PONE-D-24-29660Knowledge, attitude, and practice regarding venous thromboembolism prophylaxis: A multicenter cross-sectional study of medical staff in GuineaPLOS ONE

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https://journals.lww.com/md-journal/fulltext/2021/12100/knowledge,_attitudes,_and_practices_regarding.27.aspx

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Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

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Reviewer #1: Partly

Reviewer #2: Yes

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

Reviewer #1: No

Reviewer #2: No

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3. Have the authors made all data underlying the findings in their manuscript fully available?

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Reviewer #1: No

Reviewer #2: Yes

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Reviewer #1: Yes

Reviewer #2: 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: Article review PONE-D-24-29660

For Editors: Thank you for the opportunity to review this manuscript. Though I have some major concerns on the methods and results, I encourage the authors to address the concerns and resubmit for publication. In a brief PubMed search, I was unable to find any published material regarding VTE in Guinea. As developing nations increase their risk factors for VTE, it is important that their healthcare systems facilitate VTE prevention education for providers and patients. Thus, this work is likely to be an important step in the process.

Available comments for Authors:

Summary: The authors describe an important analysis of healthcare provider knowledge and attitudes regarding VTE prophylaxis in Guinea. This work is innovative in this population and a better understanding can help hospitals, universities, and other agencies advocate for increased awareness and education to address barriers and gaps. Though the manuscript is well-written, there are several areas that require significant revision of the methods, statistical results, conclusions.

Data Availability: Authors state data is available but did not describe where the data may be found.

Abstract:

• The objective is reporting the awareness of medical staff regarding VTE prophylaxis using a survey examining the demographic data, knowledge, attitude, and practice regarding VTE prophylaxis.

o How this leads to the ability of the authors to “provide suggestions for improvement in VTE prevention and treatment” is unclear and is never addressed further in the manuscript.

Introduction:

• Line 43: Reference 3 is 25 years out of date. In discussions of disease burden a more recent reference would be preferred. For example, the author of Reference 2 published an estimate of US VTE burden in 2021. doi: 10.1055/s-0040-1722189.

• Line 48: Reference 5 does not apply to the sentence, nor does it apply to the previous sentence to explain the rise in VTE-related hospitalizations in China. A more applicable reference is warranted.

• Line 49-50: Refence 6 discusses gender related risk factors for cardiovascular disease among several sub-Saharan African nations. As this is just one non-communicable disease impacting Guinea, it does support the sentence of “poor healthcare and a double burden of communicable and non-communicable diseases”. Suggest adding references for support, for example: the WHO data on Global health estimates by country.

• Line 50-52: While it is well known that proper prophylactic protocols have the potential to prevent VTE among hospitalized patients, Reference 7 is a review of risk factors not prophylaxis. Suggest a more targeted reference. Also, the phrase “unintended death in hospitalized patients” implies there are “intended death in hospitalized patients”, different phrasing may be a reasonable consideration.

Methods:

• Overall comments: The authors well describe the population and analysis, though a few questions remain.

• 34 questionnaires were not returned. The authors do not describe the reasons for non-returned surveys or if the surveys were returned but incomplete and thus excluded.

• How was the survey validated in this population?

Results:

• Overall comments: The authors did not include the list of questions asked regarding VTE prophylaxis knowledge. References 9 and 10 link to previously published surveys that were adapted for this study, consisting of 21 and 68 knowledge questions respectively. Since the previous surveys consist of differing numbers of questions and the previous populations were both in China, it is questionable if the authors can establish the current survey as validated as no steps for validation in this population or the current number of knowledge questions are described. In addition, if the knowledge questions are similar in scope to the questions described in Reference 10, then the majority of questions are related to VTE risk factors, and the text of the manuscript should accurately reflect that fact. Statistics on correct knowledge responses and Table 1 are recommended to be reanalyzed by knowledge categories, i.e. signs and symptoms, risk factors, prophylaxis, etc.

• Table 1 education level: Correct the spelling of “Heigh” to High.

• Table 2 Attitude regarding VTE prophylaxis of medical staff in Guinea.

o These questions should NOT be combined to create a single overall affirmative response rate. Two of the questions are assessing the respondent’s assessment of their employers’ opinion of VTE prophylaxis; and two are multi part questions assessing concerns and difficulties where a negative response would be better assessed as a positive.

• Table 3. Practice regarding VTE prophylaxis of medical staff in Guinea.

o Is it standard practice in Guinea for nurses to conduct VTE risk assessment? The discussion should reflect that. In the US, VTE risk assessment is usually conducted by clinicians.

o Question 4 is very vague and the much lower affirmative response rates may reflect that vagueness. Which VTE risk assessment scales are being referenced? In the US there are many different VTE risk assessment scales in practice, some are for different populations (cancer, pregnancy, pediatric) or different settings (medical, surgical, trauma) or developed in house versus externally validated. It is unreasonable to require providers in different specialties to have mastered ALL VTE risk assessment scales.

Given the above issue, it is also recommended that an overall affirmative response rate not be reported.

Discussion:

• Line 161: The authors discuss results that were not presented in the results section. But these are results I’m recommending they present, the breakout of topic areas for the knowledge questions.

• Line 168: “found a positive attitude toward VTE prophylaxis among nurses” Should the word “more” been included? Also, must present the sub-analysis data in the results.

• Line 171-174: Sentence needs adjustment to not make a causation statement.

• Line 174-176: Reference 12 is a review article and 13 occurs in Spain; neither address the statement as applied to “developing countries”.

• Line 178-181: Reference 14 presents the Padua Prediction Score and Reference 15 presents ASH’s guidelines for VTE among patients with cancer; at no time do either mention that conducting a risk assessment is mandatory for nurses but not clinicians. This is a disingenuous use of these references. If nurses conducting risk assessment is standard practice in Guinea then the authors should just state that fact.

• Line 181-183: See previous comment regarding the vagueness of the question regarding VTE risk assessment “score”.

Conclusion:

• Current conclusion is based on the current results. There may be a significant shift if authors undertake suggest revisions to methodology and analysis.

Reviewer #2: Xinnong Liu et al report on "Knowledge, attitude, and practice regarding venous thromboembolism prophylaxis: A

multicenter cross-sectional study of medical staff in Guinea". The authors report on data from filling out self-designed questionnaire including four parts composed of demographic data, knowledge, attitude, and practice regarding VTE prophylaxis. The authors analysed 211 (86.1%).staff member responders' questionaires. "Correct" respnses were found in a range of 65% up to 84%, which was considered poor by the authors and the somewhat simple conclusion was to train better.

The topic is timely and of interest.

Emerging countries are cathching up and should be supported in their endeavour to train the staff in thrombosis prophylaxis.

Issues that should be considered:

1) 65%-84% positive answers should be wighed more differentiated. The (vast) majority seem to be compliant with the defined endpoints and answers correctly.

2) Given the situation in a emerging country, the verdict should be primarily positive.

3) The direct comparision of a partner hospital in China and /or of the western world would be desirable.

4) Data from the literature could alternatively flow in for more direct comparisions.

5) Consider also that ideal situations of procedures in emerging countries could differ greatly from other countries in the western world.

6) One example: "A multidisciplinary team must provide therapy to patients with VTE". This is how it works in other countries, but the structure of command may differ in Guinea.

7) "must" in VTE prophylaxis may induce counter actions and negative feelings towards outside authorities.

8) "What arrives" actually to the patients in need of VTE prophylaxis and to the ones who should not get it would be an important addition to the study, data may be available.

9) If not, recent data from other countries surveys on VTE prophylaxis could be directly compared.

10) More constructive advices on how to improve and perhaps to support the quality-measures would be very welcome, since this may apply to many other countries.

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Reviewer #1: No

Reviewer #2: No

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PONE-D-24-29660R1Knowledge, attitude, and practice regarding venous thromboembolism prophylaxis: A multicenter cross-sectional study of medical staff in GuineaPLOS ONE Dear Dr. Liu,

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 Feb 12 2025 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,

Mohammed Abutaleb, PhD

Academic Editor

PLOS ONE

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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 #3: All comments have been addressed

Reviewer #4: (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 #3: Yes

Reviewer #4: Partly

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

Reviewer #3: (No Response)

Reviewer #4: 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 #3: Yes

Reviewer #4: 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 #3: Yes

Reviewer #4: 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 #3: thanks for the revision and address the all comments. Happy to be part to review the paper.

Reviewer #4: The study investigated the awareness of medical staff regarding venous thromboembolism (VTE) prophylaxis in Guinea. I recommend the following minor corrections:

1. Provide more details on how you determined the sample size of 245 cases. This could include the statistical methods or calculations used, any assumptions made, and the confidence level and margin of error considered.

2. Was the internal consistency of each part of the questionnaire assessed? Please report the Cronbach's Alpha value or any other relevant statistic that would help to understand the reliability of the questionnaire.

3. Clearly state the inclusion and exclusion criteria used in the study. This will help readers understand the characteristics of the study population and ensure the study's reproducibility and validity.

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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 #3: Yes:  Mohammad Ashraful Amin

Reviewer #4: No

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Knowledge, attitude, and practice regarding venous thromboembolism prophylaxis: A multicenter cross-sectional study of medical staff in Guinea

PONE-D-24-29660R2

Dear Dr. Liu,

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,

Mohammed Abutaleb, PhD

Academic Editor

PLOS ONE

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