PONE-D-24-01288Identifying and prioritising barriers to injury care in Northern Malawi, results of a multifacility multidisciplinary health facility staff surveyPLOS ONE

Dear Dr. Whitaker,

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Novel N. Chegou, Ph.D

Academic Editor

PLOS ONE

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Reviewers' comments:

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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

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

Reviewer #1: Yes

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

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

Reviewer #1: Yes

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Reviewer #1: Yes

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5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: The authors report on the results of a survey of health care workers, primarily, from several health care centers in Malawi. A total of 228 workers, mostly clinicians, were asked about barriers that lead to delays in either seeking, reaching, or receiving injury (trauma) care. Overall, the manuscript is very well written with minimal need for editing (see below single comment). However, the results are not surprising, given the population interviewed, and mirror those of other surveys from sub-Saharan Africa. As mentioned by the authors, there are key differences between centers that likely influence the prioritization given to the questions posed. For example, the faith-based facilities required payment for services, making this a much more significant barrier for patients, but could lead to better resource availability due to reduced demand and higher revenue. As a result of pooling all the responses together, the authors likely suppressed any key differences in barriers to care seeking and delivery that may exist between care delivery models. The analysis would be more informative if it was analyzed by site type. Public vs Military vs Private (faith-based). Or if that is not possible, at least by level, so that responses at the tertiary facility are looked at separate from the “front line” facilities.

While the perspectives of the care providers were argued to also reflect the views of the patients in the communities served, this is not necessarily true. Why weren’t patients surveyed? Were they not also in the facilities that were visited? Having both perspectives and looking at areas of alignment would have been more useful in planning and design of future interventions.

It is human nature to say that you could do a better job if you had more resources (even in HICs), so this too is a significant bias affecting the survey results. While it is simple to say the facilities lack human and supply resources and this is perceived as easily addressable, the reality of creating a sustainable change in any health care related resource is far from simple. Thus, it is of interest to know how these providers felt this could be easily achieved? What is it they needed that was easily implemented? Again, this is key to making the reported information useful in future efforts to improve care in the region. From the data presented in figure 6, the lack of transport to a facility for care stands out, with multiple orange bars essentially highlighting the cost and availability of transport as a major barrier. From the time data, about half seem to get care within 2 hours, but the remaining half face much longer delays, and this is perceived as being very harmful. Thus, the greatest impact on the greatest number would seem to be getting patients to the care that is available, and not necessarily changing the care that is delivered in under an hour for most, based on the data. This conclusion would seem to be at odds with the current conclusions of the manuscript. “Health facility staff priorities should inform health system improvements, although specific findings may differ between health systems and from the priorities of community members and patients.” One could argue, alternatively, in a resource limited environment, the greatest good for the greatest number should, perhaps, drive policy.

While some of the biases and influences on the results are part of the discussion throughout, the formal limitation paragraph is underdeveloped and should include a concise summary of the biases and limitations of the approach taken. What were limits on analysis? Why did you consolidate so many categories into dichotomous groups? Presumably there were some key limitations to the analyses that were the bases for this and should be addressed. If the above suggested analyses can’t be performed, then this should also be addressed.

As presented, the results and discussion do not provide a foundation or direction for future efforts to impact the care delivery in the region. Presumably the purpose for this work was to identify barriers that could be addressed. Thus, consolidating some of the discussion to focus on the key results and the implications for future efforts to impact care would be welcome changes in the manuscript.

One typo noted on page 14: I think you may want to change “meaningful” to “meaningfully”

“…offers an expeditious way to meaningful improve the system of care they work within…”

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Reviewer #1: No

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PONE-D-24-01288R1Identifying and prioritising barriers to injury care in Northern Malawi, results of a multifacility multidisciplinary health facility staff surveyPLOS ONE

Dear Dr. Whitaker,

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 Aug 29 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,

Novel N Chegou, Ph.D

Academic Editor

PLOS ONE

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

Additional Editor Comments:

The reviewer has identified additional important concerns regarding the figures - color scheme and quality, and figure legends. Please attend to these and other issues pointed out by the reviewer.

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

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

Reviewer #1: All comments have been addressed

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2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

**********

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

Reviewer #1: N/A

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

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

Reviewer #1: Yes

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

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

**********

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 the primary concerns raised by the initial review. A few minor edits should be made prior to publication. Regarding the figures, Figures 1 and 6 should use the same colors to represent the given delays. It is noted that figure titles are provided within the text, presumably as place holders for figure location, but these should also have figure legends to support interpretation of the figure as a stand-alone presentation of the data. Key findings should be noted in the legend and any significant differences upon which statistical analysis was performed should be highlighted. This latter aspect may not be relevant for the figures in this manuscript, but may be relevant to any supplemental data and figures. Finally the image quality seems low, this is a consistent problem for the default graphic outputs of Microsoft office applications. Check to be sure exports of images are at least 600 DPI which will require some manual adjustment of these output settings.

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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

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While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

Identifying and prioritising barriers to injury care in Northern Malawi, results of a multifacility multidisciplinary health facility staff survey

PONE-D-24-01288R2

Dear John

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Novel N. Chegou, Ph.D

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

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