The role of implementation climate in shaping early essential newborn care practice: Insights from a multi-center cross-sectional study in China

Hongxiao He; Jiahe Li; Junying Li; Hong Lu; Jie Lu; Linlin Cao; Luxia Gong; Ruyan Pang; Xiu Zhu

doi:10.1371/journal.pone.0334855

Peer Review History

Original SubmissionMay 22, 2025
21 Jul 2025 Decision Letter - Muhammad Stanikzai, Editor PONE-D-25-27091The Role of Implementation Climate in Shaping Early Essential Newborn Care Practice: Insights from a Multi-Center Cross-Sectional Study in ChinaPLOS ONE Dear Dr. Zhu, 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. Two review reports have been obtained. Please revise manuscript according to the reviewers' comments and my suggestions in the additional editor section comments. Please submit your revised manuscript by Sep 04 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 . 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If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.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: - Abstract: It is better to write results section paragraph-vise rather to present in a bullet manner. - The authors should proof read the entire article for language correction and grammar. - Please look at published papers on PLOS ONE for in-text citation. The authors should a single space between the in-text citation and text. In most cases, they are now attached. - Tables 3 & 4: Radio should be ratio. - Line 104: Settings should be with small letter. - Discussion: Please make only the first letter of subheading capital. - Line 337-339: Add the following citations; https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0324758 - References: Please review the reference and set them as per journal styles. References 1 and 4 are incomplete. Please provide availability link and access date. - I noticed color changes in the text. Please use black color for all text. Best of Luck. [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? 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 ******** 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? 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Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here. Reviewer #1: Yes Reviewer #2: Yes ****** 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: thank you for sharing a very important study on EENC. Abstract: it is better to remove bullet numbering in your results section: (1)..., (2)...., (3).... please write your results in continues prose. methodology your tools for measurement of attitude was developed by authors? if yes please give more information about its validity. Results Table 3, 4: COR and AOR; clarify abbreviations at first mention, and please write ratio instead of radio. Thank you Reviewer #2: Dear Editors and Authors, Thank you for giving me the opportunity to review the manuscript, under the title “The Role of Implementation Climate in Shaping Early Essential Newborn Care (EENC) Practice: Insights from a Multi-Center Cross-Sectional Study in China”. The authors chose a very important topic on newborn care in China. This study was conducted between Dec 2022 and April 2023 among nurse-midwives from 12 tertiary-level maternity facilities across China. The authors developed and validated a structured questionnaire, using the WHO guidelines. The study examined EENC-related knowledge, attitudes, practices, and perceived implementation climate, using path analysis and logistic regression to assess direct and indirect associations. The authors reported prevalence of good EENC practice, mean score of implementation climate, and found that good knowledge, positive attitudes, training, leadership role, and perceived workload to be predictors of good EENC practice (with heavier workloads having a negative effect on positive attitude, which impacted good EENC practice, and with good knowledge, in-service training, positive attitude, and leadership role having a positive effect on good EENC practice). Better implementation climate had positive effects on attitude, and implementation climate positively affected EENC practice indirectly through attitudes. The authors concluded that both individual factors and organizational climate are important influential factors of EENC practices. To improve EENC implementation, healthcare systems should focus on enhancing the implementation climate through leadership support, training staff, appropriate reward systems, and addressing workload challenges. My overall assessment of the manuscript is that it has been written well and can be considered for publication. There are some minor issues that the authors need to address. 1. In table3 and table 4, there is an inconsistency in using “bivariable” and “univariable”. The authors can use either one; but this should be consistent throughout the manuscript. 2. For figure1, some words start with capital letters; while others start with small letters (e.g., Training, knowledge). They need to be consistent – either start with small or capital letters. 3. Oversampling of female nurse-midwives can be a potential limitation in this study. The authors may opt to discuss it in the limitation of this study, because male nurses may have different attitudes and practices with respect to EENC, although I understand that midwives are female and this sample can present a valid representation of those health workers, who are mainly involved in newborn care. ****** 6. 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Revision 1
3 Sep 2025 Author Response Dear Editors and Reviewers: Thank you for your letter and for the time you have taken to review our manuscript. We greatly appreciate your valuable feedback, which has been essential in improving our paper. We have carefully studied all comments and have incorporated revision accordingly. The main corrections and our point-by point response are provided below. Reviewer 1 Abstract: it is better to remove bullet numbering in your results section: (1)..., (2)...., (3).... please write your results in continues prose. Response: We thank you for this suggestion. The results section of the abstract has been revised into continuous prose by removing the bullet points, which improves the flow and readability. Methodology: your tools for measurement of attitude was developed by authors? if yes please give more information about its validity. Response: Thank you for raising this important point. Yes, the attitude measurement tool was developed by the authors. Its validity was supported through a combination of qualitative insight, expert review, and statistical evaluation. The tool was designed based on qualitative fieldwork, expert review, and psychometric testing. Specifically, we included items 4 and 5 to capture locally relevant attitudes toward two controversial EENC practices—non-routine cord disinfection and non-traditional suctioning—which were frequently raised by midwives in our context. Although Items 4, 5, and 10 had modest factor loading, they were retained due to their contextual and theoretical relevance. Item 10, in particular, reflects institutional motivation and perceived competitive pressure, a dimension not covered by other items. Except for these three items, all other items exhibited standardized regression weights ranging from 0.596 to 0.905, exceeding the conventional threshold of 0.5, thus indicating satisfactory convergent validity for the latent construct of attitude. Below are the standardized regression weights for all items: Estimate Item 1<---Attitude 0.891 Item 2<---Attitude 0.898 Item 3<---Attitude 0.834 Item 4<---Attitude 0.253 Item 5<---Attitude 0.414 Item 6<---Attitude 0.905 Item 7<---Attitude 0.629 Item 8<---Attitude 0.596 Item 9<---Attitude 0.687 Item 10<---Attitude 0.322 We hope this clarification adequately addresses your question regarding the validity of the attitude scale.The corresponding modifications have been incorporated into the revised manuscript on line 164-173. Results: Table 3, 4: COR and AOR; clarify abbreviations at first mention, and please write ratio instead of radio. Response:Thank you for these valuable corrections. We have clarified the abbreviations "COR" (Crude Odds Ratio) and "AOR" (Adjusted Odds Ratio) at their first mention in the text (Line 282 and Line 200, respectively). Additionally, the typographical error of "radio" has been corrected to "ratio". Reviewer 2 In table3 and table 4, there is an inconsistency in using “bivariable” and“univariable”. The authors can use either one; but this should be consistent throughout the manuscript. Response:We sincerely thank the reviewer for this careful observation and valuable comment. We apologize for this inconsistency in our terminology.We have now revised the manuscript to consistently use the term "univariable" throughout, including in Tables 3 and 4 and in the corresponding descriptions in the main text. 2. For figure1, some words start with capital letters; while others start with small letters (e.g., Training, knowledge). They need to be consistent – either start with small or capital letters. Response:Thank you for this helpful feedback. We have revised Figure 1 to ensure consistent capitalization (all words now begin with a capital letter) and have re-uploaded the updated figure. 3. Oversampling of female nurse-midwives can be a potential limitation in this study. The authors may opt to discuss it in the limitation of this study, because male nurses may have different attitudes and practices with respect to EENC, although I understand that midwives are female and this sample can present a valid representation of those health workers, who are mainly involved in newborn care. Response:We thank you for this insightful comment. We agree that the predominance of female nurse-midwives in our sample is an important point to address. Although this reflects the real-world gender distribution of midwifery professionals in the study context—where midwives are predominantly female—we acknowledge that including more male nurses could provide additional perspectives on EENC attitudes and practices. We have added this point to the limitations section on line 425-429 to offer a more comprehensive discussion of the generalizability of our findings. Additional Editor Comments Abstract: It is better to write results section paragraph-vise rather to present in a bullet manner. Response:Thank you for the suggestion. We have revised the results section of the abstract into a paragraph format as recommended. The authors should proof read the entire article for language correction and grammar. Response:Thank you for this comment.Our team has carefully re-examined the manuscript to address grammatical issues and refine the expression. We would be grateful if the reviewer could point out any specific passages that still require attention. Please look at published papers on PLOS ONE for in-text citation. The authors should a single space between the in-text citation and text. In most cases, they are now attached. Response:Thank you for this meticulous feedback. We have carefully reviewed the entire manuscript and ensured that a single space is now consistently applied between all in-text citations and the preceding text. Tables 3 & 4: Radio should be ratio. Response: We thank the reviewer for pointing out this typographical error. We have corrected "Radio" to "Ratio" in both Table 3 and Table 4. We apologize for any confusion this may have caused. Line 104: Settings should be with small letter. Response:Thank you for pointing this out. The word on line 104 has been corrected to "settings" as suggested. We have also taken care to ensure consistent capitalization throughout the manuscript. Discussion: Please make only the first letter of subheading capital. Response: Thank you for pointing this out. We have revised the subheading in the Discussion section to have only the first letter capitalized. Line 337-339: Add the following citations https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0324758 Response: We agree with your suggestion. The recommended citation has been added to the discussion section (lines 343–345), as it provides valuable external validation for our argument on the necessity of ongoing training. The added sentence reads: “This is consistent with another study from Afghanistan, which underscores ongoing training of healthcare workers to ensure consistent SSC practices (34). ” References: Please review the reference and set them as per journal styles. References 1 and 4 are incomplete. Please provide availability link and access date. Response: Thank you for this suggestion. We have carefully reviewed and reformatted all references according to the journal’s style guidelines. In particular, references 1 and 4 have been completed with the required access links and retrieval dates. I noticed color changes in the text. Please use black color for all text. Response: Thank you for pointing this out. We have revised the manuscript to use black text throughout and ensured all text now consistently appears in black. Attachments Attachment Submitted filename: Response to Reviewers.docx https://doi.org/10.1371/journal.pone.0334855.r002
8 Sep 2025 Decision Letter - Muhammad Stanikzai, Editor <div>PONE-D-25-27091R1The Role of Implementation Climate in Shaping Early Essential Newborn Care Practice: Insights from a Multi-Center Cross-Sectional Study in ChinaPLOS ONE Dear Dr. Zhu, 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. ==============================Thank you for positively responding to esteemed reviewers' comments and suggestions. I request some minor corrections before the manuscript can be accepted for publication. You can find my suggestions at additional editor comments section.============================== Please submit your revised manuscript by Oct 23 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, Muhammad Haroon Stanikzai 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. Additional Editor Comments: - For PLOS ONE publication, we use [] for in-text citation. Please revise across the documents. - Line 301: Please put figure legend below the figure. Please upload Figure 1 as Per PLOS One style using https://ngplosjournals.pagemajik.ai/artanalysis. Delete figure 1 from document and upload as figure file after following journal guidelines. Only leave figure legend in the manuscript document. - Tables 3 and 4. There is no single space between frequency and percentage brackets in some rows. Be consistent. - In tables 3 and 4, some cells have value less than 5, which increases the chances of uncertainty. It is better to correct or state as a limitation of the study. - The term ‘early essential newborn care (EENC)’ was used in the manuscript several times. Once a term is abbreviated for the first time, it is not necessary to use the abbreviated form with its full form repeatedly. I can see the term is abbreviated in lines 226, 233, 307, and 404. Only the abbreviated term EENC can be used subsequently across the document. [Note: HTML markup is below. Please do not edit.] [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.0334855.r003
Revision 2
27 Sep 2025 Author Response Dear Editors and Reviewers: Thank you for your letter and for the time you have taken to review our manuscript. We greatly appreciate your valuable feedback, which has been essential in improving our paper. We have carefully studied all comments and have incorporated revision accordingly. The main corrections and our point-by point response are provided below. 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. Response: Yes, we received a recommendation to cite a specific published study. We have reviewed the suggested paper, which examines the prevalence and factors associated with mother-newborn skin-to-skin contact in Afghanistan, and found it highly relevant to our work--particularly in supporting our findings related to training. Accordingly, we have cited this reference in the revised manuscript (lines 371-373). 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. Response: We thank the editor for highlighting this important step. We have thoroughly reviewed all references in our manuscript and confirmed that none have been retracted. We have reviewed the reference list to ensure completeness and accuracy. Additional Editor Comments: 1. For PLOS ONE publication, we use [] for in-text citation. Please revise across the documents. Response: Thank you for pointing this out. We have revised all in-text citations throughout the manuscript to use square brackets in accordance with PLOS ONE style requirements. 2. Line 301: Please put figure legend below the figure. Please upload Figure 1 as Per PLOS One style using https://ngplosjournals.pagemajik.ai/artanalysis. Delete figure 1 from document and upload as figure file after following journal guidelines. Only leave figure legend in the manuscript document. Response: Thank you for this guidance. We have removed Figure 1 from the manuscript document and uploaded it as a separate figure file following the journal’s guidelines. 3.Tables 3 and 4. There is no single space between frequency and percentage brackets in some rows. Be consistent. Response: Thank you for this meticulous feedback. We have carefully reformatted Tables 3 and 4 to ensure consistent single spacing between frequency values and percentage brackets throughout. 4. In tables 3 and 4, some cells have value less than 5, which increases the chances of uncertainty. It is better to correct or state as a limitation of the study. Response: We appreciate this suggestion. We have stated this as a limitation of the study in the revised manuscript (line 456-463). 5. The term ‘early essential newborn care (EENC)’ was used in the manuscript several times. Once a term is abbreviated for the first time, it is not necessary to use the abbreviated form with its full form repeatedly. I can see the term is abbreviated in lines 226, 233, 307, and 404. Only the abbreviated term EENC can be used subsequently across the document. Response: Thank you for pointing this out. We have revised the manuscript to use the abbreviated form “EENC” after its first full introduction. The full term with abbreviation now appears only once, and the abbreviated form is used consistently thereafter. Attachments Attachment Submitted filename: Response_to_Reviewers_auresp_2.docx https://doi.org/10.1371/journal.pone.0334855.r004
2 Oct 2025 Decision Letter - Muhammad Stanikzai, Editor The Role of Implementation Climate in Shaping Early Essential Newborn Care Practice: Insights from a Multi-Center Cross-Sectional Study in China PONE-D-25-27091R2 Dear Dr. Zhu, 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, Muhammad Haroon Stanikzai Academic Editor PLOS ONE Additional Editor Comments (optional): Congratulations on this wonderful work. Reviewers' comments: https://doi.org/10.1371/journal.pone.0334855.r005
Formally Accepted
Acceptance Letter - Muhammad Stanikzai, Editor PONE-D-25-27091R2 PLOS ONE Dear Dr. Zhu, 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. Muhammad Haroon Stanikzai Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0334855.r006

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