PONE-D-25-35439 Mixed-methods evaluation and behavior change interventions to improve hand hygiene resources and practices among healthcare workers in rural polyclinics and health centers in Belize, 2023 PLOS ONE

Dear Dr. Murray,

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Additional Editor Comments (if provided):

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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: Partly

Reviewer #2: Yes

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

Reviewer #1: I Don't Know

Reviewer #2: 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: No

Reviewer #2: Yes

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

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Reviewer #1: Yes

Reviewer #2: 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: Thank you to the authors for their work. Overall, this study provides reference value for the field of hand hygiene. However, I have several suggestions:

The methods section of the abstract needs to clearly specify the specific intervention measures and statistical analysis methods; the conclusion section of the abstract needs to be more specific, as the specific intervention measures cannot be determined from the entire abstract.

The introduction should include more details about the specific situation of hand hygiene in Belize.

Methods section: The title of the paper clearly limits the region to rural areas, but from the description in the methods section, it cannot be determined that the 26 sites and the subsequent 12 sites belong to rural areas; more information about the sites needs to be added, such as whether the department settings are consistent, the educational level of medical staff, etc.; the variables of logistic regression and their definitions should be listed; it is recommended to provide the source code and source data.

There are deficiencies in representativeness: the inclusion and exclusion criteria for the sites are open to discussion. The selection basis for the 26 sites is not objective enough, and the subsequent selection of 12 sites based on the number of people is not representative.

The description of intervention measures needs to be more specific, as the specific steps of the intervention measures cannot be determined from the methods section.

The methods section should further clarify, after selecting the sites, the basis for selecting the respondents, the number of respondents, and the number of observations (it is currently unclear how many times the same person was observed and whether different people were observed the same number of times).

The discussion section should explore more relevant studies in the country

Check whether the references actually exist.

Reviewer #2: I enjoyed reading this manuscript. It’s a clear and thoughtfully designed mixed-methods study that looks at both the availability of hand hygiene (HH) resources and the impact of a peer-led champion intervention in rural Belizean health facilities. This focus on small outpatient settings in a low-resource context is important and often overlooked in infection prevention and control (IPC) research. The mixed approach of combining quantitative data with in-depth interviews makes the findings richer and more meaningful.

The work is technically sound. The data are collected systematically, the statistical analysis is appropriate for the study design, and the results are interpreted sensibly, with limitations openly acknowledged. The paper is well structured, easy to follow, and written in clear English.

Major Points to Think About

Timing of Follow-Up

The follow-up was done right after the six-week program. This makes it hard to know whether the improvements will stick over time and could mean staff were on their “best behavior” because they knew they were being observed. It would be good to expand on this in the discussion and talk about how future work might check for longer-term impact.

How Sites Were Chosen

Choosing pilot sites based on staff size is practical, but it might mean the results lean toward better-staffed, better-resourced facilities. A short note on how this could affect generalizability would be helpful.

What Was Observed

HH adherence was only tracked before and after patient contact, so some of the WHO “5 Moments” were missed. Explaining why this approach was taken and what that means for interpreting the results would add clarity.

Hand Dirtiness Scores

The qPHAT tool measures visible dirt, not germs. You’ve already noted this, but I’d highlight it a bit more so readers don’t confuse “clean-looking” with “pathogen-free.”

Minor Suggestions

The qualitative results are engaging. Linking the barriers staff mentioned more directly to specific, actionable program improvements would make them even more useful.

It would be great to say a little more about how this champion model could fit into Belize’s national IPC strategies for long-term, sustainable scale-up.

Overall Impression

This is a solid, relevant, and well-written piece of work that has real-world value for IPC programs in similar contexts. The recommendations are practical, and the mix of methods gives the findings both depth and credibility. With a few clarifications and some extra discussion on sustainability and generalizability, it will be even stronger.

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Reviewer #1: No

Reviewer #2: No

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Mixed-methods evaluation and behavior change interventions to improve hand hygiene resources and practices among healthcare workers in rural polyclinics and health centers in Belize, 2023

PONE-D-25-35439R1

Dear Dr. Murray,

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,

Alison Parker

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

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 #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 #2: Yes

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

Reviewer #2: Yes

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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 #2: No

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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 #2: 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 #2: The revised manuscript is methodologically sound, clearly written, and addresses the prior reviewer comments thoroughly. The study fits well within PLOS ONE’s scope (public health, WASH, behavior change, applied implementation science), and it contributes useful evidence from an under-researched setting (Belize).

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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 #2: No

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