The gap between knowledge and action in Zimbabwe: The limits of individual awareness in the face of structural violence in cholera endemicity

Saime Ulucayli; Afet Arkut; Anele Lunga

doi:10.1371/journal.pone.0347844

Peer Review History

Original SubmissionMarch 11, 2026
30 Mar 2026 Decision Letter - Alison Parker, Editor Dear Dr. Ulucayli, Please submit your revised manuscript by May 14 2026 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.. 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.. 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.. 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. 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Specifically, Please change your title from "To the Editorial Board, PLOS ONE The Gap Between Knowledge and Action in Zimbabwe: The Limits of Individual Awareness in the Face of Structural Violence in Cholera Endemicity"" to "The Gap Between Knowledge and Action in Zimbabwe: The Limits of Individual Awareness in the Face of Structural Violence in Cholera Endemicity. 3. We note that you have indicated that there are restrictions to data sharing for this study. For studies involving human research participant data or other sensitive data, we encourage authors to share de-identified or anonymized data. However, when data cannot be publicly shared for ethical reasons, we allow authors to make their data sets available upon request. For information on unacceptable data access restrictions, please see http://journals.plos.org/plosone/s/data-availability#loc-unacceptable-data-access-restrictions. 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If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references.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 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: I Don't Know Reviewer #2: I Don't Know ****** 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.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 ****** 4. Is the manuscript presented in an intelligible fashion and written in standard English??> Reviewer #1: Yes Reviewer #2: Yes ****** Reviewer #1: Comments: This is a well written article that clearly describes the current cholera situation on the ground. The manuscript effectively highlights that the ongoing outbreak is largely driven by the lack of adequate WASH (Water, Sanitation, and Hygiene) facilities. The contextual explanations are strong and help the reader understand the underlying structural challenges contributing to transmission. Minor Edits: 1. The correct scientific name is Vibrio cholerae, not Vibrio cholera. Please update this throughout the manuscript. Reviewer #2: General comments The message of this article is important and unfortunately needs to be repeated often. You could reference qualitative research that has covered the same ground, for example Oberg (2019) who found that behaviour change messaging often focuses on educating people on “the biological dangers of shit, assuming that lack of scientific knowledge is the problem”. It’s useful to have the proof of this messaging through the survey data collected here. I believe you can make the point even more strongly that the ‘behaviour change’ narrative has little value in an environment of no or poor-quality water and sanitation services. This could include referring to the obvious fact that water and sanitation services do not only make it possible for households to engage in better hygiene behaviour to tackle cholera, but also many other health and other risks. (No need to say all this, but also: better services contribute to meeting government obligations to realise the human rights to water and sanitation, relieve particularly women and (girl) children of onerous tasks, increase opportunities for income generation, improve and protect the environment etc., including supporting governments’ obligations to realise the human right to a safe environment.) In short - this behaviour change narrative is not only damaging for efforts to address the risk of cholera. The article needs a grammar edit – there are a couple of typos (for example first sentence of the introduction needs attention). I am not sufficiently well-versed in statistical analysis to respond to that aspect of the paper, but I have the following questions: Line 89 Study population I don’t understand the rationale, or perhaps I don’t understand the selection criteria. The way it is currently worded, you have selected people over 18 with high-level education and internet access, therefore living without adequate water, sanitation and hygiene. But I think what you mean is that they both have high level of education AND water, sanitation and hygiene challenges? Can you reword this to be clearer. Likewise internet access –is the only relevance to the study population that the respondents are able to fill in the survey online? Perhaps clarify whether this has any other relevance. Also on the study population – perhaps you could also clarify why focused more on the population with higher education. How would the study be different if you looked at people without higher education? Would you expect to see different results? Is there a population group that does benefit from behaviour change messaging over better service provision? Line 102 – I am interested that cholera vaccinations in this list of treatments is not referred to at all, despite this being a WHO preference over sanitation interventions, see (Hichilema and Ghebreyesus, 2025). Are they not prevalent in Zimbabwe? Would that not be something that people had taken and would influence cholera infections? (Let me stress that I personally do not think that cholera vaccinations are a better solution than water and sanitation, just that they are touted as a solution, so it is interesting that this is not mentioned in the survey). Table 1 – Under Gender (Male, Female, Other) Did 7.2% refer to themselves as ‘other’ or just not respond to this question? If the former, what constitutes ‘other’ in this context? Also – wealth was mentioned as a factor for choosing the study population, but that is not mentioned here. Do you have relevant wealth data? If not, perhaps take it out of the definition of the study population. Hichilema, H. & Ghebreyesus, T. A. 2025. Cholera is spreading fast, yet it can be stopped. Why haven’t we consigned it to history? The Guardian, 25 October 2025. Oberg, A. 2019. Problematizing Urban Shit(ting): Representing Human Waste as a Problem. International Journal of Urban and Regional Research, 43, 377-392. ****** 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 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 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 ******** [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.] 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: Comment_TM.docx https://doi.org/10.1371/journal.pone.0347844.r001
Revision 1
6 Apr 2026 Author Response Response to Reviewers Manuscript ID: PONE-D-26-12022 Title: The Gap Between Knowledge and Action in Zimbabwe: The Limits of Individual Awareness in the Face of Structural Violence in Cholera Endemicity Authors: Saime Ulucayli, Afet Arkut, Anele Lunga Dear Dr. Parker and the Editorial Board of PLOS ONE, We would like to thank the editorial team and the reviewers for their insightful comments and constructive feedback. We have addressed each point raised and believe the revisions have significantly strengthened the manuscript. All changes are highlighted using the Track Changes feature in the revised manuscript. Below is our point-by-point response: Part 1: Academic Editor’s Requirements 1. Title and Header Correction: • Comment: Change your title from "To the Editorial Board, PLOS ONE..." to the actual title. • Response: We have removed the editorial salutation from the header. The manuscript now begins directly with the formal title. (See Lines 1-3) 2. Data Availability Statement: • Comment: Address restrictions to data sharing. • Response: In compliance with PLOS ONE’s policy, we have provided the minimal, fully anonymized data set as a CSV file (S1_Data.csv) under the Supporting Information category. This includes all raw data used for the statistical analyses. (See Data Availability Statement, Lines 394-396) 3. Ethics Statement Placement: • Comment: Ethics statement should only appear in the Methods section. • Response: The ethics statement has been removed from the end of the manuscript and is now exclusively located within the Methods section under the "Ethical Approval" subsection. (See Lines 127-134) Part 2: Response to Reviewer #1 1. Scientific Nomenclature: • Comment: Use the correct name Vibrio cholerae. • Response: We have corrected "Vibrio cholera" to Vibrio cholerae (italicized) throughout the entire manuscript. (See Lines 33, 35, 41, 42 and 44) Part 3: Response to Reviewer #2 1. Grammar and Opening Sentence: • Comment: The first sentence of the introduction needs attention. • Response: We have rewritten the first sentence to correct the grammar and to better introduce the biological and structural context of the study. (See Lines 33-43) 2. 'Behaviour Change' Narrative and Human Rights: • Comment: Strengthen the argument that the ‘behaviour change’ narrative has little value in infrastructure-deprived environments. • Response: We have revised the Introduction to emphasize that WASH infrastructure is a fundamental human right. We explicitly state that focusing on individual behavior without addressing structural deprivation can be counterproductive. (See Lines 33-43) 3. Study Population Rationale (Education and Internet): • Comment: Clarify why a sample with high education and internet access was examined. • Response: We have added a clarification in the Methods section. We argue that this sample provides an "analytical advantage": it allowed us to examine whether individuals who possess both the education and the means to access health information are still constrained by systemic factors. By focusing on this group, we were able to isolate the impact of structural violence from individual awareness, demonstrating that even high health literacy cannot overcome the barriers of a decaying municipal infrastructure. (See Lines 106-116) 4. Oral Cholera Vaccines (OCV): • Comment: Address why vaccinations are not referred to. • Response: We have integrated a discussion on OCV, citing Hichilema and Ghebreyesus (2025). We clarify that while vaccines are vital reactive tools, our focus is on the more sustainable solution of long-term infrastructural investment. (See Lines 299-305) 5. Qualitative Literature (Oberg, 2019): • Comment: Refer to qualitative research like Oberg (2019). • Response: We have incorporated Oberg (2019) into the Discussion to support our findings regarding the failure of individual-focused behavior change messaging in the absence of basic services. (See Lines 255-258) 6. Table 1 "Other" Category: • Comment: Clarify the "Other" gender category. • Response: We have added a clarifying note below Table 1, specifying that this category includes participants who chose not to self-identify or preferred not to disclose their gender. (See Lines 183-185) We hope these revisions meet the requirements for publication in PLOS ONE. Sincerely, Dr. Saime Ulucayli (on behalf of all authors) Corresponding Author Cyprus International University Attachments Attachment Submitted filename: Response to Reviewers.docx https://doi.org/10.1371/journal.pone.0347844.r002
8 Apr 2026 Decision Letter - Alison Parker, Editor The Gap Between Knowledge and Action in Zimbabwe: The Limits of Individual Awareness in the Face of Structural Violence in Cholera Endemicity PONE-D-26-12022R1 Dear Dr. Ulucayli, 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 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, Alison Parker Academic Editor PLOS One Additional Editor Comments (optional): Reviewers' comments: Reviewer's Responses to Questions Comments to the Author Reviewer #2: All comments have been addressed ******** 2. Is the manuscript technically sound, and do the data support the conclusions??> Reviewer #2: (No Response) ****** 3. Has the statistical analysis been performed appropriately and rigorously? -->?> Reviewer #2: (No Response) ****** 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.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 Response) ****** 5. Is the manuscript presented in an intelligible fashion and written in standard English??> Reviewer #2: (No Response) ****** Reviewer #2: (No Response) ****** 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 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 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 #2: No ******** https://doi.org/10.1371/journal.pone.0347844.r003
Formally Accepted
Acceptance Letter - Alison Parker, Editor PONE-D-26-12022R1 PLOS One Dear Dr. Ulucayli, 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. Alison Parker Academic Editor PLOS One https://doi.org/10.1371/journal.pone.0347844.r004

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