-->PONE-D-25-41084-->-->Implementation Fidelity of Ethiopia’s Malaria Test-and-Treat Guideline Amid a Resurgence in the Amhara Region: A Mixed Methods Study-->-->PLOS One

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Reviewer #1: Partly

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Reviewer #1: Yes

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Reviewer #1: Yes

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Reviewer #1: Yes

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Reviewer #1: This manuscript reports a convergent mixed-methods study (facility survey + in-depth interviews) assessing implementation fidelity of Ethiopia’s malaria “test-and-treat” guideline in 53 public/private facilities in Amhara during the 2024–2025 resurgence. Fidelity is operationalized using Carroll’s framework (content, coverage, frequency) standardized to a 0–100 composite score, and qualitative interviews are used to explain barriers using CFIR concepts. The topic is important and the public–private comparison is potentially useful for malaria control in conflict-affected/resurgence settings. However, I have several major concerns about (1) measurement validity and construction of the fidelity outcome, (2) statistical modeling with a small sample and unclear covariates, and (3) alignment between the qualitative approach and the CFIR framing. Substantial revision is needed before the work can be considered.

Major comments

1. The construction of the implementation fidelity outcome requires stronger conceptual and methodological justification. The composite score equally weights content, coverage, and frequency after standardization to a 0–100 scale. However, these domains are measured using different approaches: coverage is register-verified, content appears partly self-reported, and frequency relies on a single Likert-type recall item, which is vulnerable to social desirability bias. Combining these without sensitivity analyses may inflate fidelity estimates. The authors should justify the equal weighting, clarify how each component was measured at the item level, and explore alternative specifications (e.g., excluding the self-reported frequency item).

2. The regression analysis raises concerns about overfitting and transparency given the small sample of 53 facilities. Multiple predictors and moderators are included without clear justification of model complexity relative to sample size. The manuscript refers to “resurgence covariates” without defining their measurement or variability. The bounded nature of the fidelity outcome also challenges linear regression assumptions and should be discussed. It should further be clarified whether one provider was sampled per facility; if not, clustering should be addressed.

3. There are inconsistencies in reported fidelity statistics across the text and tables, particularly regarding median scores by facility type. It is unclear whether reported values refer to composite fidelity or domain-specific measures, and statistical test labels are inconsistent. The authors should carefully audit all results to ensure internal coherence and transparent interpretation.

4. Although CFIR is presented as the guiding framework for the qualitative component, the analysis is largely descriptive of adherence behaviors rather than clearly structured around implementation determinants. The linkage between qualitative themes and CFIR constructs is insufficiently explicit. Mapping findings to CFIR domains and directly connecting them to quantitative results would strengthen mixed-methods integration and explanatory depth.

5. The sampling strategy would benefit from clearer documentation. The manuscript should specify the geographic units included, how the malaria resurgence criterion was operationalized, and the structure of the private facility sampling frame. A concise flow diagram showing eligibility, sampling, and participation would enhance transparency.

Minor Comments.

The manuscript would benefit from language editing to improve clarity and reduce grammatical errors and repetition. Ethical procedures should be described more fully, particularly regarding interview privacy and confidentiality. The survey instrument and composite constructs should be presented more explicitly, including item composition and reliability by scale. Operational indicators such as stockouts should be clearly defined, and causal language should be avoided given the cross-sectional design.

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Reviewer #1: No

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Implementation Fidelity of Ethiopia’s Malaria Test-and-Treat Guideline Amid a Resurgence in the Amhara Region: A Mixed Methods Study

PONE-D-25-41084R1

Dear Dr. Lake,

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.

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Kind regards,

Mohammed Hasen Badeso, Epidemiologist

Academic Editor

PLOS One

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