High acceptability of newborn screening for sickle cell disease among post-natal mothers in Western Kenya

John Orimbo; Shehu Shagari Awandu; Faith Muhonja; Patrick Owili; Dickens Omondi

doi:10.1371/journal.pone.0305156

Peer Review History

Original SubmissionMay 25, 2024
Decision Letter - Ibrahim Sebutu Bello, Editor Dear Dr. Orimbo, 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 Sep 27 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. 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'. 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If your ethics statement is written in any section besides the Methods, please move it to the Methods section and delete it from any other section. Please ensure that your ethics statement is included in your manuscript, as the ethics statement entered into the online submission form will not be published alongside your manuscript. 6. 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 If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references.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 If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice. [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? Reviewer #1: Yes Reviewer #2: Yes ******** 2. Has the statistical analysis been performed appropriately and rigorously? -->?> Reviewer #1: Yes Reviewer #2: Yes ****** 3. Have the authors made all data underlying the findings in their manuscript fully available??> The PLOS Data policy Reviewer #1: No Reviewer #2: No ****** 4. Is the manuscript presented in an intelligible fashion and written in standard English??> Reviewer #1: Yes Reviewer #2: Yes ****** Reviewer #1: well written manuscript. Some comments: - 1. Introduction- Could you highlight the national government newborn screening policy on SCD? This is referenced in the methods and discussion section. 2. Its likely the data are clustered around the study facility. Its important to provide the geographical location of the participants - the data shown in the discussion under limitations 'with each subcounty contributing at least 5% of the 369 total sample has not been provided. 3. Consider dropping this phrase 'at Homabay County Teaching and Referral Hospital, western Kenya' to improve readability 4. Consider dropping figure 1 as it does not add much value 5. What informed the questions on acceptability? They seem narrow focusing on beliefs. There might be other key aspects of acceptability that these narrowly focused questions would not evaluate. its also not clear how responses to these questions could inform improved acceptability in other areas. 6. Screening Barriers: Could you comment on why, despite high acceptance and knowledge of SCD screening, the majority of the mothers reported not having been screened? What could be the barriers to screening that would need specific recommendations? 7. was the effect of clustering in time and space explored in this study 8 The discussion needs to be revised to be succinct and clear-- a maximum of two pages 9. Read the paper to correct grammar and appropriate punctuations Reviewer #2: Summary The authors assessed acceptability of newborn screening for Sickle Cell disease among 399 post-natal mothers at Homa Bay county hospital in western Kenya. They focused on assessing level of acceptability as a step in the pathway towards programmatic scale up of newborn screening. Mothers who chose to participate were consented and interviewed using a structured questionnaire and their newborns were screened using Sickle SCAN point-of-care test. Acceptability of screening was high at 94%. Being a student was associated with a higher likelihood of accepting screening. The authors recommended that Homabay county and the Kenyan ministry of health should implement routine newborn screening for sickle cell disease in all level 2-6 hospitals. General Comment The manuscript is clearly written and addresses an important topic. It could however benefit from some edits. Authors should pay particular attention to data analysis and interpretation of results on factors associated with acceptability screening. Abstract 1. Methods (Line 21-27): It is not clear whether potential participants were empowered with information on the benefits of screening newborns for SCD before being invited to make an informed choice to enroll in the study. 2. Conclusion (Line 35-36): The second sentence is directive and not fully supported by the results. Why all level 2-6 hospitals? Consider editing this sentence to improve its clarity. Background It is stated that the prevalence of sickle cell disease and sickle cell trait in western Kenya is 4.5% and 18%, respectively. Please specify age band for reported estimates. Methods It is stated that Minor mothers also were provided with a signed assent… edit this to improve clarity. Specify what was done. Assented and signed an assent form or assented verbally and someone else signed a consent form on their behalf? There are no details of how mothers with no prior knowledge on sickle disease were empowered with information to make informed choice about participating in the study is missing. Consider editing to include the missing information. Line 127: To is misplaced within the sentence: Consider deleting. Results Line 191: Replace “belived” with believed. The confidence intervals for some estimates are uncomfortably wide thus undermining the utility of some results. Please review. E.g. line 32-33: being a student (aOR= 25.02; 95% CI=1.29-484.51; p= 0.033). Table 5: 1. Review choice of reference group for population categories in table 5. 2. The authors have only used 4 variables to check associations based on chi square tabulations instead of using all the variables in the unadjusted model to determine those to be used in adjusted model. 3. Overall, the very wide confidence intervals may undermine the practical applications of results touching on the predictors acceptability. ****** 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: Yes: Peninah Munyua 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 https://doi.org/10.1371/journal.pone.0305156.r001
Revision 1
11 Feb 2025 Author Response 1. Introduction- Could you highlight the national government newborn screening policy on SCD? This is referenced in the methods and discussion section. Response: This has been added to the abstract to read, “The Kenyan ministry of health, in 2020, published a policy on newborn screening for sickle cell disease from levels 2 to 6 healthcare facilities.” 2. Its likely the data are clustered around the study facility. Its important to provide the geographical location of the participants - the data shown in the discussion under limitations 'with each subcounty contributing at least 5% of the 369 total sample has not been provided. Response: This has now been provided in the table 1 of the results section under the sociodemographic characteristics of the participants 3. Consider dropping this phrase 'at Homabay County Teaching and Referral Hospital, western Kenya' to improve readability Response: This has been dropped in all other parts except the abstract where it is retained to explain the study setting 4. Consider dropping figure 1 as it does not add much value Response: Figure one has been dropped 5. What informed the questions on acceptability? They seem narrow focusing on beliefs. There might be other key aspects of acceptability that these narrowly focused questions would not evaluate. its also not clear how responses to these questions could inform improved acceptability in other areas. Response: The questions were largely informed by the review of literature on the previous studies on the factors that have influenced user acceptability especially at user level and guided by the theoretical framework of acceptability. Other factors like access and provider attitude which affect majorly concurrent acceptability were not explored in this study since newborn screening is not yet implemented in the county. 6. Screening Barriers: Could you comment on why, despite high acceptance and knowledge of SCD screening, the majority of the mothers reported not having been screened? What could be the barriers to screening that would need specific recommendations? Response: This has been added to the discussion section on paragraph 3 to read, “Further, despite the high acceptance and good knowledge on screening for sickle cell disease among the postnatal mothers who were interviewed, only few of the mothers had been screened for sickle cell disease. This was mainly due to the fact that routine screening for sickle cell disease has not been adopted in the county, and including among newborns, and thus only those with symptoms of sickle cell disease are tested or screened for the disease.” 7. was the effect of clustering in time and space explored in this study Response: No, this was not explored 8 The discussion needs to be revised to be succinct and clear-- a maximum of two pages Response: This has been revised 9. Read the paper to correct grammar and appropriate punctuations Response: Grammar and punctuations have been corrected across the paper. Reviewer #2: Summary The authors assessed acceptability of newborn screening for Sickle Cell disease among 399 post-natal mothers at Homa Bay county hospital in western Kenya. They focused on assessing level of acceptability as a step in the pathway towards programmatic scale up of newborn screening. Mothers who chose to participate were consented and interviewed using a structured questionnaire and their newborns were screened using Sickle SCAN point-of-care test. Acceptability of screening was high at 94%. Being a student was associated with a higher likelihood of accepting screening. The authors recommended that Homabay county and the Kenyan ministry of health should implement routine newborn screening for sickle cell disease in all level 2-6 hospitals. General Comment The manuscript is clearly written and addresses an important topic. It could however benefit from some edits. Authors should pay particular attention to data analysis and interpretation of results on factors associated with acceptability screening. Abstract 1. Methods (Line 21-27): It is not clear whether potential participants were empowered with information on the benefits of screening newborns for SCD before being invited to make an informed choice to enroll in the study. Response: All the potential participants were taken through written informed consent prior to participation. The informed consent had both the risks and benefits of participation in the study, including of doing screening for sickle cell disease on the newborn, and this were adequately explained to the participant prior. Only participants who were willing after being taken through the informed consent signed the consent and were subsequently enrolled. This thus met the threshold of adequate informed to allow them make an informed decision. This has been added to the abstract to read, “After obtaining informed consent, a semi-structured questionnaire was used for data collection.” 2. Conclusion (Line 35-36): The second sentence is directive and not fully supported by the results. Why all level 2-6 hospitals? Consider editing this sentence to improve its clarity. Response: This has been revised to read, “The Homabay county ministry of health should implement routine newborn screening for sickle cell disease in all health care facilities conducting deliveries of newborns”. This is since the study was conducted among post delivery mothers, it can be extrapolated for all healthcare facilities conducting deliveries across the county. Background It is stated that the prevalence of sickle cell disease and sickle cell trait in western Kenya is 4.5% and 18%, respectively. Please specify age band for reported estimates. Response: This statement has been revised to read, “The prevalence of sickle cell disease around western Kenya at birth is about 4.5% for sickle cell disease, and 18% for sickle cell trait” Methods It is stated that Minor mothers also were provided with a signed assent… edit this to improve clarity. Specify what was done. Assented and signed an assent form or assented verbally and someone else signed a consent form on their behalf? Response: This has been edited to read, “Written informed consent was obtained from potential participants who were 18years and above. A written informed assent was obtained from minor mothers (those less than 18 years and lacking legal capacity to consent on their own) in addition to a written consent from their parents or guardians.” There are no details of how mothers with no prior knowledge on sickle disease were empowered with information to make informed choice about participating in the study is missing. Consider editing to include the missing information. Response: This information was provided to the mothers through the informed consent and assent and has now been added to read, “Written informed consent was obtained from potential participants who were 18years and above. A written informed assent was obtained from minor mothers (those less than 18 years and lacking legal capacity to consent on their own) in addition to a written consent from their parents or guardians. The informed consents and assents were adequate details on sickle cell disease and their participation in the study, and also on risk and benefits of participation. This was made so in order to provide the potential participants with adequate prior information for making an informed decision before signing the informed consent or assent.” Line 127: To is misplaced within the sentence: Consider deleting. Response: This has been deleted Results Line 191: Replace “belived” with believed. Response: The spelling has been corrected to believed. The confidence intervals for some estimates are uncomfortably wide thus undermining the utility of some results. Please review. E.g. line 32-33: being a student (aOR= 25.02; 95% CI=1.29-484.51; p= 0.033). Response: This has been reviewed Table 5: 1. Review choice of reference group for population categories in table 5. Response: This has been reviewed 2. The authors have only used 4 variables to check associations based on chi square tabulations instead of using all the variables in the unadjusted model to determine those to be used in adjusted model. Response: Only the variables that had a statistically significant association with the acceptability of newborn screening for sickle cell disease were moved to unadjusted model to determine the strength of association thus only 4 variables moved. 3. Overall, the very wide confidence intervals may undermine the practical applications of results touching on the predictors acceptability. Response: This has been reviewed upon review of the choice of reference group Attachments Attachment Submitted filename: RESPONSE TO REVIEWERS.docx https://doi.org/10.1371/journal.pone.0305156.r002
Decision Letter - Abiola Olukayode Olaleye, Editor Dear Dr. Orimbo, Overall, it is a well written manuscript. Kindly consider a minor revision of the manuscript based on the following comments: Introduction - Are there no studies in literature on acceptability of newborn screening at all? You may please consider and review articles such as the article by “Nnachi OC et. Acceptability of Newborn Screening for Sickle Cell Disease among Post-Partum Mothers in Abakaliki, South East Nigeria. West Afr J Med. 2023 Mar 31;40(3):298-304. PMID: 37017939.” And other related literature. Methods – Line 117 - Did you obtain assent from children? Assent is not the same as consent. Your manuscript implies they are similar. Please clarify what you did. Assent is usually obtained from minors, and consent from adults. Methods – Line 131 – 133. There’s need to describe the government policy in a section in the initially under methods. Methods – Linie 181 - Assent is not the same as consent. Discussion – Line 314 – 425. Please revise the discussion section. Kindly write this section in a systematic, focused manner. i. Start with a Summary of Key Findings (May be 2-3 key findings). ii. Interpret the Findings. iii. Compare with Existing Literature. Iv. Explain the Strengths and Limitations. v. Discuss Implications for Practice or Policy. vi. Offer Recommendations or Future Research Directions. vii.Write a clear conclusion. While most elements of the discussion are present in the Discussion Section in its present form, the discussion section will benefit from a re-organisation. In addition, the authors are also advised to address the peer reviewer's comments below: "Summary The authors assessed acceptability of newborn screening for Sickle Cell disease among 399 post-natal mothers at Homa Bay county hospital in western Kenya. They focused on assessing level of acceptability as a step in the pathway towards programmatic scale up of newborn screening. Mothers who chose to participate were consented and interviewed using a structured questionnaire and their newborns were screened using Sickle SCAN point-of-care test. Acceptability of screening was high at 94%. Being a student was associated with a higher likelihood of accepting screening. The authors recommended that Homabay county and the Kenyan ministry of health should implement routine newborn screening for sickle cell disease in all level 2-6 hospitals. General Comment The manuscript is clearly written and addresses an important topic. It could however benefit from some edits. Authors should pay particular attention to data analysis and interpretation of results on factors associated with acceptability screening. Abstract 1. Methods (Line 21-27): It is not clear whether potential participants were empowered with information on the benefits of screening newborns for SCD before being invited to make an informed choice to enroll in the study. 2. Conclusion (Line 35-36): The second sentence is directive and not fully supported by the results. Why all level 2-6 hospitals? Consider editing this sentence to improve its clarity. Background It is stated that the prevalence of sickle cell disease and sickle cell trait in western Kenya is 4.5% and 18%, respectively. Please specify age band for reported estimates. Methods It is stated that Minor mothers also were provided with a signed assent… edit this to improve clarity. Specify what was done. Assented and signed an assent form or assented verbally and someone else signed a consent form on their behalf? There are no details of how mothers with no prior knowledge on sickle disease were empowered with information to make informed choice about participating in the study is missing. Consider editing to include the missing information. Line 127: To is misplaced within the sentence: Consider deleting. Results Line 191: Replace “belived” with believed. The confidence intervals for some estimates are uncomfortably wide thus undermining the utility of some results. Please review. E.g. line 32-33: being a student (aOR= 25.02; 95% CI=1.29-484.51; p= 0.033). Table 5: 1. Review choice of reference group for population categories in table 5. 2. The authors have only used 4 variables to check associations based on chi square tabulations instead of using all the variables in the unadjusted model to determine those to be used in adjusted model. 3. Overall, the very wide confidence intervals may undermine the practical applications of results touching on the predictors acceptability." Please submit your revised manuscript by Jun 06 2025 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. 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 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, Abiola Olukayode Olaleye, MBBS, MPH, FWACP 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. [Note: HTML markup is below. Please do not edit.] Reviewers' comments: Reviewer's Responses to Questions Comments to the Author Reviewer #2: All comments have been addressed ******** 2. Is the manuscript technically sound, and do the data support the conclusions??> Reviewer #2: Yes ****** 3. Has the statistical analysis been performed appropriately and rigorously? -->?> Reviewer #2: Yes ****** 4. Have the authors made all data underlying the findings in their manuscript fully available??> The PLOS Data policy Reviewer #2: Yes ****** 5. Is the manuscript presented in an intelligible fashion and written in standard English??> Reviewer #2: Yes ****** Reviewer #2: (No Response) ****** 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 ******** [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 https://doi.org/10.1371/journal.pone.0305156.r003
Revision 2
11 Jun 2025 Author Response Introduction - Are there no studies in literature on acceptability of newborn screening at all? You may please consider and review articles such as the article by “Nnachi OC et. Acceptability of Newborn Screening for Sickle Cell Disease among Post-Partum Mothers in Abakaliki, South East Nigeria. West Afr J Med. 2023 Mar 31;40(3):298-304. PMID: 37017939.” And other related literature. Response: Thank you for the input. However, the introduction reads. “There is however, paucity of data on the acceptability of newborn screening in the county” This implies there has not been any study previous assessing acceptability in Homa bay county. We however acknowledge that several studies have been done across sub-Saharan Africa on acceptability of newborn screening for sickle cell disease. Methods – Line 117 - Did you obtain assent from children? Assent is not the same as consent. Your manuscript implies they are similar. Please clarify what you did. Assent is usually obtained from minors, and consent from adults. Response: Consent was obtained from adult mothers. For minor mothers, they signed an assent and their parent or guardian signed the consent. This has now been clarified. Methods – Line 131 – 133. There’s need to describe the government policy in a section in the initially under methods. Response: Thank you. The policy has been explained under the introduction section. Methods – Linie 181 - Assent is not the same as consent. Response: Thank you, this has been clarified. Discussion – Line 314 – 425. Please revise the discussion section. Kindly write this section in a systematic, focused manner. i. Start with a Summary of Key Findings (May be 2-3 key findings). ii. Interpret the Findings. iii. Compare with Existing Literature. Iv. Explain the Strengths and Limitations. v. Discuss Implications for Practice or Policy. vi. Offer Recommendations or Future Research Directions. vii.Write a clear conclusion. While most elements of the discussion are present in the Discussion Section in its present form, the discussion section will benefit from a re-organisation. Response: This has been revised appropriately as guided. In addition, the authors are also advised to address the peer reviewer's comments below: "Summary The authors assessed acceptability of newborn screening for Sickle Cell disease among 399 post-natal mothers at Homa Bay county hospital in western Kenya. They focused on assessing level of acceptability as a step in the pathway towards programmatic scale up of newborn screening. Mothers who chose to participate were consented and interviewed using a structured questionnaire and their newborns were screened using Sickle SCAN point-of-care test. Acceptability of screening was high at 94%. Being a student was associated with a higher likelihood of accepting screening. The authors recommended that Homabay county and the Kenyan ministry of health should implement routine newborn screening for sickle cell disease in all level 2-6 hospitals. General Comment The manuscript is clearly written and addresses an important topic. It could however benefit from some edits. Authors should pay particular attention to data analysis and interpretation of results on factors associated with acceptability screening. Abstract 1. Methods (Line 21-27): It is not clear whether potential participants were empowered with information on the benefits of screening newborns for SCD before being invited to make an informed choice to enroll in the study. Response: The potential participants were provided with the information through the informed consent documents which they were taken through by a research assistant in a language of their choice before making informed decision to enrol. The information included benefits of screening the newborn, result interpretation, linkages to care and possible risks of participation in the study. 2. Conclusion (Line 35-36): The second sentence is directive and not fully supported by the results. Why all level 2-6 hospitals? Consider editing this sentence to improve its clarity. Response: This has been edited to read, “The acceptability of newborn screening for sickle cell disease is high in the county. The Homabay county ministry of health should implement routine newborn screening for sickle cell disease in all healthcare facilities conducting deliveries of newborns.” Background It is stated that the prevalence of sickle cell disease and sickle cell trait in western Kenya is 4.5% and 18%, respectively. Please specify age band for reported estimates. Response: This has been clarified to read, “The prevalence of sickle cell disease around western Kenya at birth is about 4.5% for sickle cell disease, and 18% for sickle cell trait.” Methods It is stated that Minor mothers also were provided with a signed assent… edit this to improve clarity. Specify what was done. Assented and signed an assent form or assented verbally and someone else signed a consent form on their behalf? There are no details of how mothers with no prior knowledge on sickle disease were empowered with information to make informed choice about participating in the study is missing. Consider editing to include the missing information. Response: This has been added in the methods section under the sub topic enrolment and data collection, lines 184-193 Line 127: To is misplaced within the sentence: Consider deleting. Response: This was deleted. Results Line 191: Replace “belived” with believed. Response: This was updated accordingly The confidence intervals for some estimates are uncomfortably wide thus undermining the utility of some results. Please review. E.g. line 32-33: being a student (aOR= 25.02; 95% CI=1.29-484.51; p= 0.033). Response: This was reviewed to “(aOR= 0.04; 95% CI=0.00-0.78; p= 0.033)” after re-analysis Table 5: 1. Review choice of reference group for population categories in table 5. Reviewed: This has been reviewed. 2. The authors have only used 4 variables to check associations based on chi square tabulations instead of using all the variables in the unadjusted model to determine those to be used in adjusted model. Response: All the variables were subject ton test of association using either chi-square or fisher’s exact, where criteria for chi-square was not met. Only the variables that had an association with acceptability of newborn screening for sickle cell disease were subjected with univariate logistic regression (unadjusted model) in order to determine the strength of association thus not all variables were used for the unadjusted model. This was as per the approved protocol statistical analysis plan. 3. Overall, the very wide confidence intervals may undermine the practical applications of results touching on the predictors acceptability." Response: upon re-analysis, the confidence intervals are now much better. However, this can be attributed to slightly smaller sample size even though our sample size was larger than the calculated sample size. Attachments Attachment Submitted filename: Response to Reviewers John.docx https://doi.org/10.1371/journal.pone.0305156.r004
Decision Letter - Abiola Olukayode Olaleye, Editor High acceptability of newborn screening for sickle cell disease among post-natal mothers in western Kenya PLOS ONE Dear Dr. Orimbo, 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 revise the title of the manuscript as follows and resubmit: *"High Acceptability of Newborn Screening for Sickle Cell Disease Among Post-Natal Mothers in Western Kenya"* Please submit your revised manuscript by Aug 18 2025 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, Abiola Olukayode Olaleye, MBBS, MPH, FWACP 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. 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 https://doi.org/10.1371/journal.pone.0305156.r005
Revision 3
4 Jul 2025 Author Response The title has been updated to read, "High Acceptability of Newborn Screening for Sickle Cell Disease Among Post-Natal Mothers in Western Kenya "as was suggested Attachments Attachment Submitted filename: Response_to_reviewers_auresp_3.docx https://doi.org/10.1371/journal.pone.0305156.r006
Decision Letter - Abiola Olukayode Olaleye, Editor High acceptability of newborn screening for sickle cell disease among post-natal mothers in western Kenya PONE-D-24-20006R3 Dear Dr. Orimbo, 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 will be generated when your article is formally accepted. Please note, if your institution has a publishing partnership with PLOS and your article meets the relevant criteria, all or part of your publication costs will be covered. Please make sure your user information is up-to-date by logging into Editorial Manager at Editorial Manager® and clicking the ‘Update My Information' link at the top of the page. If you have any questions relating to publication charges, 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, Abiola Olukayode Olaleye, MBBS, MPH, FWACP Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0305156.r007
Formally Accepted
Acceptance Letter - Abiola Olukayode Olaleye, Editor PONE-D-24-20006R3 PLOS ONE Dear Dr. Orimbo, 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 You will receive further instructions from the production team, including instructions on how to review your proof when it is ready. Please keep in mind that we are working through a large volume of accepted articles, so please give us a few days 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. Abiola Olukayode Olaleye Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0305156.r008

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