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Additional Editor Comments:

Two reviewers have provided many useful comments and suggestions. Please carefully revise the manuscript accordingly, preparing a point-by-point response and a tracked-changes version to document all modifications made.

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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?

Reviewer #1: Yes

Reviewer #2: Yes

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

Reviewer #1: N/A

Reviewer #2: 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

Reviewer #1: Yes

Reviewer #2: Yes

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4. Is the manuscript presented in an intelligible fashion and written in standard English??>

Reviewer #1: Yes

Reviewer #2: Yes

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Reviewer #1: This paper by Chambers et al. describes the results of qualitative research conducted along an ivermectin treatment of livestock (ITL) in Sumba, Indonesia. Overall, additional information on certain aspects of the methods, and a more detailed conclusion section on how the results can be used to improve research in this context, would benefit the manuscript.

Please see below specific comments:

Introduction

The introduction is very well written and very informative.

Line 88: minor but suggest grouping this information (the specific number of cases) with the information in line 60.

Study design

It would be helpful to include very clear information on the timing of this study related to the SLIM project. Although implied that you did not work before the implementation of SLIM, it is only in the discussion section where this information is specified.

Minor, but suggest adding “author” to all instances where the authors initials are used

Results

Line 170: school children were all participants up to 18? 21? And then anyone over that age was considered adult? Seems that only having two categories here “school children” and “adults” would leave some participants out? I suggest adding information to clarify

It would be interesting to know the age distribution of your participants. Were there on the older side? Age can be a key determinant for perception on ‘new’ methods to control mosquitoes, and it would be helpful to know if all your participants were younger vs older adults.

Table 1: Add the total N to the table. Make sure that the title of the table is complete, including dates, and place, so that stands alone.

Line 198: Consider moving this to the discussion section

Line 227: More information on informational/educational campaigns that took place before the implementation of SLIM would be helpful to give more context to this part of the study. Was there a broad community outreach effort before this study?

Line 233: this seems to be a very important finding, that animal owners trust government veterinarians and their involvement in projects like these could improve participation, but I don’t think this is highlighted in the discussion. Government involvement is not always a factor that increases participation in research studies, and this would be an important context-specific finding.

Line 235: It is not clear to me what do you mean by “further into the trial”. Do you mean that in activities conducted at a later time, you got these findings?

Line 263: This study was conducted after the COVID-19 pandemic. Was ivermectin use also widely discussed in media and social media in Indonesia? If yes, did you get any insight on participants perceptions associated with the use of ivermectin for covid and how that translate to MDA?

Line 280: Just curious, I understand that you are translating directly from participants’ quotes, but was “drunk on drugs” the most accurate translation? Did they mean that drugs could be toxic for them? Or is being “drunk on drugs” a common saying in your population?

Line 283: This section doesn’t seem to be something that you assessed through your study activities, but rather a description of some situations observed during the activities conducted to recruit participants for the SLIM study. When I read the section where you describe the topics, I thought you were going to describe results of specific questions asked to participants regarding what they perceive as barriers for implementing malaria research. I suggest modifying your results section to clarify that this is additional information but not part of your study questions/assessment or to modify language to clarify how you assessed this in your study.

Line 299: Minor, but consider deleting “devastating” here or in the previous line 296

Line 300: This information is not clear, and Im not sure is relevant as it is included. Do you mean that there were reports that animals had died because of the application of ivermectin?

Discussion

Line 310: I suggest not using “confirmed” here. Malaria diagnosis can be based on clinical findings and can be also confused with other febrile illness (even some transmitted by mosquitoes, such as dengue) and I don’t think is accurate to say that your participants can confirm that malaria is a very common disease, as confirmation would need laboratory results. Suggest modifying the language.

Line 317: This is an important finding in this context, but in many cases, children are the “right hosts” for interventions, so I don’t think it is accurate to say that having adults instead of children is a basic element of research globally. Suggest modifying the language here.

Line 359: This further emphasizes the convenience of including additional information on the specific timing of your activities and the occurrence of additional information activities before the study implementation

Another limitation of your study is that it seems to have been conducted along the implementation of the SLIM trial, but you did not have the chance to assess community perceptions before, hence the applicability to the planning phase of other studies can be limited.

Line 379: Minor but consider changing “must”. New vector control tools for Anopheles are needed?

Line 379: the sentence starting with “Two of the…” reads strange. Please review and consider modifying for readability.

Overall, the discussion section can benefit from additional content on how your results can improve the implementation of research in Sumba, the description and conclusions seem very general and broad. Simple, regular, and respectful communication should be part of any community engagement effort; it would be very valuable to get more specific information on how you think your results can inform the implementation of additional malaria research around ivermectin.

Reviewer #2: General Comment:

Mary and colleagues’ study on community perceptions of ivermectin for malaria control on Sumba Island is both timely and well-articulated. I commend the authors for this thoughtful and engaging work. I have a few overall and specific comments, primarily aimed at enhancing readability and encouraging additional engagement with relevant literature, particularly from similar interventions in Southeast Asia.

Abstract

If possible, please avoid using too many acronyms in the abstract. Terms like ITL forced me to go back and forth while reading. You don’t want readers to feel interrupted.

Methods

You mention using mixed methods, but only describe the qualitative data analysis. Please include details about the quantitative or other methods used as well.

Also, consider briefly explaining what NVivo is for readers who may not be familiar with it.

Results

The phrase trust-building efforts feels vague. Can you provide specific examples to make this clearer?

Similarly, low social cohesion posed barriers would benefit from an illustrative example.

You introduce the term pre-trial here without having explained the category structure of pre-, during-, and post-trial stages earlier in the manuscript. For a broader audience unfamiliar with engagement-specific terminology, it might be clearer to say something like before the trial or as early as possible.

Conclusions

You raise some compelling points in your results — for instance, about children’s participation, social cohesion, and engagement with authorities. Why not make the conclusion section slightly more specific? As you know, terms like trust, engagement, and cultural considerations are often overused. You could strengthen your conclusions by pointing out how you specifically addressed these — not just through engagement in general, but through what aspects of engagement (e.g., dialogue, informal interactions, mediators)? You've discussed this effectively in the main text — you could reflect that clarity here too.

Specific Lines

• Line 119: Did you mean written informed consent?

• Line 139: You previously mentioned 75 participants, but here you say 24 transcripts. Can you clarify the discrepancy?

• Somewhere in the data collection section, could you add a table or box summarizing the types of data collected and the number of participants involved in each? I see you have table 1, but something simple, for readers to give an idea of types and breath of data collection, without having to navigate the acronyms.

• Line 303–307: The results related to low social cohesion is quite interesting, and quite unique to the research site you have collected data from. Do you have more elaboration or data to support this?

Discussion: Knowledge Deficit Model (Lines 328–337)

I appreciate your argument regarding the knowledge deficit model — in essence, challenging the idea that community members are "deficient" in understanding. But concepts like MDA are genuinely complex. In many of our studies across Southeast Asia, people have questioned the rationale: Why take medicine when you're apparently healthy?

This isn't ignorance — it’s a natural and valid response. Some of your co-authors have long studied how MDA is perceived, especially in the context of asymptomatic malaria. As you rightly emphasize, the answer isn’t to preach but to communicate with respect and clarity. Still, informed participation requires explanation — what is MDA, how does it work, and why is it necessary? Trust (but not blind placed trust) matters, yes, but so does making the concept understandable — that’s the essence of meaningful informed consent, isn’t it?

Additional Reflection: Social Cohesion

As a collaborator of multi-disciplinary research, we also found lack of social cohesion to be a major factor in MDA participation — particularly along the Thai–Myanmar border. Political divisions within communities, or tensions between ethnic groups, heavily influenced community responses. In contrast, settings like Laos and Cambodia, with stronger cohesion, saw greater participation. You might find that experience relevant and worth integrating into your discussion.

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Reviewer #1: No

Reviewer #2: No

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Dear Dr. Chambers,

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 Dec 05 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.

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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,

Pyae Linn Aung

Academic Editor

PLOS ONE

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If the reviewer comments include a recommendation to cite specific previously published works, please review and evaluate these publications to determine whether they are relevant and should be cited. There is no requirement to cite these works unless the editor has indicated otherwise.

Additional Editor Comments :

Thank you for revising the manuscript in response to the reviewers’ comments. As one of the reviewers is unavailable for the second round, I have read the revised version from an editorial perspective. Please see my comments below.

1. In the abstract, the Methods section should specify the target population and indicate the timeline of data collection (e.g., before or after the trial). The total sample size (n = 75) should be clearly categorized by data collection method (e.g., FGDs, IDIs, etc.).

2. In the Introduction, it would be useful to acknowledge the recent resurgence of malaria in Indonesia. Additionally, please clarify that different Anopheles species exhibit varied host-seeking behaviors, some are zoophilic, while others are anthropophilic, given that the intervention in this trial targeted only animals.

3. The Methodology section requires particular attention. The map should include a north arrow for clarity. The sampling strategy is unclear: please explain how participants were selected for each data collection method to ensure representativeness across study areas. Line 141 mentions gender balance, yet the majority of participants were male; moreover, Lines 148–149 indicate that women were uncomfortable participating in FGDs, which further limited female representation. This suggests that the findings primarily reflect male perspectives. Please describe the tools used for each data collection method, and consider attaching them as supplementary materials. Explain how responses were recorded, given that only one researcher conducted the data collection with assistance from a translator. Clarify the process of language translation and ensure the NVivo software is properly cited.

4. Line 202: Participants included government officials, health cadres, community leaders, and livestock owners. Given their differing social roles and backgrounds, please explain how you ensured that all voices were equally represented during discussions.

5. Line 204: Please clarify what is meant by “their experience.” For example, does this refer to years of livestock farming or another indicator?

6. Although multiple qualitative methods were employed, the manuscript contains very few participant quotes. Including more direct quotations would strengthen the findings and illustrate key themes. Given the diversity of participants’ socioeconomic and demographic backgrounds, it would also be useful to identify the speaker type (e.g., community livestock owner, government official) when quoting, as their perspectives likely differ.

7. Lines 290–310 discuss ivermectin MDA for humans. Please clarify how you ensured that participants understood the purpose of the drug when applied to humans, particularly since they observed its use in animals. This could have caused confusion about whether a drug given to animals is safe or appropriate for human use.

8. Several sentences should be reviewed for technical accuracy and precision. For example, Lines 24–25: not all Anopheles species transmit malaria. Lines 68–69: the claim that having many Anopheles species makes vector control difficult should be reconsidered or supported with evidence.

9. All references need to be revised to conform to the journal’s formatting requirements, both in the reference list and in-text citations. For instance, see Lines 371 and 433.

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

Reviewer #2: All comments have been addressed

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

Reviewer #2: Yes

**********

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

Reviewer #2: N/A

**********

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

The PLOS Data policy

Reviewer #2: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English??>

Reviewer #2: Yes

**********

Reviewer #2: (No Response)

**********

what does this mean? ). If published, this will include your full peer review and any attached files.

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Reviewer #2: No

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Community perceptions and acceptance of ivermectin for malaria control on Sumba Island, Indonesia

PONE-D-25-10247R2

Dear Dr. Chambers,

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.

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Kind regards,

Pyae Linn Aung

Academic Editor

PLOS One

Additional Editor Comments (optional):

Thank you to the authors for improving the manuscript in response to my comments. For me, it is now acceptable, although I still notice some typographical errors and inconsistencies in reference formatting. Please review and correct these during the proofing stage, especially since PLOS does not provide editorial editing support.

Reviewers' comments: