Maintaining essential healthcare services in Addis Ababa during COVID-19: A qualitative study

Esete Habtemariam Fenta; Berhan Tassew; Admas Abera; Firmaye Bogale Wolde; Meseret Legesse; Justin Pulford; Siobhan Mor; Mirgissa Kaba

doi:10.1371/journal.pone.0308534

Peer Review History

Original SubmissionSeptember 15, 2023
9 Nov 2023 Decision Letter - Admasu Belay Gizaw, Editor PONE-D-23-27438Sustaining essential healthcare services in Addis Ababa during COVID-19: A qualitative study.PLOS ONE Dear Dr. Woldehanna, 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 24 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. 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Additional Editor Comments: Review results of manuscript entitled ‘sustaining essential healthcare services in Addis Ababa during COVID-19: A qualitative study’. I am happy to review an interesting manuscript. For the better improvements and consideration, I recommended getting a clear answer for the following issues before proceeding to the next process. 1. What about feasibility of this study in relation to the current status of COVID-19 and re-initiation of essential healthcare services. 2. What is the novelty of this study? a) What is already known about the problem? b) What is not known about the problem? c) What is the possible implication/s for practice? 3. What does it mean by sustaining essential healthcare services? 4. What does it mean by health system’s response to maintaining essential healthcare services and sustaining essential healthcare services? 5. What about validity and reliability of the data collection tools? 6. The analysis method is not clear and strong! 7. What are the main findings & conclusion from this study? Result or hypothesis? 8. The study uses the small number of participants; why? 9. What is the relationship between the objective and the result section? 10. The conclusion section is difficult to understand and very crude and vague for understanding. 11. Which citation style the authors used? Clarifying and revision may be helpful. 12. Considering English grammar and language revision is also very important. Author need to clarify the above points via point by point response just before considering the next review [Note: HTML markup is below. Please do not edit.] [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: Review results of sustaining essential healthcare services.docx* https://doi.org/10.1371/journal.pone.0308534.r001
Revision 1
20 Dec 2023 Author Response 12/20/2023 PLOS ONE Dear Editor, We thank you for the opportunity to revise and resubmit this manuscript. We also appreciate constructive comments and recommendations from the reviewer. Below are our responses to the comments from the reviewer and a description of the changes we have made (texts in bullet points and italic font). Reviewer comment 1. What about feasibility of this study in relation to the current status of COVID-19 and re-initiation of essential healthcare services. • The feasibility of this study is reflected in the fact that though COVID-19 is no longer a pandemic, we can use the findings of this study as input for inferring as a learning point to similar public health situations. Additionally, the adaptation strategies identified in this study can be used for emergency preparedness programs and decision-making. This has been described in the conclusion section of the manuscript (lines 494-496). 2. What is the novelty of this study? a) What is already known about the problem? b) What is not known about the problem? c) What is the possible implication/s for practice? • This study is novel because it has studied the less explored effect of COVID-19 on essential health service provision in health facilities of urban settings serving a large number of populations. The context of the study is emphasized in this study to improve the applicability of findings to similar public health situations in relation to essential healthcare services. Thus, it highlights the existing knowledge base on the effect of the pandemic on health systems as a whole and narrows in the specifics of the selected setting and phenomena for future contextualization. This is mainly highlighted in the final paragraph of the background section of the manuscript (line 83-93). 3. What does it mean by sustaining essential healthcare services? • Sustaining essential healthcare services in this study is used to show the provision of uninterrupted essential healthcare services to communities. This is defined in the third paragraph of the background section on line 72-73. Note: we have used the term sustaining and maintaining essential healthcare services interchangeably in this manuscript. To avoid confusion, we have now used the word maintaining throughout. 4. What does it mean by health system’s response to maintaining essential healthcare services and sustaining essential healthcare services? • The concept of the health system’s response to maintaining essential healthcare services indicates actions taken by the different levels/parts of the health sector to ensure the continued provision of health services, where the statement “maintaining essential healthcare services” holds the same meaning. However, as mentioned in the response to the above question, we have used the terms sustaining and maintaining interchangeably, which can be confusing. Hence, to avoid any confusion and to align with documents of the same concept, we have now used uniform wording, i.e., maintaining essential healthcare services. This is shown in the description of the aim of the study in the last sentence of the Background section of the manuscript. 5. What about validity and reliability of the data collection tools? • We pilot-tested interview guides and made the necessary refinements before data collection to ensure the validity and reliability of data collection tool. We’ve included this under Data collection and Procedure (line 125-129). 6. The analysis method is not clear and strong! • We have edited the analysis method for clarity (line 139-151). 7. What are the main findings & conclusion from this study? Result or hypothesis? • The study highlights the effect of COVID-19 on the health system and the health sector's action to ensure the continued provision of essential health services during the pandemic's initial phase. The main findings of this study are summarized in the first paragraph of the discussion. (line 430-442). 8. The study uses small number of participants; why? • We determined the sample size based on the saturation of information. We have clarified this in (line 117-118). 9. What is the relationship between the objective and the result section? • This study was conducted with the aim of exploring the actions taken by the health sector to ensure sustained provision of essential healthcare services during the COVID-19 pandemic. With this study, we were able to highlight the impact of COVID-19 on service utilization and provision. The result also highlighted key adaptation strategies implemented by the health sector to sustain the provision of essential healthcare services and the challenges encountered. These key findings have been reported in the result section and were discussed accordingly. 10. The conclusion section is difficult to understand and very crude and vague for understanding. • We have edited the conclusion section for clarity (line 495-505). 11. Which citation style the authors used? Clarifying and revision may be helpful. • We have used the Vancouver style for citation. Revision to the reference section has been made accordingly. 12. Considering English grammar and language revision is also very important. • We have made edits to the manuscript for English grammar and language. All authors reviewed and edited the manuscript. Attachments Attachment Submitted filename: Response to reveiwers.docx https://doi.org/10.1371/journal.pone.0308534.r002
12 Apr 2024 Decision Letter - Faten Amer, Editor PONE-D-23-27438R1Maintaining essential healthcare services in Addis Ababa during COVID-19: A qualitative study.PLOS ONE Dear Dr. Woldehanna, 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 May 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. 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, Faten Amer, PhD in Health Sciences Academic Editor PLOS ONE Additional Editor Comments: The manuscript under review presents a comprehensive qualitative analysis of the impact of COVID-19 on healthcare service utilization and provision in Addis Ababa, Ethiopia. It meticulously examines the challenges encountered by the healthcare system, encompassing reduced service utilization, provider apprehension, and compromised service quality. Despite notable strengths, such as the inclusion of stakeholders from diverse levels of the healthcare system and the provision of rich qualitative data, the study falls short of meeting several criteria outlined by the COREQ (Consolidated Criteria for Reporting Qualitative Research) checklist. Consequently, the authors are encouraged to address these deficiencies to enhance the rigor and transparency of their study. Domain 1: Research Team and Reflexivity - Interviewer/Facilitator: Interviews were conducted with participants, but details regarding the credentials, occupation, gender, experience, training, and relationship establishment of the interviewers/facilitators remain undisclosed. Domain 2: Study Design - Theoretical Framework: The manuscript lacks explicit reference to a theoretical framework, which is pivotal for contextualizing the study. - Participant Selection: Purposive sampling was employed, yet details regarding the method of approach, sample size, non-participation, setting of data collection, presence of non-participants, and description of the sample are absent. Domain 3: Analysis and Findings - Interview Guide: The development and pilot testing of interview guides are not addressed, which is crucial for ensuring data collection validity. - Data Analysis: Although themes were derived from the data, information regarding the number of data coders, description of the coding tree, software used for analysis, and participant checking is notably absent. Reporting - Quotations Presented: Participant quotations are utilized to illustrate themes/findings, but consistency between data presented and findings, clarity of major and minor themes, and discussion of diverse cases warrant improvement for enhanced clarity and transparency. Conclusion Overall, while the manuscript provides valuable insights into the effects of COVID-19 on healthcare in Addis Ababa, Ethiopia, it is essential for the authors to address the aforementioned deficiencies outlined by the COREQ checklist to strengthen the study's methodological rigor and reporting clarity. By doing so, the manuscript would significantly contribute to the existing literature on pandemic response strategies in healthcare settings, thereby [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: (No Response) ******** 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 ****** 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) ****** 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: I have a few concern and questions on this work: 1. Why are the authors interested to employ only key informant interviews? Why are they interested in interviewing only "highly knowlesgeable" respondents? What does highly knowledgeable even mean? For example let me just use one of your findings to explain my concern. It was found out that discontinuance of service utilization (such as ART follow_up). Were you thinking that the drivers and means of mitigation of such discontinuece is most understood and addressed through the recomendations and ideas of highly knowledgeable health system workers alone? What do you think was the role of discussing with communities or beneficiaries (through indepth interviews and FGDs)? Do not you think missing relevant ideas from such population would have benefited the study? Moreover, do not you think that mitigations and maintainace of essential services are collective and participantory responses whereby community engagement should be manifested in? Hence, I see some limitation on the study design and methods which should be honestly reported in the study. 2. Can you please give a separate section in the methods for "rigor"? Wherein you discuss the main dimensions of trusthworthineass of the study and how you implemented them: crediblity, depedabality, transferrablity, and conformablity Thank you for the great job ****** 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 ******** [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.0308534.r003
Revision 2
29 May 2024 Author Response 5/25/2024 PLOS ONE Dear Editor, We thank you for the opportunity to revise and resubmit this manuscript. We also appreciate constructive comments and recommendations from the reviewer. Below are our responses to the comments from the reviewer and a description of the changes we have made (texts in bullet points and italic font). Editor’s comment Domain 1: Research Team and Reflexivity - Interviewer/Facilitator: Interviews were conducted with participants, but details regarding the credentials, occupation, gender, experience, training, and relationship establishment of the interviewers/facilitators remain undisclosed. - Thank you for your comments. We have included the details of the interviewers in the methods section (line 143-147). Domain 2: Study Design - Theoretical Framework: The manuscript lacks explicit reference to a theoretical framework, which is pivotal for contextualizing the study. - Thank you for the comments. We have used an exploratory study design to guide this study. We have now included the study design in the method section under study design and setting section (line 97-100). - Participant Selection: Purposive sampling was employed, yet details regarding the method of approach, sample size, non-participation, setting of data collection, presence of non-participants, and description of the sample are absent. - Thank you for the comments. We have included the method of approach, sample size, non-participation, setting of data collection, presence of non-participants, and the study size in the method section under Sample size and study participants (line 114-126). Furthermore, the sample description is now included in the first part of the result (line 199-202). Domain 3: Analysis and Findings - Interview Guide: The development and pilot testing of interview guides are not addressed, which is crucial for ensuring data collection validity. - The aspects of interview guide development, components of the guide, pilot testing and changes as a result of pilot testing are addressed in the “Data collection tool and procedure” sections (line 129-138) - Data Analysis: Although themes were derived from the data, information regarding the number of data coders, description of the coding tree, software used for analysis, and participant checking is notably absent. - Thank you for your comments. We have addressed issues of coding in the methods and materials section under data analysis and we have provided description of the coding tree at the beginning of the results section (line 203-108). The software used for analysis is also indicated in the analysis section (line 165). We have now included details of rigor in the Methods and materials section under rigor (line 168-184). Reporting - Quotations Presented: Participant quotations are utilized to illustrate themes/findings, but consistency between data presented and findings, clarity of major and minor themes, and discussion of diverse cases warrant improvement for enhanced clarity and transparency. - Thank you for the important insight. We have indicated the themes and sub-themes to show the major and minor themes and their relationship, we have also included the sources of the quotations to create more clarity and transparency. Reviewers' comments I have a few concern and questions on this work: 1. Why are the authors interested to employ only key informant interviews? Why are they interested in interviewing only "highly knowlesgeable" respondents? What does highly knowledgeable even mean? For example let me just use one of your findings to explain my concern. It was found out that discontinuance of service utilization (such as ART follow_up). Were you thinking that the drivers and means of mitigation of such discontinuece is most understood and addressed through the recomendations and ideas of highly knowledgeable health system workers alone? What do you think was the role of discussing with communities or beneficiaries (through indepth interviews and FGDs)? Do not you think missing relevant ideas from such population would have benefited the study? Moreover, do not you think that mitigations and maintainace of essential services are collective and participatory responses whereby community engagement should be manifested in? Hence, I see some limitation on the study design and methods which should be honestly reported in the study. - Thank you for the valuable comment and insight. We accept that this study would have been more comprehensive if the community’s perspective had been included. Thus, we have put this as a limitation of this study (line 539-540). - With the word “knowledgeable”, we were trying to indicate that the participants possibly had comprehensive information about the effect of COVID-19 and the mitigation strategies and/ or the health system response to sustain the provision of essential healthcare services in their respective departments. Thus, we have removed the term knowledgeable to avoid ambiguity and replaced it with the meaning it portrays (line 114-118). 2. Can you please give a separate section in the methods for "rigor"? Wherein you discuss the main dimensions of trusthworthineass of the study and how you implemented them: crediblity, depedabality, transferrablity, and conformablity Thank you for the great job - We have now created a separate rigor section in the methods and materials and included details about activities conducted to ensure trustworthiness (line 168-184) Attachments Attachment Submitted filename: Response to reveiwers.docx https://doi.org/10.1371/journal.pone.0308534.r004
25 Jul 2024 Decision Letter - Faten Amer, Editor Maintaining essential healthcare services in Addis Ababa during COVID-19: A qualitative study. PONE-D-23-27438R2 Dear Dr. Woldehanna, 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, Faten Amer, PhD in Health Sciences 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 ******** 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 ****** 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) ****** 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) ****** 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) ****** 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 ******** https://doi.org/10.1371/journal.pone.0308534.r005
Formally Accepted
5 Aug 2024 Acceptance Letter - Faten Amer, Editor PONE-D-23-27438R2 PLOS ONE Dear Dr. Woldehanna, 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. Faten Amer Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0308534.r006

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