PONE-D-24-32196Healthcare waste management practice and associated factors among healthcare workers in Sub-Saharan Africa:  a systematic review and meta-analysis.PLOS ONE

Dear Dr. Berihun,

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.

Dear authors try to address the comments given by reviewer 1 and 2 as their decision is major reviesion.

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Kind regards,

Tsegaye Alemayehu, Msc

Academic Editor

PLOS ONE

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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?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Partly

Reviewer #3: Yes

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

Reviewer #1: Yes

Reviewer #2: No

Reviewer #3: Yes

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

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

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

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: No

Reviewer #3: Yes

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5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Date: 15 September 2024

Manuscript Title: Healthcare waste management practice and associated factors among healthcare workers in Sub-Saharan Africa: a systematic review and meta-analysis

Journal: PLOS ONE

Manuscript ID: PONE-D-24-32196

Manuscript type: Review article

GENERAL COMMENTS:

Authors reviewed a topic which is highly relevant for healthcare workers, practitioners, regulators, and policy makers regarding healthcare waste management. The methodology and results are very good. However, the articles included in the review are mainly from East Africa/Ethiopia. Hence, further literature search and analysis is required if the term SSA is included in the title of the manuscript. Therefore, the manuscript can be accepted for publication after major revision.

SPECIFIC COMMENTS:

Introduction:

1. Authors cited local studies for global figures which is not appropriate. For example, line 61-63: “Annually, 5.2 million people worldwide, including 4 million children, death are reported as a result of improper management [7]. Additionally, more than 2 million healthcare workers are infected by over 30 dangerous blood - borne pathogens [4]. Reference number 4 and 7 are a study from Ethiopia but cited for the global public health burden associated with poor healthcare waste management..

2. Check the validity of the statement from line 64-66: “Exposure to hazardous waste containing mercury and expired drugs can lead to serious health issues like cancer, mutations, teratogenicity, and infections of the eyes, respiratory system, and skin diseases [9]” How infection of the eye and the like from mercury and expired drugs exposure.

3. Line 69-74 discusses improper disposal of healthcare waste such as indiscriminate dumping, burying and burning as well as the associated health and environmental risks. Thes practices are not related to healthcare workers. These issues are applicable for management bodies and medical waste handlers/janitors. It’s better to remove this part.

4. The introduction lacks healthcare workers waste management practice information. Authors reviewed mainly risks associated with poor waste management practices.

Materials and Methods:

5. On page 4, Line 106: Delete the subtitle “Study Setting: The study setting is SSA.” As it is already indicated in the manuscript title and in line 92-93 on the same page.

6. Among 18 articles included in the meta-analysis, more than 60% were from Ethiopia. When articles from Ethiopia, Ruanda and Uganda combined, they account for 83% from the total articles in the SSA countries. Is it appropriate to mention SSA in the title? If it appears in the title, more articles are required from other SSA countries. Authors compared their review result with the study conducted in Kenya [“………… the finding of this review was lower than the studies done in Kenya (72.5%) [43]”] but did not include it in the review. Why?

Country Number of included articles %

Ethiopia 11 61.1

Ruanda 2 11.1

Uganda 2 11.1

East Africa 15 83.3

Nigeria 1 5.6

Cameron 1 5.6

South Africa 1 5.6

Total 18 100

7. Authors reach a conclusion based on the ‘Good Practice’ report of each included study. However, the operational definition of ‘Good Practice’ might not be similar for all studies. This will have implications for the validity and reliability of the method to measure the outcome variable. This need clarification.

Discussion:

8. Page 14: “This review also revealed that the sex of the healthcare workers, the presence of healthcare waste management manuals/ guidelines in their working departments, the knowledge status of the healthcare workers, the presence of training on healthcare waste management practices, and working hours per a day were factors significantly associated with healthcare waste management practices among healthcare workers.” Is it a result or a discussion?

9. In the last paragraph: though the findings are compared with similar study results, justification for favoring or discouraging good practices were not mentioned.

10. No comparison is made with studies from North African countries, Latin America countries and the like.

Conclusions and Recommendations:

11. “This review revealed that the pooled estimated good practices of HCWM among healthcare workers in SSA were relatively low.” What does ‘relatively low mean’?

12. “The sex of the healthcare worker, the presence of waste management manuals/guidelines, knowledge of healthcare workers on healthcare waste management, training on waste management, and the working hours per day were factors significantly associated with HCWM practices among healthcare workers.“ Is it being male or female that tends to good practice? Is working less than or more than 8 hours that favors good practice? Show the direction of each factor towards good practice.

Reviewer #2: Thank you for submitting your manuscript titled "Healthcare waste management practice and associated factors among healthcare workers in Sub-Saharan Africa: a systematic review and meta-analysis." Below, I provide detailed feedback based on my evaluation of the manuscript.

The manuscript is based on a systematic review and meta-analysis, which is an appropriate method for synthesizing data on healthcare waste management (HCWM) practices in Sub-Saharan Africa. The methodology is described in detail, including adherence to PRISMA guidelines, the use of statistical software (STATA), and inclusion criteria based on robust study designs.

The conclusions are partly supported by the data but are limited by the following:

• The pooled estimate of HCWM practices (50.42%) is based on studies with very high heterogeneity (I² = 97.7%). While subgroup analyses attempt to explore sources of heterogeneity, significant variability remains, limiting the generalizability of the results.

• Pooling data across diverse countries with varying healthcare systems and policies may mask important contextual factors influencing HCWM practices.

• The exclusion of qualitative studies limits a deeper understanding of barriers and facilitators to HCWM practices, which is critical for policy and practice recommendations.

Address the high heterogeneity more thoroughly by exploring meta-regression or other advanced statistical methods. Consider discussing the potential limitations of pooling data across diverse contexts in more depth.

Appropriate statistical techniques were used, including random-effects modeling, Egger’s regression test for publication bias, and sensitivity analyses. Subgroup analyses by country, healthcare facility ownership, and pre- versus post-COVID-19 pandemic periods add depth to the findings.

• Despite subgroup analyses, high heterogeneity persists, which undermines the reliability of the pooled estimates.

• The justification for choosing the random-effects model is not explicitly stated, and alternative approaches (e.g., mixed-effects models) are not considered.

• The authors could have performed a meta-regression to explore potential moderators contributing to the observed heterogeneity.

Provide a clearer rationale for model selection and explore advanced methods to account for heterogeneity. This would enhance the robustness of the findings.

The authors have stated that all relevant data are fully available within the manuscript and supporting information. References to included studies and the search strategy are provided, ensuring transparency and compliance with PLOS ONE’s data policy.

The manuscript communicates the main findings and methodology effectively.

There are several grammatical errors, typographical mistakes, and instances of unclear phrasing that impact the readability and professionalism of the manuscript. Examples include:

• Overly complex sentences, such as “The pooled estimate of good HCWM practices among study participants was found to be 50.42%...” These could be simplified for clarity.

• Repetitive phrases, such as “good healthcare waste management practices,” could be varied to improve flow.

• Ambiguities in phrasing, such as “may cause the missing of some important studies,” should be revised to “may result in the omission of important studies.”

The manuscript requires editing for grammar, syntax, and readability to meet the standard of clear and unambiguous English required by PLOS ONE. A professional language editing service may be beneficial.

The manuscript outlines some strengths, such as the use of PRISMA guidelines, comprehensive literature search, and robust inclusion criteria. However:

• The exclusion of non-English studies may introduce bias and limit the generalizability of findings, particularly in multilingual regions.

• The reliance on quantitative studies excludes valuable qualitative insights that could enrich understanding.

Expand the discussion of the study’s limitations, particularly regarding heterogeneity, language restrictions, and the exclusion of qualitative studies. This would provide a more balanced view of the study’s findings.

• No concerns regarding research ethics or dual publication were identified.

• The forest plots and PRISMA diagram are informative but could benefit from improved labeling to enhance clarity for readers.

• While the authors provide recommendations for improving HCWM practices, these could be strengthened by incorporating actionable steps tailored to specific contexts (e.g., low-resource settings).

This manuscript addresses an important public health issue and has potential for significant impact. However, improvements in addressing heterogeneity, refining the statistical approach, and enhancing the clarity of the language are essential. I encourage the authors to revise the manuscript based on the feedback provided.

Thank you for the opportunity to review this manuscript.

Reviewer #3: The manuscript is technically sound, with a robust statistical framework appropriate for the systematic review and meta-analysis.

1. Enhance the introduction by clearly articulating the novel contributions of the study, such as new insights into the factors influencing healthcare waste management practices in this specific regional context.

2. I recommend using abbreviations sparingly, only for frequently repeated terms, or providing an abbreviation guide with the full meanings.

3. The reported high heterogeneity (I² = 97.7%) suggests substantial variability in the study outcomes, which could impact the generalisability of the findings. A more detailed exploration of the sources of this heterogeneity could strengthen the conclusions.

4. Some grammatical phrases need revision to enhance clarity and readability, e.g., "However, during by the two independent reviewers, the issues were resolved through an evidence-based discussion.".

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Reviewer #1: Yes:  Taffere Addis

Reviewer #2: Yes:  Volkan Medeni

Reviewer #3: Yes:  Sumayya Al-Mansur

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Attachments

Attachment

Submitted filename: Review report.docx

PONE-D-24-32196R1Healthcare waste management practice and associated factors among healthcare workers in Sub-Saharan Africa:  a systematic review and meta-analysis.PLOS ONE

Dear Dr. Berihun,

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. Dear author, try to address the comments given by the reviewers.

Please submit your revised manuscript by Oct 02 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.

Please include the following items when submitting your revised manuscript:

• 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,

Tsegaye Alemayehu, Msc

Academic Editor

PLOS ONE

Journal Requirements:

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. 

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.

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

Reviewer #2: All comments have been addressed

Reviewer #3: (No Response)

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

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Partly

Reviewer #3: Yes

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

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

**********

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

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: No

Reviewer #3: Yes

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

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: (No Response)

Reviewer #2: Yes

Reviewer #3: Yes

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6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: I congratulate authors for their significant efforts to improve the quality of revised manuscript. My comments are fully addressed and I found the revised manuscript acceptable for publication in the journal.

Reviewer #2: Thank you for your thoughtful revisions and efforts to improve the manuscript. Most of the previous concerns have been adequately addressed, particularly the improvements in methodology and interpretation. However, I encourage you to provide more detailed reporting of the meta-regression results (e.g., coefficients, p-values), and ensure that the dataset used for the analysis is made publicly available in line with PLOS ONE’s data policy. These are minor revisions and can be addressed without extensive changes. So I recommend minor revisions to address some remaining concerns prior to publication.

While the revised manuscript represents a significant improvement in clarity, structure, and methodological explanation, several technical concerns remain that limit the overall robustness and reproducibility of the findings:

1. The meta-analysis continues to exhibit very high heterogeneity (I² = 97.7%), which is only partially addressed through subgroup analyses and meta-regression. Although the authors explored variability by country, facility ownership, and the COVID-19 period, residual heterogeneity remains substantial. This weakens the strength of the pooled estimate and limits the generalizability of the findings. Moreover, the inclusion of studies from diverse healthcare systems with varying definitions of “good HCWM practices” introduces further contextual variability that is not fully accounted for in the interpretation. The decision to exclude non-English and qualitative studies—while methodologically valid—reduces the comprehensiveness of the evidence base. Policy recommendations, though revised, are still somewhat generic and not consistently anchored in the patterns identified through analysis.

The authors should elaborate on the meta-regression findings by reporting key statistics such as p-values, regression coefficients, and the proportion of variance explained (R²). Additionally, they should explicitly discuss how differences in healthcare systems and definitions of “good HCWM practices” across countries may limit the generalizability of the pooled estimate.

2. The authors have strengthened the statistical methods in the revised version by applying random-effects modeling, performing subgroup analyses and meta-regression, and assessing publication bias and sensitivity. However, the rationale for selecting specific models, such as the random-effects approach over mixed-effects or Bayesian models, could be more thoroughly articulated. Importantly, the results of the meta-regression are not adequately detailed—regression coefficients, p-values, and explained variance (e.g., R²) are not reported, limiting the reader’s ability to assess its effectiveness. Confidence intervals for subgroup estimates and heterogeneity statistics within subgroups should also be reported and discussed more explicitly. Finally, assumptions underlying the statistical models are not addressed.

While random-effects models are appropriate, the rationale for their selection over alternative models (e.g., mixed-effects or Bayesian approaches) should be explained more clearly. The manuscript should also provide more detailed reporting of subgroup analyses, including subgroup-level heterogeneity (I²) and confidence intervals for each pooled estimate.

3. The current Data Availability Statement does not fully comply with PLOS ONE’s requirements. While the authors state that all relevant data are within the manuscript and Supporting Information, no raw data (e.g., extracted prevalence rates, sample sizes, standard errors) are provided. There is no supplementary data table summarizing the inputs used for meta-analysis, nor is there a public repository link or access to analysis code. This lack of raw data and transparency hinders reproducibility and limits the scientific value of the review.

The authors should include a detailed table listing study-level data extracted for the meta-analysis (e.g., sample sizes, effect sizes, standard errors), and ideally upload the dataset to a public repository (e.g., OSF, Figshare). They should also consider sharing the statistical code used for analysis to enhance transparency and reproducibility in line with PLOS ONE’s data policy.

In summary, while the manuscript now presents a clearer and more technically sound review, further improvements are needed in the justification and reporting of statistical methods and in meeting open data standards to ensure full transparency and reliability of the findings.

Reviewer #3: The authors have addressed many reviewer concerns and made commendable progress in revising the manuscript; however, several methodological, reporting, and clarity issues persist, particularly surrounding heterogeneity handling, framing of pooled estimates, language quality, and overgeneralization based on data from a few countries.

The high heterogeneity remains a serious limitation to the pooled estimate’s reliability. While a meta-regression was conducted and a table provided the results, the interpretation is not sufficiently detailed in the Results or Discussion. Include a clear interpretation of key moderators.

Over 60% of the included studies are from Ethiopia. While SSA is in the title and rationale, this regional label gives a false sense of geographic representativeness. Either adjust the title to reflect “Eastern Africa” or reframe the findings throughout to highlight this imbalance

Authors state “≥50% of recommended practices” as the threshold, but this criterion is inconsistent across studies.

Although improvements were made, multiple instances of awkward phrasing, grammatical errors, and redundant repetition persist.

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7. PLOS authors have the option to publish the peer review history of their article (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: Yes:  Taffere Addis, Addis Ababa University, Addis Ababa, Ethiopia

Reviewer #2: Yes:  Volkan Medeni

Reviewer #3: No

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[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.

Healthcare waste management practice and associated factors among healthcare workers in Sub-Saharan Africa:  a systematic review and meta-analysis.

PONE-D-24-32196R2

Dear Dr. Berihun,

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.

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Kind regards,

Tsegaye Alemayehu, Msc

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewer #1:

Reviewer #2:

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

Reviewer #2: All comments have been addressed

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

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

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 requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

**********

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

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: The second revised version is significantly improved and publishable in its current form. The methodologies followed, the statistical analysis, results and interpretation are valid and appropriate. It is highly informative for decision makers, managers and practitioners in the area of healthcare waste management.

Reviewer #2: I would like to thank the authors for their thoughtful and detailed responses to the reviewers' comments, and for submitting a substantially improved version of the manuscript. I appreciate the effort put into clarifying the methodology, expanding the discussion, and refining the manuscript’s structure and language. The concerns I previously raised have been sufficiently addressed. I recommend accepting the manuscript in its current form or with minor editorial revisions.

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7. PLOS authors have the option to publish the peer review history of their article (what does this mean? ). If published, this will include your full peer review and any attached files.

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Reviewer #1: Yes:  Taffere Addis, Addis Ababa University, Ethiopia.

Reviewer #2: No

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