Dear Dr. Adongo,

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.

Could you please carefully revise the manuscript to address all comments raised?

Please submit your revised manuscript by Feb 28 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.

• 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,

Avanti Dey

Staff 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 include a complete copy of PLOS’ questionnaire on inclusivity in global research in your revised manuscript. Our policy for research in this area aims to improve transparency in the reporting of research performed outside of researchers’ own country or community. The policy applies to researchers who have travelled to a different country to conduct research, research with Indigenous populations or their lands, and research on cultural artefacts. The questionnaire can also be requested at the journal’s discretion for any other submissions, even if these conditions are not met.  Please find more information on the policy and a link to download a blank copy of the questionnaire here: https://journals.plos.org/plosone/s/best-practices-in-research-reporting. Please upload a completed version of your questionnaire as Supporting Information when you resubmit your manuscript.

3. Thank you for stating the following in your Competing Interests section:  No competing interest

Please complete your Competing Interests on the online submission form to state any Competing Interests. If you have no competing interests, please state ""The authors have declared that no competing interests exist."", as detailed online in our guide for authors at http://journals.plos.org/plosone/s/submit-now 

 This information should be included in your cover letter; we will change the online submission form on your behalf.

4. We note that you have indicated that there are restrictions to data sharing for this study. For studies involving human research participant data or other sensitive data, we encourage authors to share de-identified or anonymized data. However, when data cannot be publicly shared for ethical reasons, we allow authors to make their data sets available upon request. For information on unacceptable data access restrictions, please see http://journals.plos.org/plosone/s/data-availability#loc-unacceptable-data-access-restrictions. 

Before we proceed with your manuscript, please address the following prompts:

a) If there are ethical or legal restrictions on sharing a de-identified data set, please explain them in detail (e.g., data contain potentially identifying or sensitive patient information, data are owned by a third-party organization, etc.) and who has imposed them (e.g., a Research Ethics Committee or Institutional Review Board, etc.). Please also provide contact information for a data access committee, ethics committee, or other institutional body to which data requests may be sent.

b) If there are no restrictions, please upload the minimal anonymized data set necessary to replicate your study findings to a stable, public repository and provide us with the relevant URLs, DOIs, or accession numbers. Please see http://www.bmj.com/content/340/bmj.c181.long for guidelines on how to de-identify and prepare clinical data for publication. For a list of recommended repositories, please see https://journals.plos.org/plosone/s/recommended-repositories. You also have the option of uploading the data as Supporting Information files, but we would recommend depositing data directly to a data repository if possible.

Please update your Data Availability statement in the submission form accordingly.

[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?

Reviewer #1: Yes

Reviewer #2: Yes

**********

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

Reviewer #1: N/A

Reviewer #2: Yes

**********

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

**********

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

Reviewer #1: Yes

Reviewer #2: Yes

**********

Reviewer #1: The manuscript is presented in a clear and logically manners, contains very minimal typing errors and is very easy to follow.

Comments

This study is about barriers to exclusive breastfeeding and replacement feeding and provides interesting and valuable insights into the situation as it exists in Ghana. The authors are commended for conducting this important study.

Below please receive my minor inputs

1. There are two titles which present different variables, though related. However, this is confusing in light of the contents of the article and the conclusions drawn. My input was based on the title: ‘Breastfeeding complexities and sociocultural barriers in the context of preventing perinatal transmission of HIV’. This is theme that seemed to run through the article. This is however in conflict with the title of the manuscript shared by the journal: Indigenous Breastfeeding Beliefs and Practices in Rural Northern Ghana: A Study Among HIV-positive Mothers

The authors are advised to explicitly state the title of this manuscript.

Abstract:

Purpose:

2. Replace replacement breastfeeding with replacement feeding. Please effect this change throughout the manuscript where replacement feeding is referred to as replacement breastfeeding.

3. The authors are advised to include a phrase ‘as an alternative where feasible’ between ‘excusive breastfeeding and replacement feeding’ in the sentence to make it clear that replacement feeding is not equated to exclusive breastfeeding. Or any phrase of the authors choice

Methods

Describe the population and sampling method

Results:

4. Remove the discussion about foremilk. Include only the themes and (subthemes, if the word count allows).

5. Sentence starting with ‘factors influencing exclusive breastfeeding… ‘ . Mention those factors and remove all points that relate to the discussion of findings.

Keywords:

6. Suggestion to include barriers

Introduction

7. After the 1st paragraph, please describe the PMTCT programme. As well take the reader through the situation before PMTCT and its success and perhaps gaps as an introduction to the study. The authors are also advised to give some background related to the benefits of exclusive breastfeeding within the HIV context and replacement feeding as an alternative. Inclusion of some actual studies would add some depth to the introduction.

The use of the term ‘further’ in the sentence starting with: ‘cultural perceptions of breastfeeding among pregnant and postpartum women’ gives the impression that other factors have been discussed already. Please revise the use of the term ‘further’.

The authors are advised to make reference to existing studies related to breastfeeding practices among HIV positive women elsewhere and briefly outline some of those practices. The last paragraph before the theoretical framework: please include the perinatal period as well, as implicated within the manuscript’s contents.

The use of the term adherence in the last paragraph of the introduction may need to be revised or be extended by including barriers as well

8. Theoretical framework

The discussion on the theoretical framework can be removed. The framework details the phenomenological framework, which is not the main focal point of this study. More attention could rather be paid to the introduction and background to this study.

Research methods

Study setting and design

9. Explain what ‘traditional marketing’ refers to.

10. It is not clear how the teenage pregnancy rates relate to this manuscript. Consider revising its inclusion or alternatively, expand on its significance. Were the clinics only servicing HIV positive patients?

11. Again there is extensive description of the descriptive phenomenology’ . The authors are advised to summarise the concept within the design section and move aspects related to trustworthiness and analysis to the relevant sections of the manuscript.

12. Revise the data collection period included in the study. The period is mentioned as April – Dec, whereas it is mentioned as March – Sept in the data collection section.

Participants and recruitment criteria

13. In exploring the registers, explain how far long back the authors went in identifying the respondents for inclusion into the study (number of years/months).

14. Please explain how the participants were accessed. Were they called on their phones? Visited in their homes? Recruited on the day of consultation?

15. Explain how the sample size of 32 was decided upon.

Data collection tool and procedure

16. Explain what is meant by ‘data collection was carried out systematically……

17. It is not clear who was subjected to informal interviews and who took part in in-depth interviews, whether the same tool was used or not or the reasons for using different approaches to data collection.

18. There are a number of statements that need to be referenced as they represent other author’s ideas.

19. Did both the informal and in-depth interviews last for 45 -60 min?

20. Expand on the tool a bit- how it was designed and the actual questions included in the interview guide or themes

21. Explain whether a co-coder was involved or not

22. Explain how data was analysed: whether inductive, deductive or abductive?

Ethical statement

23. Remove ‘this PhD thesis…

Results

24. Suggestion to present the sociodemographic data in a Table format

25. It is not clear how the authors determined the factors contributing to MTCT mentioned under the sociodemographic data (refusal to attend antenatal care, etc.) since no statistical tests were run, unless mothers explicitly said so. Please revise.

Presentation of results:

26.Within the first sentence in this section, the authors refer to results related to breastfeeding practices and nothing is mentioned about the barriers as per the title (this raises confusion as this very statement relates to one of the title and not the title that seems to be aligned with the current manuscript). The authors are advised to relook the terminologies used, or otherwise explain links between practice and attitudes (how one was derived from the others, if this was the case).

The authors are advised to compare the themes outlined here as opposed to the ones mentioned in the introduction. Please align the two sections. E.g foremilk being perceived as toxic, being mentioned in the abstract and not the results section, etc. (It would be useful to include the questionnaire as an appendix. This would assist in reviewing the themes presented).

27. Breastfeeding as a long-standing practice. The use of the term mothers is suggested, instead of HIV positive mothers.

28. Traditional infants water feeding as a cultural practice. Use the term forcefully instead of forcibly. Also use the correct noun instead of ‘it’ in the phrase: ‘Beliefs it improves infants health’.

29. Influence of older women in the family. Do the mothers-in-law imply that exclusive breastfeeding denies the child to get employment later in life? Please explain.

30. Challenges in food availability: I am checking if zoomkoom is made from water or fruit juice, in light of the fact that it is high in vitamin C? please verify or ignore if correct. The authors are advised to relook into the statement that zoomkoos serves as breastmilk, rather use the term ‘lactogogue’ when referring to mothers, maybe?

Discussion

31. The discussion and the conclusion sections are too long. The authors are advised to be succinct and to the point.

32. New results are presented in this section, there is a bit of repetition and the authors are advised to rework the sections

Reviewer #2: Dear researcher,

You have done an important and meaningful study that contributes to the field.

Thank you for your efforts.

I have carefully reviewed your article.

Some corrections need to be made.

I have written the necessary clarifications for you in the attached file.

Please read these carefully and take them into consideration.

I wish you success.

**********

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

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.

Attachments

Attachment

Submitted filename: Comments_Indigenous breastfeeding knowledge.docx

Attachment

Submitted filename: PONE-D-24-40482.pdf

Dear Dr. Adongo,

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 Jul 24 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.

• 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 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,

Jennifer Yourkavitch

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.

Additional Editor Comments:

Thank you for this submission. Please note that these last few comments come from the editor, not the reviewers.

1. In your description of Descriptive Phenomenology, you emphasize the researcher as an outside, neutral observer but you don't describe anywhere the relationship of the researcher to the community being studied. For transparency and in keeping with your methodology, could you describe the relationship of the researchers to the community being studied, in terms of geographical, cultural, or experiential overlap? This analysis may be best placed just above or before the ethical statement. If there are overlaps that compromise the researchers' impartiality, please discuss that in the Limitations section.

2. "Data" is a plural term. Please correct verb agreement throughout the manuscript. For example, on p. 11, "The data were gathered...." rather than, "The data was gathered...."

3. p. 17, first paragraph under "Presentation of Results," the work "role" is missing from the sentence stating, "The customary role of mothers-in-law...."

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

Reviewer #2: All comments have been addressed

**********

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: Yes

**********

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:  The research complies with ethics.

It does not pose an ethical risk in its publication.

I believe that the research will contribute to the literature.

**********

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: Yes:  Uyar Hazar

**********

[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

Breastfeeding complexities and sociocultural barriers in the context of preventing perinatal transmission of HIV: A descriptive phenomenology in Northern Ghana

PONE-D-24-40482R2

Dear Dr. Adongo,

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,

Jennifer Yourkavitch

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments: