PONE-D-24-34411Networks of Care for Optimizing Community Health Programs in Ethiopia: Enhancing Linkages and Coordination within Primary Health CarePLOS ONE

Dear Dr. Tiruneh,

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.

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ACADEMIC EDITOR:In order to make the article more compliant with scientific criteria, I suggest eliminating the italicized citations in the text of subjects who, moreover, are not clearly identifiable. Alternatively, they must be reported according to rigorous and standardized criteria.

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Please submit your revised manuscript by Nov 22 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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Flora De Conto, Ph.D.

Academic Editor

PLOS ONE

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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: Partly

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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: No

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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

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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 article is comprehensive and provides detailed insights into the topic, but some sections could be streamlined for clarity.

1. The section detailing the Networks of Care (NOC) is overly long and could benefit from conciseness. Summarizing key elements of NOC—such as its role in improving coordination, resource sharing, and maternal care outcomes—would make the manuscript more accessible without losing important information.

2. The mention of the RE-AIM framework feels underdeveloped. If the authors are not applying it fully by reporting on key dimensions like reach, adoption, implementation, and maintenance, it may be better to omit the framework from the methodology or expand its use and provide relevant data for each component.

3. Fidelity should be clearly defined. Currently, it is discussed without specifying what components of the intervention were monitored for adherence, or how deviations were measured. A more structured discussion on how fidelity was evaluated would improve the rigor of the paper.

4. A summary table showing key indicators and the corresponding data collection methods would be helpful for readers. This would clarify how the study measured outcomes and tracked progress over time.

5. The key informant interview methodology was very briefly mentioned ("Qualitative data from key informant interviews were transcribed, coded, and thematically analyzed using Atlas.ti"). I suggest following a standard checklist, such as COREQ, to provide more detailed information on qualitative data collection, including sampling, interview guides, and the coding process.

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Reviewer #1: No

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PONE-D-24-34411R1Networks of Care for Optimizing Primary Health Care Service Delivery in Ethiopia: Enhancing Relational Linkages and Care CoordinationPLOS ONE

Dear Dr. Tiruneh,

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.

The manuscript has been implemented compared to the first version. However, you must complete the review in accordance with the guidance provided by the reviewers. Furthermore, it is necessary to explain the changes that have occurred in the list of authors, since a new author has been added and to certify that all the authors of the manuscript are aware of and in agreement with them, in compliance with the policy of the Journal PLOS ONE.

Please submit your revised manuscript by Dec 26 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,

Flora De Conto, Ph.D.

Academic Editor

PLOS ONE

Journal Requirements:

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.

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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: (No Response)

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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: Partly

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

Reviewer #1: No

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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

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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

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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: Thank you for the revision. The manuscript has improved in many ways. However, I have included my responses and a few additional comments below (in purple).

Overall comments

Previous responses and comments

1. Thank you for the revision. Table S2 provides an adequate overview of the framework.

2. "The mention of the RE-AIM framework feels underdeveloped. If the authors are not applying it fully by reporting on key dimensions like reach, adoption, implementation, and maintenance, it may be better to omit the framework from the methodology or expand its use and provide relevant data for each component.

Response: Comment acknowledged. Since we did not report on all dimensions of the RE-AIM framework, we have removed it in this version."

Further comments:

In my opinion, if the authors do not expand on their use of the RE-AIM framework (specifying which components guided which indicators and acknowledging any components omitted due to limitations), they should consider mentioning other frameworks that may better suit the manuscript. Otherwise, readers may be confused about how each indicator was selected for analysis.

3. Fidelity should be clearly defined. Currently, it is discussed without specifying what

components of the intervention were monitored for adherence, or how deviations were

measured. A more structured discussion on how fidelity was evaluated would improve

the rigor of the paper.

Response: Comment acknowledged. In the measurement section, we have now

defined fidelity and outlined how we measured it, see Table 1 (page 10, line 188)

Further comments:

Thank you for defining fidelity. However, in line with the previous comment, the presentation of other indicators is confusing, as they don’t seem to clearly adhere to any specific framework.

For example, in the results section of the main text, the authors briefly mention fidelity with the statement: “Fidelity: A sizable progress in NoCs implementation fidelity was achieved.” Then, under the Fidelity subsection, functionality is reported instead: “The NoCs functionality score improved from 56% to 89% in agrarian settings and from 38% to 60% in pastoral settings (Fig 2). Improvements included enhanced coordination, standardized referral practices, and increased resource sharing among facilities. Coaching and mentorship strengthened at primary care levels, improving efficiency, access, and quality of care.”

This is confusing because the authors previously defined functionality as a separate indicator. Following a specific implementation evaluation framework (such as the RE-AIM framework or the MRC Process Evaluation Framework, https://pubmed.ncbi.nlm.nih.gov/25791983/) might clarify the structure and interpretation.

4. “A summary table showing key indicators and the corresponding data collection

methods would be helpful for readers. This would clarify how the study measured

outcomes and tracked progress over time.

Response: Comment well taken and Table 1 presents the key indicators measured,

along with their definitions and data sources (page 10, line 183)”.

Further comments: See comments above.

Additional comments

1. Please avoid overusing abbreviations, as it can make the text difficult to understand. For example, "QI" should be written in full.

2. Results (abstract)

“Results: The NoCs approach has significantly strengthened both administrative and technical connections, while enhancing relational linkages, multi-level collaboration, and bidirectional communication. This has fostered trust, improved care coordination, boosted primary health care performance, and increased health service utilization within woreda health systems. The Interrupted time series analysis indicated that the rate of ANC 8+ visits was 29.8% per month higher than expected without the NoCs strategy (Coef: 2.39; p-value < 0.01) and an 18.4% increase in obstetric complications managed (Coef: 1.71; p-value 36 = 0.050), with a 43% overall increase. Perinatal mortality decreased by 34%, from 31.3 to 20.1 per 1,000 births [t-test: 2.12; p-value: 0.040)].”

Could you clarify the definitions and distinctions between “administrative connections,” “technical connections,” “relational linkages,” “multi-level collaboration,” and “bidirectional communication”?

The results section in the main text reports different indicators than these terms. Could you explain the reason for this discrepancy? Furthermore, why does the abstract use a different format, such as “Implementation fidelity, challenges, and adaptations,” “Enhanced bidirectional linkages,” “Optimized HEP and improved performance and efficiency of the PHC system,” and “Improved utilization, quality, and continuity of care”?

3. Discussions

“…Previous studies underscore that involving communities in these networks and quality improvement efforts significantly boosts maternal health program effectiveness. By engaging community members, local leaders, and stakeholders in service design, implementation, and evaluation, programs become more accessible, culturally sensitive, and widely utilized. Initiatives like participatory learning groups, community health committees, and training for health workers increase antenatal visits, skilled birth attendance, and postnatal care, ultimately lowering maternal and neonatal mortality rates [22-24]. These engaged networks build trust between health care providers and communities, ensuring interventions meet local needs sustainably.”

This section would benefit from additional references. For example, the statement “…Previous studies underscore that involving communities in these networks and quality improvement efforts significantly boosts maternal health program effectiveness” should be followed by citations that demonstrate the effectiveness of “involving communities in these networks…”

Additionally, the discussion section appears to emphasize the importance of the NOC framework without comparing other aspects of the research, such as fidelity, functionality, or the evaluation methodology, with existing literature. Please consider including these comparisons.

4. Please provide the study’s limitations.

5. Please provide necessary information about the shared data in Supplementary #6.csv (e.g., brief descriptions, data dictionary).

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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: No

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[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.]

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Attachments

Attachment

Submitted filename: review NOC.docx

Networks of Care for Optimizing Primary Health Care Service Delivery in Ethiopia: Enhancing Relational Linkages and Care Coordination

PONE-D-24-34411R2

Dear Dr. Tiruneh,

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,

Flora De Conto, Ph.D.

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments: