PONE-D-25-16839“...in Kiambu county, there are different things being done”: A Qualitative Study Exploring the Experiences of Healthcare Workers with 7.1% Chlorhexidine digluconate Cord Care in Kiambu County, Kenya

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Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Partly

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Reviewer #1: N/A

Reviewer #2: Yes

Reviewer #3: Yes

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Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

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Reviewer #1: No

Reviewer #2: Yes

Reviewer #3: Yes

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5. Review Comments to the Author

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Reviewer #1: This article provides an insightful and contextually appropriate qualitative study into healthcare providers’ experiences with 7.1% chlorohexidine (CHX) digluconate for umbilical cord care in Kiambu County, Kenya. Given Kenya’s public health goals for infant mortality and WHO guidelines for CHX in areas with high newborn sepsis risk, this topic is highly significant.

Methodologically, in-depth interviews and thematic analysis are appropriate, and the data collected clearly supports the core study findings. This study provides a useful insight into barriers (e.g., cost, availability, and knowledge gaps), facilitators (perceived efficacy and ease of use), and systemic concerns (training, policy compliance) that influence CHX adoption.

Meanwhile, this paper needs to be strengthened in these fields:

Strengthening Manuscript Structure:

Though the English of this paper is mostly clear, it needs somewhere to increase more clarity and conciseness. The results section should follow thematic frameworks and could be classified in several subheadings like barriers, facilitators, and knowledge gaps. Moreover, there is a lack of demarcation, like blending description, interpretation, and respondents’ quotations. There are some repeated sections in the discussion part, and it would be better if it could be synthesized with previous literature.

Lack of thematic analysis presentation:

Although NVivo was used for doing thematic analysis, presentation of the coding tree (arranging the data set in a theme/subtheme structure) is missing from this manuscript (only a part is shown in Table 1). Consider including a diagram to visually summarize key themes and their relationships to subthemes.

Using quotations in a standard way:

Quotes are useful for qualitative study, but they should not interrupt the flow of narrative. Some quotes are quite lengthy and should be condensed and narrowed down to better explain the key findings.

Lack of critical engagement in the discussion part:

The discussion part should be integrated with literature. The authors wrote the discussion part of this manuscript in a highly cited and descriptive manner. They often list other studies without deeply comparing study findings.

The abstract part is too detailed:

The abstract part of this article is too detailed, which could exceed PLOS ONE length expectations. It could focus on key findings and methods and brief recommendations.

Collusions should be sharply stated:

The conclusion part of this article is somehow reiterating findings. The article fails to provide a compelling conclusion or policy recommendation for future actions.

General recommendation: Major Revisions

This article may make a meaningful contribution to infant care interventions in low-resource settings once the above issues, notably the structure of results, depth of discussion, and clarity of language, are addressed.

Reviewer #2: In methodology better have a description on available formulations gel/ liquid form. SOP if any on how to use it, whether adequate training conducted by government or hospital authority on how to use and how frequently to apply CHX (once or multiple times}

HCW also faced interview through Kiswahili as well, it is better to mention whether questionnaire was validated in that language

Seems consent taken from hospital medical superintendent but here information lacking whether consent was taken from the individuals

Out of 2,600 HCWs only 38 were interviewed which may decrease the strength of the study

As it is a qualitative study it is better to mention about FGD, KII to get an overall idea to fulfill the objective of the study which seems missing here.

Existing cord care practice section

Please try to mention percentages in bracket after the term mentioned as majority/ many like that

Different facilities like 1 to 5 need to explain clearly

Please make it clear idea about recommendation about who to put CHX on umbilical cord; mother or health care provider?

Having high institutional delivery, please include the information about the responsible person to apply CHX while the baby is in hospital; health care provider/ mother where HCW can apply CHX considering safety and hygiene issue.

Reviewer #3: Thank you for submitting your manuscript. This manuscript explores an important topic, cord care practices and CHX implementation in a Kenyan county. While the study is timely and relevant, several critical areas require improvement to strengthen its scientific contribution. Detailed, section-wise suggestions are given below

Background:

• Add local epidemiological data: estimates of NNS, omphalitis, or mortality attributable to cord infections which would assist to understand the magnitude of the problem and strengthen the rationale for the study.

• This paragraph (third) is confusing. Contradictory evidence is described but not synthesized. what is the current consensus or lack thereof? Would recommend focus more the updated recommendation of WHO as these recommendations are made from multiple and multicountry studies and based on strong evidences.

• What was the specific evidence from Bangladesh study is missing here. Would suggest to clarify the conflict for clear understanding of the readers.

• "CHX protocol” is vague. Would recommend to specify if referring to 4% CHX gel, application frequency, or WHO guidance.

• The rationale is very weak. There is no mention of the systemic barriers (supply chain, training gaps, facility-level enforcement) that might present in the low-resouce settings which would provide context for CHX underutilization. Additionally, there is no mention whether any previous studies were conducted in Kenya or in the similar settings to understand HCW perspective, any gaps and limitation of those studies and what more this study may address particularly. Would strongly suggest to address these things to make the background scientifically sounder and more comprehensible.

Method:

• The design is identified as “exploratory qualitative,” but the justification for this choice is missing. Explain why this design was most suitable for assessing HCWs’ experiences.

• Lacks demographic details (cadre mix, gender, years of experience, urban vs rural distribution) which is crucial for assessing diversity and representativeness.

• Mention the qualification of JMG and BNO whether they received any qualitative interview training.

• Data management is briefly mentioned, but no info on data encryption, password protection, or cloud security for Kobo/NVivo files. would suggest to address.

Result:

• Add a table for clear understanding summarizing:

o Number of HCWs by cadre (nurses, pediatrician, pharmacist, MO, clinical officers, etc.)

o Facility type (Level 5/4/3, public/private/faith-based)

o Urban vs rural distribution.

Findings:

• Merge overlapping themes/sub-themes (e.g., “availability” and “access”) and synthesize common patterns across quotes rather than listing them sequentially.

• This findings section provides a rich, grounded understanding of cord care practices and CHX implementation challenges in a Kenyan county. However, the current presentation is verbose, and could benefit from clearer synthesis and critical reflection. Consider a thematic framework diagram to visually depict intensity and co-occurrence of themes across categories (e.g., advantages, barriers). With revisions focused on thematic clarity, and contextual framing, this section could substantially enhance the manuscript’s contribution to the research in newborn health.

• While quotes are tagged by anonymized ID, more information (e.g., facility type or cadre) would help interpret responses.

Discussion:

• Would suggest to emphasize what new insights this study offers beyond confirming previous finding. For instance, specific systems-level insights about devolution and supply chains in Kiambu.

• The discrepancy in reported CHX pricing between studies (e.g., Ksh. 40 vs. 200) requires deeper discussion. Is this due to procurement models, subsidies, or corruption?

• While lack of training is mentioned, the scope or standard of existing training programs is not elaborated. Are they nonexistent, outdated, or misaligned with WHO protocols?

Conclusion:

• The conclusion blends findings and recommendations without clearly differentiating them. This weakens the take-home message.

• "One healthcare facility actively practiced cord care against the National Guidelines” is serious but underexplaine. This needs clarification or should be omitted from the conclusion unless further elaborated.

• Consider including a final sentence with a stronger policy implication (e.g., need for CHX to be prioritized in county-level budgets, routine supervision, or national monitoring frameworks)

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Reviewer #1: Yes:  Md Taqbir Us Samad Talha

Reviewer #2: Yes:  Sanjoy kumer Dey

Reviewer #3: Yes:  Goutom Banik

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“...in Kiambu county, there are different things being done”: A qualitative exploration of healthcare workers’ experiences with cord care practices

PONE-D-25-16839R1

Dear Dr. Juttla,

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Kind regards,

Sojib Zaman, MBBS, MSc., PhD

Academic Editor

PLOS ONE

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