A survey of knowledge and attitudes towards antibiotic use and resistance among teachers in the Republic of Kenya: Implications for using teachers in raising public awareness of rational antibiotic use in school communities

Patrick M. Mutua; Joshua. Mutiso; Michael M. Gicheru

doi:10.1371/journal.pone.0316122

Peer Review History

Original SubmissionMay 15, 2024
23 Sep 2024 Decision Letter - Ali Haider Mohammed, Editor PONE-D-24-18988A Survey of Knowledge and Attitude Towards Antibiotic use and Resistance among the Teachers in the Republic of Kenya: Implications for Using Teachers in Raising Public Awareness on Rational Antibiotic use in School CommunitiesPLOS ONE Dear Dr. Mutua, 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. Kindly find below my comments as well as the reviewers comments . Please submit your revised manuscript by Nov 07 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, Ali Haider Mohammed Academic Editor PLOS ONE Journal Requirements: When submitting your revision, we need you to address these additional requirements. 1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf 2. Please provide additional details regarding participant consent. In the ethics statement in the Methods and online submission information, please ensure that you have specified (1) whether consent was informed and (2) what type you obtained (for instance, written or verbal, and if verbal, how it was documented and witnessed). If your study included minors, state whether you obtained consent from parents or guardians. If the need for consent was waived by the ethics committee, please include this information. If you are reporting a retrospective study of medical records or archived samples, please ensure that you have discussed whether all data were fully anonymized before you accessed them and/or whether the IRB or ethics committee waived the requirement for informed consent. If patients provided informed written consent to have data from their medical records used in research, please include this information. 3. In the online submission form, you indicated that the data underlying the results presented in the study are available from the corresponding author upon request All PLOS journals now require all data underlying the findings described in their manuscript to be freely available to other researchers, either 1. In a public repository, 2. Within the manuscript itself, or 3. Uploaded as supplementary information. This policy applies to all data except where public deposition would breach compliance with the protocol approved by your research ethics board. If your data cannot be made publicly available for ethical or legal reasons (e.g., public availability would compromise patient privacy), please explain your reasons on resubmission and your exemption request will be escalated for approval. Additional Editor Comments: Methodology: Clarification of Sample Selection: The authors should clarify the selection process for the teachers involved in the survey, particularly how they ensured a representative sample across various regions and school types within Kenya. Detailed Statistical Analysis: While the statistical tools used (e.g., IBM SPSS) are mentioned, the manuscript would benefit from a more detailed explanation of the statistical methods applied, especially the models used in logistic regression. Results: Presentation of Data: Some tables are dense and could be simplified or better explained in the text to help readers understand the data without constantly referring to the tables. Comparative Analysis: It would enhance the manuscript if the authors compared their findings with similar studies in other regions or countries, discussing any notable similarities or differences. Discussion: Broader Context: The discussion should integrate more about how these findings align or contrast with global trends in antimicrobial resistance education, especially among non-health professionals. Implications for Policy and Practice: While the authors touch upon the implications of their findings, they could expand on specific policy recommendations or educational strategies tailored for teachers. [Note: HTML markup is below. Please do not edit.] 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 ******** 2. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: Yes ****** 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 ****** 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: No ****** 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: Greetings, thank you for sharing your research outcome. Kindly double check on some grammar and typing errors in the manuscript. Eg: Google was typed as “goggle” in line 112, and the word “Google” is usually not capitalized in the manuscript. Kindly double check on the reference too. Eg: Reference 15 and 24 appear to be duplicated. There are multiple different referencing styles used in Reference List, suggest to standardize based on PLOS journal’s guideline. In a Knowledge and Attitude study, the questions under “Knowledge” section should ideally be used to identify knowledge gap and misconception. Under Table 2 (Knowledge section), question no.1 asked “I can differentiate between bacterial and viral infection”. In my humble opinion, this question seems to ask the respondents’ perception/reflection regarding their own knowledge. There is no “incorrect” or “correct” response to be judged in such question, and perhaps it might not be suitable to be placed under “Knowledge” section. Can you kindly clarify? In Line 127, the authors mentioned that the study instrument has previously been used in a different study (a study from Nigeria - Reference 21), and for the purpose of this research, the authors had validated it with 100 randomly sampled teachers in Kenya. However, the actual questionnaire used in this manuscript is actually modified and not identical with the study from Nigeria (Reference 21). Suggest to clarify this in the research methodology too. Thank you. ****** 6. 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.0316122.r001
Revision 1
26 Sep 2024 Author Response From: Dr Patrick M. Mutua To: The Editor Department of Public Health, The PLoS ONE Journal School of Health and Human Sciences, Pwani University P.O Box 195-80108, Kilifi, Kenya 26th September, 2024 Email: patmbuvi@gmail.com Dear Sir/Madam RE: REBUTTAL ON THE REVISED POINTS IN MY MANUSCRIPT PONE-D-24-18988 Thank you so much for you email dated 24th September, 2024 requesting me to carry out revisions on our manuscript referenced above. My corrections are as follows: To the academic Editor: (1) I have carefully re-written references in line with PLOS one guidelines as advised. (2) I have added more information in methods section indicating that consent was informed. Additionally, the draft of the questionnaire that was used to design the online questionnaire starts with consent information that requested participants to read and understand the informed consent and either agree on the statement before responding to the online questionnaire or disagree to the consent and therefore decline to proceed with the study. Kindly refer to the questionnaire submitted together with the revised manuscript (3) In line with meeting the PLOS One journal requirement on availing data used in a study, I have submitted the questionnaire used to collect data as part of the attachment of the main manuscript. Kindly refer to the upload revised manuscript (4) On sample selection, Under the Sample size section, I have included a statement on how we ensured data on sampled teachers was representative of the teachers by sub county and by school. The statement reads “In Kenya, there are 271 sub-counties. To ensure a representative sample of the teachers in the country, respondents were required to indicate their schools’ sub-county for random proportional distribution of the submitted questionnaires based on the number of teachers in each sub-county.” Additionally, the study involved all 271 Teachers Service Commission Sub County directors who distributed the online questionnaire to the teachers in the sub counties, providing opportunity for all teachers in all the sub counties to respond to the questionnaire. (5) Under Methods and in the abstract, I have included Binary Logistic Regression as the model that was used to perform statistical analysis to determine the predicators of adequate knowledge and attitude toward antibiotic use and resistance. (6) Under discussion section, I have included related studies in East Africa and Africa that included non-professionals in assessing knowledge for and attitude toward antibiotic use and resistance. I have further demonstrated how the findings of the related studies compare with the current study (7) On Implications for policy and practice: In the conclusions section, the study recommends that policy makers in Kenya to use the study findings to plan comprehensive public education campaigns to mitigate gaps identified by the study so as to improve teachers’ knowledge on and attitude for antibiotic use. Further, the study recommends teacher training in colleges in universities to consider offering a course on AMR to teacher trainees. This will equip graduating teachers to have adequate knowledge and attitude on AMR and benefit school communities and the general public To the Reviewers: (1) I have carefully effected corrections to ensure all grammatical errors are corrected and I have highlighted the corrections for your perusal. The word goggle has been corrected to read google in line 137. (2) Duplication of reference 15 and 24 has been corrected by deleting reference 24. (3) References have been standardized based on PLOS journal guidelines (4) On whether the question “I can differentiate between bacterial infections from Viral infections” is a knowledge or a perception question, we strongly feel the question is a knowledge one because it is assessing factual understanding. For one to respond to the question, they must have scientific knowledge to distinguish between bacterial and Viral infections based on their characteristics, causes, or symptoms. We, therefore, kindly request that the question be retained as it is in Table 2. (5) We confirm that the questionnaire that we used in the study was previously used in another study in Nigeria. However, we carried out slight modifications to include a question on sub county of the respondent so as to ensure a representative sample of teachers in Kenya was well captured. We also removed a few items that sought history of use of antibiotics by respondents. In conclusion, I believe that I have responded to all the corrections I have been requested to ensure are done and that my revised manuscript now meets all the PLoS ONE requirements for publication. I look forward to getting published in your esteemed journal. T Regards Dr Patrick M. Mutua Attachments Attachment Submitted filename: RESPONSE TO REVIEWERS.docx https://doi.org/10.1371/journal.pone.0316122.r002
15 Nov 2024 Decision Letter - Ali Haider Mohammed, Editor PONE-D-24-18988R1A Survey of Knowledge and Attitude Towards Antibiotic use and Resistance among the Teachers in the Republic of Kenya: Implications for Using Teachers in Raising Public Awareness on Rational Antibiotic use in School CommunitiesPLOS ONE Dear Dr. Mutua, 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. Reviewers highlighted minor issues that need to be addressed. Please submit your revised manuscript by Dec 30 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, Ali Haider Mohammed 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. [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 #2: (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 #2: Yes ****** 3. Has the statistical analysis been performed appropriately and rigorously? Reviewer #2: 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 #2: 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 #2: 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 #2: Couple of minor comments ABSTRACT - i don't like "dearth of information" - change to Limited studies have investigated teachers - in the abstract, it is not clear who "teachers" are = can you specify it's primary and secondary school teachers. So there are no university lecturers in your sample? - the phrase "the average knowledge score on antibiotic use" is too vague in the abstract, please be specific. Knowledge can include many things. Either pick one big result or explain what you mean by knowledge. The abstract should be able to be read alone without having to go to the main text - need to add summary of number of respondents and response rate in abstract MAIN TEXT - I think you mention 5 times that "this is the first study to conduct knowledge is kenyan teachers" - i don't think you need to keep mentioning this so many times, reduce it and only mention in the discussion and maybe one more time in the intro - you did some analysis in the results regarding demotraphics of respondents and their attitude to AMR. can you discuss this in your discussion? - the one odd part i see in your study is that you investigated knowledge of primary and secondary teachers rather than tertiary. do you expect primary school and secondary teachers to teach AMR to their students? If you see a case for this foundation skill all the way back in primary school, please explain in discussion why. - there's too much information in your conclusion, you have rewritten most of your introduction again, remove first 4 sentences and start with the findings of this study.. - the findings of this study provoke - change to motivate?? ****** 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 #2: 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.0316122.r003
Revision 2
16 Nov 2024 Author Response From: Dr Patrick M. Mutua To: The Editor Department of Public Health, The PLoS ONE Journal School of Health and Human Sciences, Pwani University P.O Box 195-80108, Kilifi, Kenya 16th November, 2024 Email: patmbuvi@gmail.com Dear Sir/Madam RE: REBUTTAL ON THE REVISED POINTS IN MY MANUSCRIPT PONE-D-24-18988R1 Thank you so much for your email dated 15th November, 2024 requesting me to carry out revisions on our manuscript referenced above. My corrections are as follows: To the academic Editor: (1) I have carefully checked all my references and I confirm that none of the references quoted in our manuscript is retracted To the Reviewers: Corrections in the abstract (1) I have deleted the sentence “dearth of information…” and replaced this with “limited studies have investigated teachers’ knowledge of and attitudes towards antimicrobial use” (2) In the abstract, I have clearly indicated the study focused on primary and secondary school teachers. (3) With regard to use of knowledge, we have clearly indicated the knowledge score of teachers of antimicrobial resistance to be 9.2 out of 17. (4) In the abstract, I have included the response rate of the participants as advised Corrections in main text (1) I have reduced the number of times I have mentioned “This is the first study to” and only mentioned this in the discussion as advised (2) In our manuscript, we have quoted a related study done in Ghana that used storytelling to positively improve knowledge of antibiotics and antimicrobial resistance among children attending primary schools. This study involved primary school teachers. Therefore, it is possible for primary and secondary school teachers to teach about antimicrobial resistance using a variety of learner centered approaches as is the case with the Ghana study (3) I have deleted the first four sentences in my conclusion as advised and the revised section starts with the findings (4) I have used the word to MOTIVATE rather than to provoke…in the conclusions section with regard to using the findings to MOTIVATE teacher training colleges and universities to consider a course of antimicrobial resistance for teacher trainees In conclusion, I believe that I have responded to all the corrections I have been requested to ensure are done and that my revised manuscript now meets all the PLoS ONE requirements for publication. I look forward to getting published in your esteemed journal. T Regards Dr Patrick M. Mutua Attachments Attachment Submitted filename: RESPONSE TO REVIEWERS.docx https://doi.org/10.1371/journal.pone.0316122.r004
6 Dec 2024 Decision Letter - Ali Haider Mohammed, Editor A Survey of Knowledge and Attitudes Towards Antibiotic Use and Resistance among Teachers in the Republic of Kenya: Implications for Using Teachers in Raising Public Awareness of Rational Antibiotic Use in School Communities PONE-D-24-18988R2 Dear Dr. Patrick , Taking into consideration that you have significantly addressed the reviewers' comments and improved the quality of the paper, 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, Ali Haider Mohammed Academic Editor PLOS ONE Additional Editor Comments (optional): All comments were addressed optimally. Reviewers' comments: https://doi.org/10.1371/journal.pone.0316122.r005
Formally Accepted
10 Dec 2024 Acceptance Letter - Ali Haider Mohammed, Editor PONE-D-24-18988R2 PLOS ONE Dear Dr. Mutua, 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. Ali Haider Mohammed Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0316122.r006

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