Healthcare providers’ knowledge on sickle cell disease and its management: A pre- and post-training test evaluation outcome

Vivian Paintsil; Evans Xorse Amuzu; Eunice Ahmed; Yaa Gyamfua Oppong-Mensah; Lesley Osei; Bernice Eklu; Suraj Yawnumah Abubakar; Lawrence Osei-Tutu; Daniel Ansong; Alex Osei-Akoto; Fred Stephen Sarfo

doi:10.1371/journal.pone.0332069

Peer Review History

Original SubmissionApril 21, 2025
15 May 2025 Decision Letter - Santosh L. Saraf, Editor Dear Dr. Paintsil, Please submit your revised manuscript by Jun 29 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'. 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Saraf Academic 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 amend either the title on the online submission form (via Edit Submission) or the title in the manuscript so that they are identical. 3. Please amend your list of authors on the manuscript to ensure that each author is linked to an affiliation. Authors’ affiliations should reflect the institution where the work was done (if authors moved subsequently, you can also list the new affiliation stating “current affiliation:….” as necessary). 4. 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Please include captions for your Supporting Information files at the end of your manuscript, and update any in-text citations to match accordingly. Please see our Supporting Information guidelines for more information: http://journals.plos.org/plosone/s/supporting-information. 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: 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: No 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: This is an interesting article evaluating the impact of a structured training program on healthcare providers’ knowledge of SCD in Ghana. While educating providers about SCD is critical, this pilot study is somewhat limited and has a few significant biases. However, it is a large-scale educational project with some important characteristics. Below are some of the limitations and possible areas to improve the impact of the manuscript. Major Concerns: 1) Lack of use of a validated instrument for the knowledge test is a significant concern. a. Several questions are unrelated to sickle cell disease (e.g., #7); it is unclear what the intent is of these questions that may not be directly related to sickle cell knowledge. b. Numerous acronyms are present that may be confusing and may limit participants’ ability to respond accurately (e.g., #8,10). c. It would be helpful to include more background about how these questions were made. d. Was there any validation of these questions? If not, this is a major limitation. 2) There is likely a large knowledge gap between the different occupations, as is noted in the baseline score, and some of the occupations have a more critical role in the treatment of sickle cell disease; therefore, it would be important to know the differences between the occupations for the following: a. A breakdown of the different occupations’ completion of the pre- and post-test is needed b. Table 3 would be important to be broken down by occupation. c. Also, the pre- and post-test differences (Tables 4 and 5) would be interesting if they were analyzed by occupation. 3) Measuring knowledge before and after a single in-person workshop limits the impact of this manuscript. This pilot may not translate to affecting patient care; however, it is a large-scale training, involving many healthcare professionals in Ghana. The manuscript could also mention the importance of measuring patient-care outcomes after this intervention. 4) There is a notable drop-off from those who participated to those who had a pre- and post-test, 55%. a. This is a very large limitation and should be noted in the limitations section. b. It would be important to include a supplementary table describing the differences in demographics, profession, and other components between those who gave that information but did not complete the post-test. Minor concerns: 1) Including the slides of the workshop would be helpful for others who might want to replicate the work. 2) The score cut-off of 10 is arbitrary. Is there any justification that could make this a reasonable cutoff? If not, consider removing this cutoff and the concept of passing and failing from the manuscript. Reviewer #2: Comprehensive work and well written. i wonder why the cut offs were 0-10 and 11-20. Perhaps having in 3 groups (poor, fair, great) will give a real idea of the difference between pre and post test in various groups. ****** 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: Yes: Marwah Farooqui ******** [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: PLOS reviewer comments.docx https://doi.org/10.1371/journal.pone.0332069.r001
Revision 1
27 Jul 2025 Author Response Dear Reviewers and Editor, Point-to-point response to reviewers’ comments We would like to thank the reviewers and editor for their critical revision and valuable comments which had a tremendous effect on improving our manuscript. The points brought up by the reviewers have provided us with very important insights, and we are confident that the changes made have improved the quality of our work. Please find below our point-to-point responses to the reviewer’s comments. We hope you find the amendments satisfactory. We are happy and ready for any further steps or improvement. Reviewer Comments on Manuscript PONE-D-25-17578 Comment Response 1) Lack of use of a validated instrument for the knowledge test is a significant concern. The instrument was not statistically validated but first reviewed by experts in the field of SCD and pretested across all cadres involved in SCD care before its use. It was designed to test knowledge about the SPARCo Standards of Care Guidelines for SCD management in sub-Saharan Africa which was the source of the curriculum for the workshop. A description of its development and validation is inserted Line 101-109 a. Several questions are unrelated to sickle cell disease (e.g., #7); it is unclear what the intent is of these questions that may not be directly related to sickle cell knowledge. All questions were related to SCD. E.g. #7 is aimed at knowing if healthcare workers know what medication to use for prophylaxis for infections when a patient with SCD is allergic to regular Penicillin V b. Numerous acronyms are present that may be confusing and may limit participants’ ability to respond accurately (e.g., #8,10). The acronyms have been written in full. c. It would be helpful to include more background about how these questions were made. A description of its development and pretesting is inserted Line 101-109 d. Was there any validation of these questions? If not, this is a major limitation. The instrument was not statistically validated but pretested across all cadres involved in SCD care before its use. A description of its development and validation is inserted Line 101-109 2) There is likely a large knowledge gap between the different occupations, as is noted in the baseline score, and some of the occupations have a more critical role in the treatment of sickle cell disease; therefore, it would be important to know the differences between the occupations for the following: a. A breakdown of the different occupations’ completion of the pre- and post-test is needed A description of the participants completing the post test has been added to table 1 b. Table 3 would be important to be broken down by occupation. The difference between the pre-test and post-test by the different occupations has been done and now seen as Table 4 c. Also, the pre- and post-test differences (Tables 4 and 5) would be interesting if they were analyzed by occupation. Analysis by occupation has been done and included 3) Measuring knowledge before and after a single in-person workshop limits the impact of this manuscript. This pilot may not translate to affecting patient care; however, it is a large-scale training, involving many healthcare professionals in Ghana. The manuscript could also mention the importance of measuring patient-care outcomes after this intervention. This will be done in future studies 4) There is a notable drop-off from those who participated to those who had a pre- and post-test, 55%. a. This is a very large limitation and should be noted in the limitations section. This is well noted and has been added as a limitation. b. It would be important to include a supplementary table describing the differences in demographics, profession, and other components between those who gave that information but did not complete the post-test. Description of persons completing post test added to table 1 Minor concerns: 1) Including the slides of the workshop would be helpful for others who might want to replicate the work. This is well noted. The slides will be available for anyone upon request 2) The score cut-off of 10 is arbitrary. Is there any justification that could make this a reasonable cutoff? If not, consider removing this cutoff and the concept of passing and failing from the manuscript. Categorization has now been changed to using Bloom’s cut-off points as was used in a similar study by Alzahrani et al. Reviewer #2: Comprehensive work and well written. i wonder why the cut offs were 0-10 and 11-20. Perhaps having in 3 groups (poor, fair, great) will give a real idea of the difference between pre and post test in various groups. Categorization has now been changed to using Bloom’s cut-off points which talks about high level of knowledge, moderate knowledge and low knowledge as used by Alzahrani et al. Additional considerations: 1. Lack of Long-Term Follow-Up: The post-training assessment was immediate. A follow-up at 3–6 months would help assess retention and sustained impact. A follow-up study is being planned for the future 2. Validation of Assessment Tool: The manuscript does not clarify whether the pre/post-test questions were piloted or validated. Including psychometric properties (e.g., internal consistency) would strengthen the evaluation. A description of its development and validation is inserted Line 101-109 3. Cutoff for Knowledge Scores: Comprehensive work. That said, I wonder why the cutoffs were 0–9 (poor) and 10–20 (good). A three-tier system (e.g., poor, fair, good) may give a more nuanced view of the distribution and changes across knowledge levels. Categorization has now been changed to using Bloom’s cut-off points. This has been described in line 125-129 4. Selection Bias: Since participation was based on invitations, there may be a bias toward more engaged or motivated providers. This should be briefly acknowledged in the limitations. Acknowledged. Line 282-283 5. Participant feedback: Consider including a brief participant feedback component in future work to guide content refinement. Thanks and this is well noted 6. Barriers to implementation: Expand on the discussion of barriers to guideline uptake, especially since only 43% reported using one. This has been discussed and found in lines 235-244 Thank you Dr Vivian Paintsil https://doi.org/10.1371/journal.pone.0332069.r002
16 Aug 2025 Decision Letter - Santosh L. Saraf, Editor Dear Dr. Paintsil, Please submit your revised manuscript by Sep 30 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, Santosh L. Saraf Academic Editor PLOS ONE Journal Requirements: 1. 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. 2. 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. [Note: HTML markup is below. Please do not edit.] Reviewers' comments: Reviewer's Responses to Questions Comments to the Author Reviewer #1: (No Response) Reviewer #2: All comments have been addressed ******** 2. Is the manuscript technically sound, and do the data support the conclusions??> Reviewer #1: Yes Reviewer #2: Yes ****** 3. Has the statistical analysis been performed appropriately and rigorously? -->?> Reviewer #1: Yes 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 Reviewer #2: Yes ****** 5. Is the manuscript presented in an intelligible fashion and written in standard English??> Reviewer #1: Yes Reviewer #2: Yes ****** Reviewer #1: The authors have done a good job responding to this reviewers comments. A few more comments/clarifications would help improve the impact of this manuscript: Adding the slides as a supplemental file would be helpful. There was no description of the validation of the knowledge test in the submission. For example, how was content validity determined? The lack of a validated knowledge test should be included in the limitations. Adding that the following would be done in future studies in the manuscript as part of this reviewer’s original comments would be helpful: “. The manuscript could also mention the importance of measuring patient-care outcomes after this intervention” Reviewer #2: changing to low, moderate, and high in the pre and post scores clarifies my understanding of this. also appreciated the breakdown based on profession ****** 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 https://doi.org/10.1371/journal.pone.0332069.r003
Revision 2
21 Aug 2025 Author Response Comments and Response Comments: Adding the slides as a supplemental file would be helpful. Response: The slides have been added on as supplementary file Comments: There was no description of the validation of the knowledge test in the submission. For example, how was content validity determined? The lack of a validated knowledge test should be included in the limitations. Response: This has been added to the limitations and inserted in lines 289-290. Also, a recommendation has also been inserted in lines 293-295 for validating the knowledge test Comments: Adding that the following would be done in future studies in the manuscript as part of this reviewer’s original comments would be helpful: “. The manuscript could also mention the importance of measuring patient-care outcomes after this intervention” Response: A discussion on this has been inserted in lines 272-275. And it has also been added on in lines 291-293 as a recommendation for future studies. Attachments Attachment Submitted filename: Response to reviewers letter.docx https://doi.org/10.1371/journal.pone.0332069.r004
26 Aug 2025 Decision Letter - Santosh L. Saraf, Editor Healthcare providers’ knowledge on Sickle Cell Disease and its management: A pre- and post-training test evaluation outcome PONE-D-25-17578R2 Dear Dr. Paintsil, 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, Santosh L. Saraf Academic Editor PLOS ONE Additional Editor Comments (optional): Reviewers' comments: https://doi.org/10.1371/journal.pone.0332069.r005
Formally Accepted
Acceptance Letter - Santosh L. Saraf, Editor PONE-D-25-17578R2 PLOS ONE Dear Dr. Paintsil, I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now being handed over to our production team. At this stage, our production department will prepare your paper for publication. This includes ensuring the following: * All references, tables, and figures are properly cited * All relevant supporting information is included in the manuscript submission, * There are no issues that prevent the paper from being properly typeset You will receive further instructions from the production team, including instructions on how to review your proof when it is ready. Please keep in mind that we are working through a large volume of accepted articles, so please give us a few days to review your paper and let you know the next and final steps. Lastly, if your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. 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. You will receive an invoice from PLOS for your publication fee after your manuscript has reached the completed accept phase. If you receive an email requesting payment before acceptance or for any other service, this may be a phishing scheme. Learn how to identify phishing emails and protect your accounts at https://explore.plos.org/phishing. If we can help with anything else, please email us at customercare@plos.org. Thank you for submitting your work to PLOS ONE and supporting open access. Kind regards, PLOS ONE Editorial Office Staff on behalf of Dr. Santosh L. Saraf Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0332069.r006

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