The effects of school-based hygiene intervention programme: Systematic review and meta-analysis

Sophia Rasheeqa Ismail; Ranina Radzi; Puteri Sofia Nadira Megat Kamaruddin; Ezarul Faradianna Lokman; Han Yin Lim; Nusaibah Abdul Rahim; Hui Yin Yow; Daarshini Arumugam; Alex Ngu; Annie Ching Yi Low; Eng Hwa Wong; Sapna Patil; Priya Madhavan; Ruslin Bin Nordin; Esther van der Werf; Nai Ming Lai

doi:10.1371/journal.pone.0308390

Peer Review History

Original SubmissionApril 17, 2024
6 May 2024 Decision Letter - Muhammad Shahzad Aslam, Editor PONE-D-24-15555The effects of school-based hygiene intervention programme: Systematic Review and Meta-AnalysisPLOS ONE Dear Dr. Ismail 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 Jun 20 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. 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We note that this manuscript is a systematic review or meta-analysis; our author guidelines therefore require that you use PRISMA guidance to help improve reporting quality of this type of study. Please rename the completed PRISMA checklist as Supporting Information with a file name “PRISMA checklist”. 4. 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 If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references.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 If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.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: 1. Various studies show diverse approaches in how interventions are designed, implemented, and evaluated, impacting the applicability of findings. It's crucial to address this variability in the main text. 2. Poor documentation and reporting practices obscure a clear understanding of research outcomes, underscoring the importance of addressing this issue within the main text. 3. Focusing solely on interventions within school settings may overlook valuable insights from community-based studies. Integrating a brief acknowledgment of this in the main text could enhance the comprehensiveness of the analysis. 4. Any deviations from standard practices, like excluding key stakeholders such as schoolteachers or narrowing the scope, can potentially compromise the integrity and completeness of the study. This warrants further explanation within the main text. 5. Methodological limitations contribute to overall uncertainty, highlighting the necessity for additional research endeavors. Elaborating on these limitations within the main text can underscore the imperative for future investigations. [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: Yes Reviewer #2: Yes Reviewer #3: Yes ******** 2. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: Yes Reviewer #2: Yes Reviewer #3: Yes ****** 3. Have the authors made all data underlying the findings in their manuscript fully available? 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Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here. Reviewer #1: Yes Reviewer #2: Yes Reviewer #3: Yes ****** 5. Review Comments to the Author Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters) Reviewer #1: The authors have done a comprehensive study and have provided a clear discussion about their findings. However, some clarifications are needed to clarify about their study. Some of the clarifications needed are: 1) Suggest for the authors to clearly mention the types of college that they have taken into the inclusion criteria (Line 120) 2) The justification in the exclusion criteria for not including healthcare-related colleges is rather weak. Can the authors elaborate why they have excluded this criteria? 3) Why authors considered self-reported causes documentation as part of their study? This type of documentation is exposed with self-claimed of one's health status to avoid from attending classes. 4) For Line 137, antibiotics prescription is only applicable for bacterial infection. Have the authors considered about viral infections as well? 5) For Line 150, how did authors deal with any manuscripts that were not written in English or the authors' mother-tongue? 6) For Line 177, on what basis that a manuscript was being judged as 'Low', 'Some concerns' etc? Any criteria during this judgement process? Reviewer #2: I would like to express my gratitude to the authors for your comprehensive and insightful systematic assessment of the effects of school-based hygiene intervention programmes. Your study sheds light on the effectiveness of such interventions, with major implications for practice and future research. Reviewer #3: The research titled “The effects of school-based hygiene intervention programme: Systematic Review and Meta-Analysis” General comments: 1. The review encompasses 39 trials from 22 countries, offering a comprehensive assessment of global school-based hygiene interventions. 2. Meta-analysis suggests hand-body and genital hygiene interventions improve knowledge, attitudes, and practices, reducing infection-related absenteeism among school children. 3. Rigorous methodologies, including risk-of-bias assessment and certainty-of-evidence ratings, ensure reliable and applicable findings. Addressing the following comments: 1. High variation in intervention design, duration, and assessment methods across studies limits generalizability. In this regard, there is a need to explain in the main text. 2. Inadequate documentation and reporting hinder comprehensive understanding of results. In this context, there is a need to explain in the main text. 3. Focusing solely on school-based interventions may overlook relevant community studies. In this context, there is a need to add 1-2 sentences in the main text. 4. Deviations, such as excluding schoolteachers and narrowing scope, may affect completeness. In this context, there is a need to explain in the text. 5. Overall, certainty remains low due to methodological limitations, emphasizing the need for further research. In this regard, there is a need to elaborate in the main text. Report: After addressing the suggested comments, this paper can be published in PLOS ONE. ****** 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: Yes: MUHAMAD AFIQ FAISAL BIN YAHAYA Reviewer #2: No Reviewer #3: Yes: Vetriselvan Subramaniyan ******** [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. 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Revision 1
19 Jun 2024 Author Response Dear Reviewers, Thank you for your thorough and insightful comments on our manuscript. We appreciate the time and effort you have invested in reviewing our work. We have carefully considered each of your suggestions and have made the following revisions in response to your feedback. With this revision, we have submitted the following documents: 1. Our revised manuscript with track changes labelled as ‘Revised Manuscript With Tracked Changes’ 2. Our revised manuscript without track changes labelled as ‘Manuscript’ JOURNAL REQUIREMENTS: 1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. Thank you for your comment. We have thoroughly reviewed PLOS ONE's style requirements and ensured that our manuscript now adheres to all specified guidelines. Specifically file naming, formatting (includes font type, size and line spacing), and reference format. 2. We note that Figure 3 in your submission contain map images which may be copyrighted. All PLOS content is published under the Creative Commons Attribution License (CC BY 4.0), which means that the manuscript, images, and Supporting Information files will be freely available online, and any third party is permitted to access, download, copy, distribute, and use these materials in any way, even commercially, with proper attribution. For these reasons, we cannot publish previously copyrighted maps or satellite images created using proprietary data, such as Google software (Google Maps, Street View, and Earth). For more information, see our copyright guidelines: http://journals.plos.org/plosone/s/licenses-and-copyright. Thank you for bringing this to our attention. We would like to clarify that the image included in Figure 3 is not copyrighted. It was created by our team based on our research findings using the free version of the software tool Canva (https://www.canva.com/), which is available for such purposes. The image was generated specifically to represent our findings accurately and does not use any proprietary data. Furthermore, we confirm that this image can be freely used by future authors, promoting continued research and collaboration in the field. We have ensured that it complies with the Creative Commons Attribution License (CC BY 4.0). Please refer Figure 3. 3. We note that this manuscript is a systematic review or meta-analysis; our author guidelines therefore require that you use PRISMA guidance to help improve reporting quality of this type of study. Please rename the completed PRISMA checklist as Supporting Information with a file name “PRISMA checklist”. Thank you for your comment. We have ensured that our manuscript adheres to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines to enhance the reporting quality of our systematic review and meta-analysis. We have completed the PRISMA checklist and renamed the file as "PRISMA checklist" as per your instructions. This file is included as Supporting Information in our submission. 4. 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. Thank you for your comment. We have thoroughly reviewed our reference list to ensure it is complete and accurate. ADDITIONAL EDITOR COMMENTS: 1. Various studies show diverse approaches in how interventions are designed, implemented, and evaluated, impacting the applicability of findings. It's crucial to address this variability in the main text. Thank you for this remark. We have addressed the variability in the design, implementation, and evaluation of interventions in the Discussion section of the manuscript. We have also elaborated how differences in intervention design, implementation duration, and evaluation methods can influence the outcomes and their comparability across studies. (Please refer to lines 491 – 508) 2. Poor documentation and reporting practices obscure a clear understanding of research outcomes, underscoring the importance of addressing this issue within the main text. Thank you for the query. While we do recognise the importance of clear and thorough documentation and reporting practices in research, we believe that the large majority of the included studies demonstrated detailed methodologies, particularly in the assessment of outcomes. Therefore, poor documentation and reporting practices as a critical issue in this study. Nonetheless, we acknowledge that any instances of poor reporting and documentation of the included studies could impact the reliability of the outcomes and thus necessitate interpretation with caution. (Please refer to lines 509 – 514) 3. Focusing solely on interventions within school settings may overlook valuable insights from community-based studies. Integrating a brief acknowledgment of this in the main text could enhance the comprehensiveness of the analysis. Thank you for your comment. Our research focus on school-based interventions does not undermine the relevance of community-based interventions in child and adolescent health. We acknowledge the importance of community-based studies and their valuable insights. However, we believe that school-based interventions play a pivotal role in the holistic development of school-going children, which is why we have chosen to focus on this aspect in our manuscript. Schools provide a unique environment for child and adolescent development, offering structured settings where they can have positive and supportive interactions. These interactions are crucial for fostering healthy development and establishing long-lasting habits which would lead to better hygiene practices and ultimately resulting in positive health impacts. To address this concern, we have included a brief acknowledgment of the relevance of community-based interventions in the Discussion section of the manuscript. (Please refer to lines 515 – 521) 4. Any deviations from standard practices, like excluding key stakeholders such as schoolteachers or narrowing the scope, can potentially compromise the integrity and completeness of the study. This warrants further explanation within the main text. We acknowledge the importance of including key stakeholders, such as schoolteachers, in studies to ensure comprehensive insights. However, in our systematic review, the included studies did not demonstrate any deviations from standard practices. Thus, we are in belief that this exclusion is not a concern for the integrity and completeness of our current analysis. However, future research should consider the role of schoolteachers and other stakeholders to provide a more comprehensive understanding of intervention impacts. 5. Methodological limitations contribute to overall uncertainty, highlighting the necessity for additional research endeavours. Elaborating on these limitations within the main text can underscore the imperative for future investigations. We agree that methodological limitations contribute to overall uncertainty and that it is crucial to elaborate on these within the main text to underscore the need for future research. We have added a detailed discussion of methodological limitations, including issues related to study design, sample size, intervention implementation, and outcome measurement in the Discussion section. (Please refer to lines 522 – 536) RESPONSES TO COMMENTS BY REVIEWER 1: 1. Suggest for the authors to clearly mention the types of college that they have taken into the inclusion criteria (Line 120) Thank you for your suggestion. We have revised the manuscript to clearly specify the types of colleges included and excluded in our study. (Please refer to lines 123 – 125). 2. The justification in the exclusion criteria for not including healthcare-related colleges is rather weak. Can the authors elaborate why they have excluded this criteria? Thank you for your comment. We appreciate the opportunity to clarify our exclusion criteria. Healthcare students, such as those studying nursing, medicine, or other health-related fields, are not representative of the general population or typical school-aged children for several reasons. Firstly, healthcare students receive extensive education and training in hygiene practices and the prevention of infections as part of their curriculum. Thus this prior knowledge significantly influences their hygiene behaviours and practices, making their baseline levels of knowledge and practices different from those of the general student population. Secondly, healthcare students are also go through hygiene and infection control training throughout their curriculum and are required to have a higher standard of hygiene practices as compared to the general student population. And lastly, as the overall aim of this review is to evaluate the effectiveness of hygiene intervention programs among typical school-aged children, the inclusion of the healthcare students would skew the results of our study as their knowledge and practices are not representative of the general population. 3. Why authors considered self-reported causes documentation as part of their study? This type of documentation is exposed with self-claimed of one's health status to avoid from attending classes. We included self-reported causes of absenteeism in our study to ensure a comprehensive understanding of the impact of school-based hygiene interventions. Many illnesses, such as acute gastroenteritis, often resolve without formal medical treatment through home remedies or over-the-counter solutions. Excluding self-reported cases would result in significant underreporting of these instances, leading to a biased and incomplete picture of school absenteeism. Repeated reports from the same student also enhance the reliability of self-reported data. While we acknowledge that some self-reported absences might be due to reasons other than illness, such as avoiding classes, these instances are likely minimal. Schools typically have mechanisms to detect patterns of absenteeism due to non-medical reasons, ensuring that our data primarily reflect genuine health-related absenteeism. By considering both medically documented and self-reported causes, we aim to capture the full spectrum of absenteeism and better assess the effectiveness of hygiene interventions. 4. For Line 137, antibiotics prescription is only applicable for bacterial infection. Have the authors considered about viral infections as well? Thank you for your comment. Yes, viral infections have been considered in our study, as reflected under the same point. We recognise that mild viral infections are often treated at home with home remedies or over-the-counter medications to alleviate symptoms. In cases where the viral infection is severe, it would typically be medically documented, as the students would seek medical treatment or be hospitalised. Our analysis accounts for both scenarios, ensuring a comprehensive understanding of absenteeism due to various types of pathogens, whether it is bacterial, viral, fungal or parasites. Additional information has been added to the sentence; “The types of infections included respiratory infections (characterised by symptoms such as sore throats, coughs, asthma, and influenza-like illness), gastrointestinal infections (characterised by symptoms such as diarrhoea and vomiting), and unspecified infections requiring prescription of antibiotics or other treatments.” (Please refer to lines 134 – 140) 5. For Line 150, how did authors deal with any manuscripts that were not written in English or the authors' mother-tongue? We did not employ any language restrictions during selection of relevant articles in this review. Some articles had abstracts in dual languages. If we encounter any manuscripts not written in English or the author's mother-tongue, we will arrange for their translation. For example, we would have sought for translation assistance, ensuring that all relevant studies are accessible and included in our analysis. However, none of the potentially included articles (from full text screening) were written in a language other than English. Thus exclusion based on language was not performed. 6. For Line 177, on what basis that a manuscript was being judged as 'Low', 'Some concerns' etc? Any criteria during this judgement process? The risk of bias assessment for our manuscript was conducted using The Revised Cochrane risk-of-bias tool for randomized trials (RoB 2) (Access to tools and guidelines can be found here: https://sites.google.com/site/riskofbiastool/welcome/rob-2-0-tool?authuser=0 ) .This tool evaluates risk of bias across five domains: the randomization process, deviations from intended interventions, missing outcome data, measurement of the outcome, and selection of the reported result. Each domain's risk was assessed based on specific criteria and signalling questions provided in the RoB 2 documentation. Studies were judged as 'Low Risk of Bias' if they met the criteria for low risk in all domains, 'Some Concerns' if there were concerns in at least one domain, and 'High Risk of Bias' if there was high risk in at least one domain or multiple domains with some concerns. Additionally, adjustments were made for specific interventions and circumstances to ensure a fair assessment. These criteria and the judgement process have been elaborated in the "Methods" section of the revised manuscript. (Please refer to lines 182 – 185). RESPONSES TO COMMENTS BY REVIEWER 3: 1. High variation in intervention design, duration, and assessment methods across studies limits generalizability. In this regard, there is a need to explain in the main text. 2. Inadequate documentation and reporting hinder comprehensive understanding of results. In this context, there is a need to explain in the main text. 3. Focusing solely on school-based interventions may overlook relevant community studies. In this context, there is a need to add 1-2 sentences in the main text. 4. Deviations, such as excluding schoolteachers and narrowing scope, may affect completeness. In this context, there is a need to explain in the text. 5. Overall, certainty remains low due to methodological limitations, emphasizing the need for further research. In this regard, there is a need to elaborate in the main text. All of these comments have been responded under the Additional Editors’ Comments section and elaborated with the necessary revisions made in the manuscript. Attachments Attachment Submitted filename: Response to Reviewers_ SR Hygiene.docx https://doi.org/10.1371/journal.pone.0308390.r002
16 Jul 2024 Decision Letter - Muhammad Shahzad Aslam, Editor The effects of school-based hygiene intervention programme: Systematic Review and Meta-Analysis PONE-D-24-15555R1 Dear Dr. Ismail, 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. 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Reviewer #1: Yes 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: Yes 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: Yes 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: The authors have addressed all prior comments by providing comprehensive justifications. Also, the authors have amended the manuscript according to the given justifications. The manuscript is worth to be accepted and published. Reviewer #2: (No Response) ****** 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: Yes: MUHAMAD AFIQ FAISAL BIN YAHAYA Reviewer #2: Yes: Dr.Sreenivasulu Sura ******** https://doi.org/10.1371/journal.pone.0308390.r003
Formally Accepted
24 Jul 2024 Acceptance Letter - Muhammad Shahzad Aslam, Editor PONE-D-24-15555R1 PLOS ONE Dear Dr. Ismail, 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. Muhammad Shahzad Aslam Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0308390.r004

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