Evaluation of a training program for rheumatic heart disease screening integrated into the public health system in Uganda

Paul W. Warren; Scott Wirth; Jafesi Pulle; Doreen Nakaagayi; Charles Oyoo Akia; Evelyn Ayaa; Michaela Pardo; Francis Odong; Ronald Ogwanh; John Omagino; Isaac Otim; Craig Sable; Alison Spaziani; Henry Okello Otto; David Watkins; Emmy Okello; Kristen Danforth; Andrea Beaton

doi:10.1371/journal.pone.0344012

Peer Review History

Original SubmissionAugust 25, 2025
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If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.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 : Dear editor I do agree with comments of both Authors have to do minor revision in the lights of comments of both reviewers. Regards [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? Reviewer #1: Yes Reviewer #2: Yes ******** 2. Has the statistical analysis been performed appropriately and rigorously? -->?> Reviewer #1: Yes Reviewer #2: Yes ****** 3. 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Is the manuscript presented in an intelligible fashion and written in standard English??> Reviewer #1: Yes Reviewer #2: Yes ****** Reviewer #1: This manuscript addresses a highly relevant and timely topic: the feasibility of scaling up rheumatic heart disease (RHD) screening training within the public health system in Uganda. The work is ambitious, methodologically sound, and provides valuable lessons for other low-resource, high-prevalence settings. I believe this paper deserves publication after revisions. Below, I provide detailed comments to help strengthen the manuscript. Reviewer #2: The topic of this manuscript is highly relevant; screening for RHD is essential but is faced with low resources in many “endemic” areas. This manuscript addresses the solution to have a cost-effective scale fulfilling this gap. Generally, the manuscript is well organized, relevant, clearly written, and well supported by extensive quantitative and qualitative data. One notable strength is the use of a logic model to frame program evaluation, which helps to align implementation activities with desired results. I have a few items that need to be clarified: The improvement in screening sensitivity after retraining is encouraging, but you can claim that the experience of the health workers and the number of cases they handled added to this improvement. Also, I would recommend a discussion about ways of expanding the program and how it could fit into the national health system and if it may fit for use in other countries. The authors should also address the lack of long-term patient outcomes as study limitations. Please, explain the abbreviations when used for the first time. The authors should have the text checked for small language errors and spacing. best of luck. ****** what does this mean? ). If published, this will include your full peer review and any attached files.). 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If this link does not appear, there are no attachment files.] To ensure your figures meet our technical requirements, please review our figure guidelines: https://journals.plos.org/plosone/s/figures You may also use PLOS’s free figure tool, NAAS, to help you prepare publication quality figures: https://journals.plos.org/plosone/s/figures#loc-tools-for-figure-preparation. NAAS will assess whether your figures meet our technical requirements by comparing each figure against our figure specifications. Attachments Attachment Submitted filename: RHD UGANDA REVEIW.docx https://doi.org/10.1371/journal.pone.0344012.r001
Revision 1
7 Dec 2025 Author Response We thank the reviewers and editor for their comments which we have addressed, and which we believe improves the manuscript. Please find attached in our uploaded documents our detailed response to each comment (which is easier to review than the below responses): Reviewer #1: This manuscript addresses a highly relevant and timely topic: the feasibility of scaling up rheumatic heart disease (RHD) screening training within the public health system in Uganda. The work is ambitious, methodologically sound, and provides valuable lessons for other low-resource, high-prevalence settings. I believe this paper deserves publication after revisions. Below, I provide detailed comments to help strengthen the manuscript. This is an important manuscript on rheumatic heart disease (RHD) screening training in Uganda. Its an ambitious and timely work that addresses a major public health gap in Sub-Saharan Africa. The study is well-structured, with clear methodology and valuable findings. I believe this paper deserves publication, provided the following issues are carefully addressed: Major Points for Improvement 1. Tables and Data Presentation Several tables are overloaded with details, which may reduce readability. Please simplify by separating inputs/resources from outcomes or moving highly technical cost details to supplementary material. We have separated the human and equipment resources into separate tables (Tables 1 and 2). The outcomes data is presented by itself in Table 3. Ensure that percentages and denominators are always clear (e.g., specify the “n” for conditional vs final certification groups in tables). We have more clearly specified the denominators in Table 3 and Table 4. 2. Results and Statistics The results are descriptive, which is acceptable, but the statistical presentation can be strengthened. Confidence intervals should be added for sensitivity/specificity estimates and for major proportions (e.g., final certification rates). We have added confidence intervals to the sensitivity/specificity estimates and positive and negative predictive values to strengthen the statistical presentation (shown in Table 4). Confidence intervals have also been added for certification rates (Table 3). Statistical analysis was performed using RStudio (methods section updated). Consider logistic regression or stratified analysis to identify predictors of successful certification and sustained practice. This would add depth and highlight determinants of program success. We strongly agree with the reviewer that identification of successful certification and sustained practice is important. However, we feel it is outside the scope of this current manuscript. We highlight that the identification of key determinants is undergoing in other research projects in our “Identification of early adopters/high performers” section (lines 306-310). 3. Discussion o The discussion is somewhat repetitive in places. Please sharpen the focus by directly contrasting your findings with other large-scale RHD screening experiences (e.g., Fiji, Brazil PROVAR, etc.). We made the discussion more concise while also highlighting that in comparison to other large scale RHD screening training programs, our study was one of the first to critically evaluate the implementation process itself, which provided us with key insights that once improved upon will result in a more effective and scalable RHD screening program. o Expand on the implications of the low sensitivity (59%), and propose concrete strategies for improving early detection (e.g., booster training, AI-assisted screening, embedding RHD into standard nursing curricula). We expanded upon the implications of the low sensitivity (lines 256-260). We propose frequent and repetitive practice recognizing RHD positive screening echocardiograms as the best way to improve sensitivity. We have added our revised training program as Supplementary Information Figure 2 (line 318) as it shows the increased pattern recognition practice that is required during the initial training (1b) and independent scanning (2a) periods. o Please include regional context. There are now reports emerging from Horn of Africa, which provide valuable complementary evidence. We recommend citing: � Abdi IA, Karataş M, Öcal L, Ahmed SA, Hassan MS, Atilla K, Mohomud MF. Pattern of rheumatic heart disease among patients attending at a tertiary care hospital in Somalia: first report from Somalia. Am J Cardiovasc Dis. 2023 Oct 15;13(5):345. � Abdi IA, Karataş M, Öcal L, Elmi Abdi A, Farah Yusuf Mohamud M. Retrospective analysis of left ventricular thrombus among heart failure patients with reduced ejection fraction at a single tertiary care hospital in Somalia. Open Access Emerg Med. 2022;14:591–7. o Including these will help frame Uganda’s experience as part of a broader East African movement toward locally generated data and scalable solutions. We added the citation to the first paragraph of the discussion, highlighting the growing body of regional East African literature characterizing RHD and RHD training programs. 4. Conclusion o The conclusion should be more concise and action-oriented. Currently, it repeats parts of the discussion. Instead, emphasize three key take-home messages: 1. RHD screening training is feasible in public health systems. 2. Sensitivity remains suboptimal and requires iterative training/innovation. 3. The model is scalable and should inform regional/global policies. We have modified the conclusion to be more concise and include these three key take-home messages. Despite these areas for improvement, I want to emphasize that this is a very strong and much-needed paper. With sharper presentation of the data, strengthened analysis, and improved discussion, this manuscript will make an important contribution to the global RHD literature. If the above revisions are approached carefully, I am confident the paper will be accepted for publication. We thank the reviewer for their helpful suggestions that have improved the manuscript. Reviewer #2: The topic of this manuscript is highly relevant; screening for RHD is essential but is faced with low resources in many “endemic” areas. This manuscript addresses the solution to have a cost-effective scale fulfilling this gap. Generally, the manuscript is well organized, relevant, clearly written, and well supported by extensive quantitative and qualitative data. One notable strength is the use of a logic model to frame program evaluation, which helps to align implementation activities with desired results. I have a few items that need to be clarified: The improvement in screening sensitivity after retraining is encouraging, but you can claim that the experience of the health workers and the number of cases they handled added to this improvement. Also, I would recommend a discussion about ways of expanding the program and how it could fit into the national health system and if it may fit for use in other countries. The authors should also address the lack of long-term patient outcomes as study limitations. We agree with the reviewer that increased health care worker experience was complimentary to the re-training sessions, in improving their screening sensitivity. We have added a statement acknowledging the important role of increased healthcare worker experience and repetitions to increase sensitivity in our “Proposed modifications for the next program iteration” section (lines 329-331). We are currently expanding the program to a second district in northern Uganda. For the model to fit into the national health system in Uganda and other countries, we must first improve the sensitivity and reduce the burden on human resources. We have specified this in our “Proposed modifications for the next program iteration” section (lines 339-343). We have added a statement acknowledging the limitation of the current analysis due to lack of long-term data (line 327). Please, explain the abbreviations when used for the first time. The authors should have the text checked for small language errors and spacing. best of luck. We have ensured that all abbreviations are explained with the first use and that language/spacing errors are eliminated. Clarifications for the Editor The correct grant identification is: R01HL1646150. This is what is listed in the manuscript file. We have added the requested statement regarding role of the funder to the funding statement on the title page. Paul W Warren is listed as an author in the manuscript file and author submission form. Captions have been uploaded for the supporting information files at the end of the manuscript. Attachments Attachment Submitted filename: Response to reviewers.docx https://doi.org/10.1371/journal.pone.0344012.r002
15 Feb 2026 Decision Letter - Rano Piryani, Editor Evaluation of a Training Program for Rheumatic Heart Disease Screening Integrated into the Public Health System in Uganda PONE-D-25-39629R1 Dear Dr. Warren, 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 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, Rano Mal Piryani, MBBS, MCPS, DTCD, MD, Fellowship in Med Education Academic Editor PLOS One Additional Editor Comments (optional): Dear Authors Greetings I appreciate that you have well responded to reviewer' comments point-wise. With best regards Reviewers' comments: Reviewer's Responses to Questions Comments to the Author Reviewer #1: All comments have been addressed Reviewer #2: All comments have been addressed ******** 2. Is the manuscript technically sound, and do the data support the conclusions??> Reviewer #1: 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??> Reviewer #1: Yes Reviewer #2: Yes ****** Reviewer #1: The authors have addressed all previous comments, and the manuscript has been clearly improved. I have no further comments and consider it suitable for publication. Reviewer #2: The authors have adequately addressed the comments, and I recommend acceptance of the manuscript in its revised form. Good luck ****** what does this mean? ). If published, this will include your full peer review and any attached files.). 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 For information about this choice, including consent withdrawal, please see our Privacy Policy .--> Reviewer #1: No Reviewer #2: No ******** https://doi.org/10.1371/journal.pone.0344012.r003
Formally Accepted
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