framework was used to develop a discussion guide because if you begin to ask questions until respondents began to repeat their responses then I wonder of there wad and FGD guide and if it was followed. The FDG was conducted using a semi-structured interview guide which is provided as a supplementary material (S2) with probes to allow flexibility for the respondents provide in-depth insight on emerging themes and sub-themes and also exploring new ideas with follow-up questions until no new information is being provided Why did the authors decide to leave recommendations in table and the others in full writing? The Use of tables for the recommendations allowed for a more detailed presentation of the identified themes and sub-themes and their supporting quotes However, the implication of all identified facilitators and barriers as well as recommendations were further discussed in context and in comparison, with the quantitative data in the discussion session Attachments Attachment Submitted filename: Response to reviewers comments_2nd revision.docx https://doi.org/10.1371/journal.pone.0297472.r004
8 Jan 2024 Decision Letter - Mabel Kamweli Aworh, Editor Implementation of antimicrobial stewardship programs: a study of prescribers’ perspective of facilitators and barriers PONE-D-23-27149R2 Dear Dr. Chukwu, 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, Mabel Kamweli Aworh, DVM, MPH, PhD. FCVSN Academic Editor PLOS ONE Additional Editor Comments (optional): Reviewers' comments: Reviewer's Responses to Questions Comments to the Author 1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation. Reviewer #1: All comments have been addressed Reviewer #2: All comments have been addressed ******** 2. Is the manuscript technically sound, and do the data support the conclusions? The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented. Reviewer #1: (No Response) Reviewer #2: Yes ****** 3. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: (No Response) Reviewer #2: Yes ****** 4. Have the authors made all data underlying the findings in their manuscript fully available? The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified. Reviewer #1: (No Response) Reviewer #2: Yes ****** 5. Is the manuscript presented in an intelligible fashion and written in standard English? PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here. Reviewer #1: (No Response) Reviewer #2: Yes ****** 6. Review Comments to the Author Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters) Reviewer #1: (No Response) Reviewer #2: The manuscript looks good but with only one recommendation. "Facilitators" should be changed to "potential facilitators" because they would be facilitators if they are implemented but currently, they are not based on the responses and quotes that are presented at the moment. The authors need to review the manuscript in accordance with the PLOS ONE guidelines and then it will be good. ****** 7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files. If you choose “no”, your identity will remain anonymous but your review may still be made public. Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy. Reviewer #1: No Reviewer #2: No ******** https://doi.org/10.1371/journal.pone.0297472.r005
Formally Accepted
11 Jan 2024 Acceptance Letter - Mabel Kamweli Aworh, Editor PONE-D-23-27149R2 PLOS ONE Dear Dr. Chukwu, I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now being handed over to our production team. At this stage, our production department will prepare your paper for publication. This includes ensuring the following: * All references, tables, and figures are properly cited * All relevant supporting information is included in the manuscript submission, * There are no issues that prevent the paper from being properly typeset If revisions are needed, the production department will contact you directly to resolve them. If no revisions are needed, you will receive an email when the publication date has been set. At this time, we do not offer pre-publication proofs to authors during production of the accepted work. Please keep in mind that we are working through a large volume of accepted articles, so please give us a few weeks to review your paper and let you know the next and final steps. Lastly, 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 customercare@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. Mabel Kamweli Aworh Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0297472.r006

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