Feasibility and acceptability of research-grade wearables for health and labor capacity monitoring in the context of climate change and heat stress: The case of Nouna, Burkina Faso

Georgi Zout; Celine Höver; Edgar Eggert; Hanns-Christian Gunga; Lucienne Ouermi; Ali Sié; Sophie Huhn; Aditi Bunker; Sandra Barteit; Stefan Mendt; Martina Anna Maggioni

doi:10.1371/journal.pone.0330835

Peer Review History

Original SubmissionJuly 29, 2024
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Has the statistical analysis been performed appropriately and rigorously? -->?> Reviewer #1: Yes 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: No ****** 4. Is the manuscript presented in an intelligible fashion and written in standard English??> Reviewer #1: No Reviewer #2: Yes ****** Reviewer #1: The purpose of this investigation was to evaluate the feasibility (data completeness and quality) and acceptability of implementing research grade wearable devices in a rural setting of Nouna, Burkina Faso. While this study was very novel, there are several major limitations. First, the study focuses on sex differences in feasibility and acceptability. However, this does not appear the purpose of the study. It is also unclear the purpose of comparing indoor and outdoor WBGT measurements outside of feasibility and acceptability. It is important for the survey to be developed systematically. The authors need to expand on how the survey was developed to ensure the questions align with the study objectives. Below are several items that authors must consider before a deeper evaluation of the manuscript. Abstract: Line 28-29: sentence needs to be revised for clarity Line 39: what does it mean by data was “very” Line 39: data should be plural consistenly throughout the manuscript Introduction: Line 48: has increased by 1.1? Line 53: The sentence needs to be revised. The term “heat stress” refers to the heat load (i.e., environmental conditions, physical exertion, and PPE). It appears the authors are referring to heat illness in this statement. Line 109: It is unclear what the authors are referring to by “closing the gap”. Does this mean that the assessment of physiological responses hasn’t been done before? Authors should consider how the collection of physiological responses would benefit workers in SSA. Authors are encouraged to consider how this information, after collected, will benefit the SAA inhabitants. Methods Line 137: what is the rationale for including men and women who are from the same household? Is this referring to the main residence? If not, authors should define the term “household”. Line 154: author should clarify how many total study visits. Is the first visit part of one of two, study “runs”? Line 155: make and model of device? What height was the environmental monitor placed at ? Line 185: it should be noted that it is an estimation of core body temperature (not a direct measure) The methods for the survey development should be clearly outlined in the methods section. Data analysis It is unclear if data analysis is performed on environmental data. - The variables being collected should be included in the data analysis section (ex. Sleep duration,step count, sleep efficiency) for clarity. A comparison between sexes is not mentioned before the data analysis section. It should be included previously. Results -There is no mention of collection of blood pressure in the methods section. -Line 247: what was used to determine data quality for WBGT? - Line 248-251: Authors should consider whether the inclusion of a comparison between indoor and outdoor WBGT should be removed since the overall objective of the study is assessment of data quality and feasibility of implementation. -Line 260-266: what criteria was used to determine data completeness and quality for GPS and ACT? - the comparison of men and women does not appear to be an objective of the study. -304-307: it is unclear whether the thematic subsections were chosen before or after the questionnaire was completed by participants. If it was performed before, the methods should be outlined in more detail and it should be Reviewer #2: This is a valuable report that discusses the potential of wearable devices in the harsh environment of Africa. However, there are a number of places throughout the report where the description is insufficient. In addition, there are some places where the experimental methods and interpretation of the results are not fully explained. Please consider making revisions, focusing on the points we have commented on. L.25: You write ‘mean ambient temperatures of 1.5°’, but the unit of temperature should be ‘°C’, not ‘°’. L.64: You mention‘even moderate heat stress (18° WBGT)’, but WBGT 18°is really ‘moderate heat stress’? In the reference cite, it seems to be mild heat stress. Also, 18° and 40° are inappropriate units, and should be °C. L89: Why is PSI not used in this study, even though it is mentioned as an excellent indicator here? If possible, please mention it L.153-156, L.172-173: Please clearly state the names of the devices used in the main text, not just in Figure S2. lso, please describe how the portable WBGT meter used here calculates WBGT. The method specified in ISO 7243 is the only correct method for WBGT, and if a different method is used, it is considered to be nothing more than an estimate, so you need to show in the literature, etc., how the estimate was made. Otherwise, you should indicate that these values are merely estimates. L170-172: What measurement factors were used to estimate WBGT in this measurement system, and how was it estimated? Please specify this in the main text so that it is clear to those who have only read this paper, rather than just citing reference 28. In addition, I have looked at Reference 28, and while there is a certain degree of correlation between the methods for estimating WBGT from meteorological observation data, they are not yet established, and it is thought that more data is needed. It is thought that WBGT is correct when measured using the method specified in ISO 7243, and that the accuracy of WBGT measured using other methods needs to be considered. L.175: Fig. S3 contains technical information on environmental measurements, but this information is completely inadequate. As mentioned above, please clearly state what measurements were taken and how the WBGT value was calculated (or estimated). L177-178: You use a wrist-mounted accelerometer, but can you understand the activity status of the whole body with a wrist-mounted accelerometer? I think it would be better to cite any references you have on this point. L180: Please cite the R package used and also the references for each calculated value. L183: There is a missing period after ‘during nightly rest [30,31]’. L185-188: The deep body temperature is measured using a heat flux sensor attached to the forehead, but there is a lack of information about the validity of this. You cite reference 33, but this reference only measures CBT in the same way as this report, and does not demonstrate its validity. It seems that the paper cited in reference 33 should be cited, not reference 33? Please re-examine the validity of the cited references. Furthermore, it is our understanding that the estimation of deep body temperature using this method is not yet established, and there is debate about its validity. I think this point should be mentioned in the discussion. L188-189: Please either provide details of the ‘custom-made headband’ or a list of references. L193: Please include information that will allow readers to reproduce ‘the native software’. L197-198: We have checked the WBGT device, and it appears to be a product made by Canmore in Taiwan, not Germany. Please be more precise in your description. https://asset.conrad.com/media10/add/160267/c1/-/en/001217431ML03/manual-1217431-renkforce-gp-102-g-porter-gps-logger-blue-black.pdf L214-218, L269-271: The quality of data is evaluated by asking whether ‘all possible data points exist in the valid data set’, but is this enough to determine validity? If the accuracy of the data is not evaluated, it is difficult to evaluate the quality, isn't it? Please include your thoughts on this point in your discussion. L246: The data integrity is said to have reached 85%, but what is the reason for the remaining 15% not being complete? Please describe this in your consideration to the extent possible L247-248: You write 'No decline in data quality was observed', but how did you determine that there was no decline in quality? L249-250: It says that the indoor WBGT was higher than the outdoor WBGT, but normally, the WBGT is thought to be higher outdoors, where the black globe temperature is higher. Please describe in the discussion section any possible reasons why the indoor WBGT was higher this time. In addition, different methods are used to measure indoor and outdoor WBGT. These differ from the methods specified in ISO 7243, so is it possible to compare indoor and outdoor WBGT in this situation? Please consider this point as well. L314-318: Did the tendency to make negative statements about receptivity differ depending on the type of wearable device? Please describe this to the extent possible, as there is a possibility that receptivity will differ depending on the type of device. If you did not obtain any data, please state this in the discussion. L326-327: The same applies here as above. Were there any differences between the types of device? ****** 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. https://doi.org/10.1371/journal.pone.0330835.r001
Revision 1
24 Jun 2025 Author Response Reviewer comment: The purpose of this investigation was to evaluate the feasibility (data completeness and quality) and acceptability of implementing research grade wearable devices in a rural setting of Nouna, Burkina Faso. While this study was very novel, there are several major limitations. First, the study focuses on sex differences in feasibility and acceptability. However, this does not appear the purpose of the study. It is also unclear the purpose of comparing indoor and outdoor WBGT measurements outside of feasibility and acceptability. It is important for the survey to be developed systematically. The authors need to expand on how the survey was developed to ensure the questions align with the study objectives. Below are several items that authors must consider before a deeper evaluation of the manuscript. Authors response: Thank you for your detailed and constructive feedback. We appreciate your highlighting of the limitations regarding the focus on sex differences and the rationale behind comparing indoor and outdoor WBGT measurements. In response, we have revised the manuscript to clearly delineate our primary objectives related to evaluating feasibility and acceptability. Additionally, we have expanded the section on survey development to explain systematically how the questionnaire was developed. We addressed the raised issues and adjusted our text accordingly as provided in the table above. We believe these improvements enhance both the clarity and scientific rigor of our study, and we thank you once again for your insightful commentary. Line 28-29: sentence needs to be revised for clarity Thank you, for the suggestion. We revised the sentence, please see L. 27-29. Line 39: what does it mean by data was “very” Thank you for bringing this to our attention, we rewrote this passage. Please see L. 40. Line 48: has increased by 1.1? Thank you for your valuable suggestion. We have considered your critique. Our reasoning for phrasing it this way is, that the process of global warming, indicating and increase in temperatures within the word itself, is often referenced in relation to pre-industrial temperature recordings (considered as a sort of baseline). Therefore, we wrote that global warming has “reached 1.1°C relative to pre-industrial levels”. Line 53: The sentence needs to be revised. The term “heat stress” refers to the heat load (i.e., environmental conditions, physical exertion, and PPE). It appears the authors are referring to heat illness in this statement. Thank you very much for your suggestion on rephrasing this sentence. We agree with your observation. We rephrased the sentence for precision of language and to express the train of thought more clearly. Please see L. 53-54. Line 109: It is unclear what the authors are referring to by “closing the gap”. Does this mean that the assessment of physiological responses hasn’t been done before? Authors should consider how the collection of physiological responses would benefit workers in SSA. Thank you very much for mentioning this. The application and translation of our research to the benefit of the local community and population is a very important and foundational aspect of our work. To emphasize this in our manuscript we adjusted the text accordingly, please refer to L. 108-115. Authors are encouraged to consider how this information, after collected, will benefit the SAA inhabitants. Thank you. Please refer to our reply above and to L. 108-118. Line 137: what is the rationale for including men and women who are from the same household? Is this referring to the main residence? If not, authors should define the term “household”. Thank you for mentioning this. Yes, household does refer to the main residence. The rationale for including men and women, meaning couples, who share the same household, or main residence, if you will, is to increase protocol adherence, as well as ensure lower drop-out rates and streamline sample planning and recruitment procedures. Further, it allows us to include both men and women to evaluate the feasibility of our approach more thoroughly including a gender-specific perspective. In order to clarify this, we updated the according section of the manuscript, please see L. 144-145. Line 154: author should clarify how many total study visits. Is the first visit part of one of two, study “runs”? Thank you for bringing this to our attention. Each study run had a duration of two weeks. There were a total of three contacts with participants during each respective two-week run. The first visit was to the respective participants’ household, where an explanation of procedures, obtainment of informed consent, an entry survey, the handout of a wrist- worn accelerometer, and the positioning of indoor WBGT device were undertaken. The second visit was done by the participants to an assigned health care facility, where they received sensors for 24-h continuous measurements, and underwent Bio-impedance analysis and a medical check-up. Finally, the third visit was again done by the participants to the assigned health care facility at the end of the two-week run, whereupon participants returned the respective wearables and the WBGT sensor and underwent the acceptability questionnaire. We revised the respective section of the manuscript, to further clarify the study procedure for readers. Please refer to L. 158-159. Line 155: make and model of device? What height was the environmental monitor placed at? Thank you for bringing this to our attention. We name the make and model of the device later in the text, see L. 190-191. As for the height the monitor was placed at, it was fixated on a wall out of reach from children at a height of about 170 cm. We now added this information to the manuscript, please see L. 191-193. Line 185: it should be noted that it is an estimation of core body temperature (not a direct measure) Thank you very much for outlining this. We checked our manuscript for clarity on this subject and refer to the estimation of core body temperature as monitoring, to avoid confusion. To further outline this distinction, we updated our discussion accordingl. There we thoroughly examine the merit of the dual heat-flux method for core body temperature estimation. Please see L. 475-487. The methods for the survey development should be clearly outlined in the methods section. We appreciate your instructive critique on this point. The survey was developed jointly by our PI, our co-projects within the research unit and the local study coordinator. It was originally designed in English and later translated to our participants’ native language (French). This is specified in our methods section in L. 227-231. We additionally updated the information in L. 225-228 to better reflect the process of developing our survey. It is unclear if data analysis is performed on environmental data. Thank you for bringing this unclarity to our attention. During the process of revising and streamlining our manuscript, we primarily focused on checking environmental data for completeness and removing outliers, if present, that the indoor hygrometer should not be able to measure. Please see L. 267-269, 328-330. The variables being collected should be included in the data analysis section (ex. Sleep duration,step count, sleep efficiency) for clarity. Thank you for addressing this issue. During the revision process, we shifted our focus to appropriately demonstrate the primary aim of our study, namely the feasibility of equipping a rural population in SSA with wearables for a prolonged time. We adjusted our data processing and analysis, accordingly, now evaluating data completeness and, if possible, data quality. Therefore, we decided to not include derived calculated data such as sleep duration or step count into our analysis, as it went beyond the scope of this investigation. Instead, we focused on presenting the raw accelerometric data and exploring its completeness/the validity of measurement. A comparison between sexes is not mentioned before the data analysis section. It should be included previously Thank you for this suggestion. We intended to primarily show the technical feasibility and social acceptability of our approach and setup. However, we acknowledge, that perception and acceptability vary between genders, most probably due to behavioral factors. To specify this, we added accordingly to our results section, portraying gender-specific differences we assessed through our acceptability questionnaire. Additionally, we provide a comparison for anthropometric data. To not confuse readers, we now included a specification, that we intend to show some comparisons between men and women in the data analysis section of the methods. Please see L. 280-282. There is no mention of collection of blood pressure in the methods section. Thank you for mentioning this. The blood pressure measurement was part of the medical check-up and the successive assessment of anthropometric data. However, to clarify this for readers, we have updated this part of the methods section and included the specific measurements taken during medical check-up. Please see L. 172-174. Line 247: what was used to determine data quality for WBGT? Thank you for inquiring this. To ensure quality we relied on previously developed methodology. We directly measured for indoor WBGT implementing a portable hygrometer, which operates according to the method specified in ISO 7234 (WBGT without solar load = 0.7 × Tₙwᵦ + 0.3 × Tg). We estimated outdoor WBGT by gathering data from an automated weather station and applying the method developed by Carter et al. We acknowledge that the calculation based on the work of Carter et al. is a novel approach, that requires further validation and application to heighten its reliability. However, it still constitutes a feasible approach in our given setting. For additional clarity, we now address this in our revised discussion. please see L. 527-546. Line 248-251: Authors should consider whether the inclusion of a comparison between indoor and outdoor WBGT should be removed since the overall objective of the study is assessment of data quality and feasibility of implementation. Thank you very much for pointing this out, as it was a significant input for adjusting and refining our work. After consideration and revision, we decided, that to focus our work more on the primary goal of exploring the technical feasibility of our approach, we will exclude any comparisons that are beyond its scope. That is why, excluded comparison of WBGT. Line 260-266: what criteria was used to determine data completeness and quality for GPS and ACT? We appreciate your inquiry, as it helps to refine and adjust our manuscript. We acknowledge a lack of clarity in the previous version of our manuscript. To address this, we adjusted and redid parts of our data analysis and processing, focusing more on factors relevant for the primary objective, the technical feasibility of employing wearables for prolonged monitoring in rural SSA. Therefore, ACT data, which is a continuous accelerometric data stream and not directly physiological data with established cut-off values (for excluding outliers), was solely analyzed for data completeness. Here we decided to declare data points valid/complete, if the GENEActiv has truly been worn during measurement, which we determined by analyzing the near-body temperature it records. We applied the same reasoning to GPS data, focusing primarily on data completeness, as it is also not physiological data with established cut-off values. For our adjusted methodology please see L. 257-267. the comparison of men and women does not appear to be an objective of the study Thank you for pointing this unclarity out. Please see our response above. 304-307: it is unclear whether the thematic subsections were chosen before or after the questionnaire was completed by participants. If it was performed before, the methods should be outlined in more detail and it should be Thank you for the instructive feedback. Indeed, the questionnaire was designed in advance by the PI and the local study coordinator. It was based on previous experience and the knowledge of the community. We grouped the questionnaire into fixed thematic subsections after administering it. We took your suggestions into consideration and specified this in the updated text, please refer to L. 240-244. Reviewer comment: This is a valuable report that discusses the potential of wearable devices in the harsh environment of Africa. However, there are a number of places throughout the report where the description is insufficient. In addition, there are some places where the experimental methods and interpretation of the results are not fully explained. Please consider making revisions, focusing on the points we have commented on. Authors response: We thank you for your insightful and constructive commentary, which has been invaluable in refining our work. We acknowledge that some areas of our report required more detailed descriptions and clearer explanations of our experimental methods and results interpretation. In response, we have thoroughly revised these sections to provide additional context and clarity, ensuring that our methodology and findings are more comprehensively presented and reproducible. We addressed the raised issues and adjusted the manuscript processing accordingly as presented in detail in the table above. Our revisions include expanded details on the data collection process, adjustments in data processing and analysis, and a more rigorous discussion of our methodology and the implications of our results. We are confident that these improvements enhance the overall clarity and scientific rigor of our report. Thank you again for your thoughtful feedback, which has significantly contributed to the revision process and general quality of our manuscript. L.25: You write ‘mean ambient temperatures of 1.5°’, but the unit of temperature should be ‘°C’, not ‘°’. Thank you for pointing this out, we have adapted this accordingly. L.64: You mention‘even moderate heat stress (18° WBGT)’, but WBGT 18°is really ‘moderate heat stress’? In the reference cite, it seems to be mild heat stress.Also, 18° and 40° are inappropriate units, and should be °C. Thank you very much for bringing this to our attention. We agree that the terminology must be adjusted accordingly and have done so in the manuscript. Please see L. 65. To clarify, we chose the reference in question as the authors present novel insights on heat stress, especially so-called mild heat stress, which was formerly considered to have at best minimal effects on physical work capacity. The authors juxtapose their findings to established thresholds previously published, for example by Kjellström et al., and argue that heat stress even at as low as 18°C WGBT has been previously underestimated regarding its effect on the reduction of physical work capacity. L89: Why is PSI not used in this study, even though it is mentioned as an excellent indicator here? If possible, please mention it Thank you very much for this suggestion. We do agree that this is an important consideration. Our overarching goal is to create a platform for future investigations into occupational heat stress, including the adaption of indices such as PSI to ultimately enable the development of preventive and adaptive strategies. To demonstrate the feasibility and suitability of our methodological approach for such a goal, we added the calculation of PSI to our manuscript. We based the calculations on the works of Davey et al. and Byrne et al. Please see L. 253-257. L.153-156, L.172-173: Please clearly state the names of the devices used in the main text, not just in Figure Thank you for addressing this. The names of the implemented devices are cited later in the methods section of the manuscript within the sections dedicated to monitoring. We indeed checked once again on the completeness of the stated information and if needed adjusted it accordingly. Please see L. 200, 207-207, 213, 218. lso, please describe how the portable WBGT mete Attachments Attachment Submitted filename: Response to Reviewer 2.docx https://doi.org/10.1371/journal.pone.0330835.r002
7 Aug 2025 Decision Letter - Hidenori Otani, Editor Feasibility and acceptability of research-grade wearables for health and labor capacity monitoring in the context of climate change and heat stress: the case of Nouna, Burkina Faso PONE-D-24-28297R1 Dear Dr. Zout, 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. For questions related to billing, please contact billing support . 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, Hidenori Otani, Ph.D. Academic Editor PLOS ONE Reviewers' comments: Reviewer's Responses to Questions Comments to the Author Reviewer #1: All comments have been addressed Reviewer #2: All comments have been addressed ******** 2. Is the manuscript technically sound, and do the data support the conclusions??> Reviewer #1: (No Response) Reviewer #2: Yes ****** 3. Has the statistical analysis been performed appropriately and rigorously? -->?> Reviewer #1: (No Response) Reviewer #2: Yes ****** 4. Have the authors made all data underlying the findings in their manuscript fully available??> The PLOS Data policy Reviewer #1: (No Response) Reviewer #2: Yes ****** 5. Is the manuscript presented in an intelligible fashion and written in standard English??> Reviewer #1: (No Response) Reviewer #2: Yes ****** Reviewer #1: (No Response) Reviewer #2: Thank you for reviewing the revised manuscript. I have confirmed that you have responded appropriately to the review comments. Therefore, I have decided to accept this manuscrip ****** 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 ******** https://doi.org/10.1371/journal.pone.0330835.r003
Formally Accepted
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Open letter on the publication of peer review reports

PLOS recognizes the benefits of transparency in the peer review process. Therefore, we enable the publication of all of the content of peer review and author responses alongside final, published articles. Reviewers remain anonymous, unless they choose to reveal their names.

We encourage other journals to join us in this initiative. We hope that our action inspires the community, including researchers, research funders, and research institutions, to recognize the benefits of published peer review reports for all parts of the research system.

Learn more at ASAPbio .