Screening and treatment practices for iron deficiency in anaemic pregnant women: A cross-sectional survey of healthcare workers in Nigeria

Ochuwa Adiketu Babah; Lenka Beňová; Claudia Hanson; Ajibola Ibraheem Abioye; Elin C. Larsson; Bosede Bukola Afolabi

doi:10.1371/journal.pone.0310912

Peer Review History

Original SubmissionMarch 13, 2024
2 Jun 2024 Decision Letter - Hanna Landenmark, Editor PONE-D-24-09943Screening and treatment practices for iron deficiency anaemia during pregnancy: a cross-sectional survey of healthcare workers in NigeriaPLOS ONE Dear Dr. Babah, 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 see the comments of two reviewers below. In addition, please include the full ethics statement in the Methods section, and please ensure that you have reported all covariates and confounding variables. Please submit your revised manuscript by Jul 17 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. 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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 ****** 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: Is it "Screening and treatment practices for IDA during pregnancy among ANC visitors or among anaemic pregnant mothers?" Clearly state and write it from the result and discussion sections depending on your aim. You state various keywords even more than the recommended. You used abbreviations/acronyms at the abstract section. Show clearly how you calculated sample size. Why do you consider an attrition rate of 30%? How much is the recommendation? Put your operational definitions. More nurses/midwives (81.1%) compared to doctors (47.4%) reported lack of laboratory facilities for not screening for iron deficiency in anaemic pregnant women. Compared to doctors, a significantly higher percentage of nurses/midwives reported that they do not prescribe any treatment. Do you consider any knowledge and attitude issue in addition to referral practice? Why do you concern in low usage of intravenous iron than oral iron? Reviewer #2: Thorough background research on the state of maternal health care workforce in Nigeria. Good job by the research team. More specific references for those values of the population of maternal healthcare professionals would be better. ****** 6. 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Revision 1
17 Jun 2024 Author Response TO THE EDITOR 1. Thank you for your guidance. Ethics statements have been moved from the section on declaration to the section on ethical consideration in the methodology (Page 13, lines 287-299). 2. Manuscript has also been checked to ensure all covariates and confounding variables are reported. 3. A response letter to the reviewers’ comments, a marked copy of the manuscript (tracked), and a clean copy of the manuscript have been uploaded to portal. 4. We do not have plans to make any change to the financial disclosure. 5. We did not find a need to publish the protocol for this study since it is not laboratory-based research. However, to enhance reproducibility of the research, we have extensively described how the research was conducted in the Methods section, and also include the complete survey questionnaire and informed consent form in the appendix. 6. The journal style is well noted. We have gone through the entire manuscript to ensure that the style is in order. Revisions have been made where necessary. These include recommended symbol labels for authorship (Page 1, lines 4 and 5) and use of email only for corresponding author (Page 1, lines 15-20). In addition, we have ensured that all titles and sub-titles have the recommended fonts, and that tables, figures and supplementary information files, tables and figures are presented and labelled according to the journal requirements. 7. We have deposited the dataset for this study in Open Science Framework. The data is accessible at: https://osf.io/ybcdq/ 8. Thank you for bringing forth an observation on the need to cite the source of the map in Figure 1. The previous image was created using an editable map obtained from a colleague. Unfortunately, we could not trace the source. So, we have now created a new map of Nigeria, showing the two states where the study was conducted, on Microsoft Excel. The facility for generating map on Excel spreadsheet is powered by Bing © Microsoft OpenStreetMap and has been cited in Figure 1, with the date the map was created indicated (Figure 1). 9. In addition to the newly added reference the map (above), we have added one new reference (Reference 28) in-text in the methodology and to the reference list while expanding the section on sample size (Page 6, lines 128-130, and Page 28, lines 653-655 respectively). We have also cross-checked to ensure all references are correctly cited. TO REVIEWER #1 (1) Is it "Screening and treatment practices for IDA during pregnancy among ANC visitors or among anaemic pregnant mothers?" Clearly state and write it from the result and discussion sections depending on your aim. RESPONSE Thank you for this observation. The title has been revised to enhance clarity and in accordance with the study objectives, the results and discussion. We have changed it from “Screening and treatment practices for iron-deficiency anaemia during pregnancy: a cross-sectional survey of healthcare workers in Nigeria” to “Screening and treatment practices for iron-deficiency in anaemic pregnant women: a cross-sectional survey of healthcare workers in Nigeria” (Page 1, lines 1-3).This has also been aligned with the objectives for enhance clarity (Page 2, line 31 under Abstract, and Page 5, line 99 under introduction). (2)You state various keywords even more than the recommended. RESPONSE Thank you for drawing our attention to this. We were unsure of the maximum number of keywords allowed by the journal because we could not access the information, even now. However, we have now reduced the number of keywords from thirteen to eight (Page 3, lines 55-57). The keywords are listed in order of importance, so depending on the maximum allowed by the journal, the first five (for example) can be used if there is a need to reduce further. (3) You used abbreviations/acronyms at the abstract section. RESPONSE Thank you for bringing forth this observation. We were trying to restrict word count to maximum 300 which was the information we had. We have now revised the abstract by writing acronyms/abbreviations in full (Abstract, Page 2, lines 26-46; and Page 3, lines 50-51). The abstract is now 314-words long. We hope this is fine. We also just came across another PLOS One guide which says 300 words preferred by journal but maximum 500 words acceptable for abstracts. (4) Show clearly how you calculated sample size. RESPONSE Thank you. Details of sample size calculation has been added to the appropriate section under Methodology (Page 6, lines 124-141, and page 7, lines 142-152). (5) Why do you consider an attrition rate of 30%? How much is the recommendation? RESPONSE Thank you for this question. Generally, in clinical research, 10-20% is often used to adjust for attrition during sample size calculation. To the best of our knowledge there is no benchmark. Considering that this is a survey of health workers, we decided to use a higher value to adjust for non-response to improve our sample size for the following reasons: (i) Surveys are generally prone to higher rate of attrition compared to other forms of clinical research, and (ii) a previous study found that doctors are less likely to respond to surveys compared to patients (53% vs. 70%, p <0.05) irrespective of the mode of administering the survey and that average response rate for in-person surveys is 76%.1 (iii) When attrition is above 20% in a study, the risk of bias increases.2 To minimize these potential issues, we decided to adjust the sample size calculation for non-response of 30%. Reference 1. Meyer VM, Benjamens S, Moumni ME, Lange JFM, Pol RA. Global Overview of Response Rates in Patient and Health Care Professional Surveys in Surgery: A Systematic Review. Annals of Surgery. 2022;275(1):e75-e81. 2. Dumville JC, Torgerson DJ, Hewitt CE. Reporting attrition in randomised controlled trials. Bmj. 2006;332(7547):969-71. (6) Put your operational definitions. RESPONSE Thank you. This has been added to the methods section (Page 10, lines 234-236, and page 11, lines 237-251). (7) More nurses/midwives (81.1%) compared to doctors (47.4%) reported lack of laboratory facilities for not screening for iron deficiency in anaemic pregnant women. Compared to doctors, a significantly higher percentage of nurses/midwives reported that they do not prescribe any treatment. Do you consider any knowledge and attitude issue in addition to referral practice? RESPONSE Thank you for this question. Yes, knowledge may be relevant in explaining this; generally, doctors have better exposure and thus knowledge regarding treatment of medical conditions. The curriculum for training doctors is more elaborate than that of the nurses. So, knowledge can partly explain why nurses are less likely to use the laboratory or prescribe treatment compared to doctor. We are not quite certain if attitude can play a role. Rather, health facility policies might contribute. Policies differ from facility to facility. Some health facilities may permit doctors to screen and treat certain conditions but not the nurses. Some of these comments not previously captured in the discussion have been added to the section (Page 23, lines 504-506). (8) Why do you concern in low usage of intravenous iron than oral iron? RESPONSE Thank you. For this study, there is no specific concern. This is one of the sub-studies for my (lead author) doctoral research. The main study was a randomized controlled trial which evaluated the effectiveness of intravenous iron (ferric carboxymaltose) and oral iron (ferrous sulphate) for the treatment of iron deficiency anaemia during pregnancy. So, we were interested in knowing more about the usage rate of intravenous iron in Nigeria. TO REVIEWER #2 Thorough background research on the state of maternal health care workforce in Nigeria. Good job by the research team. More specific references for those values of the population of maternal healthcare professionals would be better. RESPONSE Thank you for this comment. Indeed, it would have been great if we were able to do so. Unfortunately, we tried to get data directly from the Medical and Dental Council of Nigeria for doctors, and Nurses and Midwifery Council of Nigeria for the nurses but did not succeed. So, we had to rely on available data. There is also no online source from which we could retrieve these data. Attachments Attachment Submitted filename: RESPONSE TO REVIEWERS - 17-06-2024.docx https://doi.org/10.1371/journal.pone.0310912.r002
9 Sep 2024 Decision Letter - Blessing Akombi-Inyang, Editor Screening and treatment practices for iron deficiency in anaemic pregnant women: a cross-sectional survey of healthcare workers in Nigeria PONE-D-24-09943R1 Dear Dr. Babah, 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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If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation. Reviewer #1: All comments have been addressed Reviewer #3: 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 Reviewer #3: Yes ****** 3. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: Yes Reviewer #3: 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 #3: 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 #3: 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: Thanks, all comments have addressed based on the comments i provided. so i have no concern if it will be accepted Reviewer #3: (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: Moges Tadesse Abebe Reviewer #3: No ******** https://doi.org/10.1371/journal.pone.0310912.r003
Formally Accepted
19 Sep 2024 Acceptance Letter - Blessing Akombi-Inyang, Editor PONE-D-24-09943R1 PLOS ONE Dear Dr. Babah, 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. Blessing Akombi-Inyang Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0310912.r004

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