PONE-D-24-16377A Qualitative Study of Heat Early Weather Warnings for Pregnant Women and Children in Kilifi, KenyaPLOS ONE

Dear Dr. Lusambili,

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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: Partly

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

Reviewer #1: N/A

Reviewer #2: Yes

Reviewer #3: N/A

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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: No

Reviewer #2: No

Reviewer #3: Yes

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4. 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

Reviewer #3: 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: Review comments

General comment

I commend the Authors for conducting the study and the well written manuscript. The study and its findings are of relevance to the community and its inhabitants. Bearing in mind the number of interviews and FGDs that were conducted, perhaps I expected mores quotes in the manuscript.

The dates Internet articles were assessed were not included in the reference section. Also, PLoS ONE makes use of square brackets for reference numbers.

The Authors should also cross-check the length and sub-headings of the abstract section to ensure that it conforms to the guidelines of the Journal.

I recommend that the manuscript be accepted for publication.

Reviewer #2: A strong paper with just a few edits suggested in the attached document.

Reviewer #3: First congratulations to the authors for the well- thought-out paper. The manuscript highlights a critical issue given the increasing recognition of the linkages between climate and health. That said, below are some suggestions to further strengthen the manuscript.

Overall comment

A few reflection issues for the authors:

i) The title of this study is "A Qualitative Study of Heat Early Weather Warnings for Pregnant Women and Children in Kilifi, Kenya". This implies that your primary target population is pregnant women and children. I am struggling with the value that CHVs and Mothers in law bring to your manuscript, since they are not your primary study population, yet their perspectives are given prominence. For instance, the authors first finding on sources of information highlights how CHVs access information. The section on indigenous information highlights how mothers in law access information. Unless these other players (CHVs etc.) are sharing experiences about how pregnant and postpartum women access information, it is not very helpful for this manuscript if they are describing their own experiences. I would suggest the authors prioritize the experiences of pregnant and post-partum women and exclude these other populations. The alternative would be to revise your study title, background and research questions - so that you expand beyond just pregnant and post-partum women, and also include the mothers in law, CHVs, spouses etc.

ii) I also didn't see the value of interviewing male spouses, yet they don't appear anywhere in the findings. They should either be included in the findings or excluded altogether if they don't fit this manuscript.

iii) The title prioritizes pregnant women and children. However, not much in the findings covers children. Also, the findings cover a lot about post-partum women, yet they are missing in the title - Reading the findings, a befitting population for the title would be pregnant and post-partum women, rather than pregnant women and children.

Specific Comments

1. Abstract - The abstract is well written.

2. Introduction: The introduction provides a good summary of the literature, clearly pinpointing the problem addressed through the study.

3. Methods: There are opportunities for the authors to strengthen the methodology so that the study is easily reproducible.

i) The authors introduce the methods used for data collection in their study design, but don't mention their sample size. It would have been helpful to include the number of FGDs and IDI's they conducted in the section where they describe the study design.

ii) The participant recruitment can also be improved. The statement by the authors "Local health facility healthcare workers and certified Community Health Volunteers (CHVs) identified potential interviewees in the communities according to our inclusion and exclusion criteria" is insufficient. What was this inclusion criteria? How big was the catchment area - The two sub-Counties mentioned under study site are vast - Did the study cover the whole sub-County? How many health workers and CHVs did they use for recruitment? How did they narrow down to the CHV or health worker to work with? How many pregnant and postpartum women were within the catchment area? What criteria or procedures did they follow to arrive at the study participant? What sampling approach did the authors use? If the authors can answer these questions, it may help improve their methodology.

iii) The section on interviewing states "pregnant and post-partum women were interviewed during antenatal and

postnatal visits at health facilities as part of their routine appointments". Based on this statement, were they recruited at the household then interviewed at the facility or were they recruited in the facilities? A clarification on this would be helpful for the reader.

4. Findings: I would suggest that the authors prioritize the findings that address the problem highlighted in the background - How heat affects maternal and child health outcomes. Some of the findings, although useful, steer away from this focus and address effects of heat and early warning systems in general.

i) It would be helpful if the authors could provide a table summarizing the participants socio-demographics. This would assist the reader make comparisons across the different groups beyond the summary they have provided.

ii) The authors could provide de-identified summary socio-demographic information to accompany each verbatim quote e.g. (28-year-old CHV, Kaloleni).

iii) Some of the findings such as how CHV's use weather warnings to plan their work doesn't appear a very good fit. Neither is the finding around drought the most ideal given the focus of the manuscript on maternal health outcomes.

5. Discussion: The authors should ensure the discussion is anchored on the findings and avoid introducing issues in the discussion that were not included in the findings. For instance, the gender differences in access to information is first included in the discussion. Same to the issue of women's participation in public meetings.

6. Conclusion: It is also important for the authors to draw conclusions that are relevant to the study population and beyond. For instance, the findings highlighted gaps in access to information through radio and television since some participants did not own these, and low mobile phone ownership, yet conclusions affirm these as the methods to be adopted. I would suggest that the authors relook at their findings when drawing conclusions and stratify their conclusions to the different subgroups.

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Reviewer #1: Yes: EDMUND NDUDI OSSAI

Reviewer #2: Yes: Beth A Tippett Barr

Reviewer #3: No

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Attachments

Attachment

Submitted filename: Review comments.docx

Attachment

Submitted filename: Review_Kilifi_HeatWarnings.docx

Community Perspectives of Heat and Weather Warnings for Pregnant and Postpartum Women in Kilifi, Kenya

PONE-D-24-16377R1

Dear Dr. Lusambili,

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.

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Kind regards,

James Colborn

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

Reviewer #2: 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

Reviewer #2: Yes

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

Reviewer #1: N/A

Reviewer #2: Yes

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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: No

Reviewer #2: 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

Reviewer #2: Yes

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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: Review comments

General comments

Once again, I commend the Authors for the well written manuscript as submitted. Keep up the good work.

I recommend that the manuscript should be accepted for publication.

Observations.

1. Even though acronyms were introduced when they were used for the first time in the abstract section, the case was not the same in the body of the manuscript. Authors should refer to lines 149 and 262.

2. Tables 1 and 2 should be titled ‘Participants’ profile’ instead of ‘Socio-demographics’.

Reviewer #2: Thank you for addressing all of the comments provided in the first review.

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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: EDMUND NDUDI OSSAI

Reviewer #2: No

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Attachments

Attachment

Submitted filename: Review comments.docx