School absenteeism among children and adolescents aged 6–19 years with sickle cell disease in Uganda: A comparative cross-sectional study

Juliane Peninah Nattimba; Sabrina Bakeera-Kitaka; Joseph Rujumba; Ruth Namazzi; Ivan Segawa; Kizza Lubega; Alphonse Taban; Edison Mworozi; Phillip Kasirye; Deogratias Munube; Grace Ndeezi; Sarah Kiguli; Thereza Piloya

doi:10.1371/journal.pone.0350308

Peer Review History

Original SubmissionNovember 30, 2025
14 Jan 2026 Decision Letter - Aloysius Gonzaga Mubuuke, Editor -->PONE-D-25-63605-->-->School absenteeism among children and adolescents aged 6-19 years with sickle cell disease in Uganda: a comparative cross-sectional study-->-->PLOS One Dear Dr. Nattimba, 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. ============================== Please revise the paper following guidance from the reviewers. In addition, re-check the design which you call a cross-sectional sectional design right from the title. You might have to re-consider giving it the appropriate name as a matched case control study right from the title because this is what you did. The authors should highlight key limitations of a case control study which readers should be aware of. The discussion, try to show how your work adds to the global discourse around SCD beyond the local study setting. Lastly, the entire still needs proof-reading to correct obvious language errors. -->-->============================== Please submit your revised manuscript by Feb 28 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. Please include the following items when submitting your revised manuscript:--> A 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, Aloysius Gonzaga Mubuuke Academic Editor PLOS One Journal Requirements: -->1. When submitting your revision, we need you to address these additional requirements.-->--> -->-->Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at -->-->https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and -->-->https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf-->--> -->-->2. Thank you for stating in your Funding Statement: -->-->This study was supported by the National Heart, Lung, and Blood Institute of the National Institutes of Health under Award Number D43TW012466. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. -->--> -->-->Please provide an amended statement that declares all the funding or sources of support (whether external or internal to your organization) received during this study, as detailed online in our guide for authors at http://journals.plos.org/plosone/s/submit-now. Please also include the statement “There was no additional external funding received for this study.” in your updated Funding Statement. -->-->Please include your amended Funding Statement within your cover letter. We will change the online submission form on your behalf.-->--> -->-->3. Thank you for stating the following financial disclosure: -->-->This study was supported by the National Heart, Lung, and Blood Institute of the National Institutes of Health under Award Number D43TW012466. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. -->--> -->-->Please state what role the funders took in the study. If the funders had no role, please state: "The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript." -->-->If this statement is not correct you must amend it as needed. -->-->Please include this amended Role of Funder statement in your cover letter; we will change the online submission form on your behalf.-->--> -->-->4. Thank you for stating the following in the Acknowledgments Section of your manuscript: -->-->I thank the research participants and clinical staff at the Sickle Cell Clinic at Mulago Hospital. I am grateful to the research assistants for collecting the data. Special thanks to Mirembe Vanessa and Kataike Peace for their commitment and hard work. I also appreciate the ENRICH program for the guidance and financial resources throughout this journey.-->--> -->-->We note that you have provided funding information that is not currently declared in your Funding Statement. However, funding information should not appear in the Acknowledgments section or other areas of your manuscript. We will only publish funding information present in the Funding Statement section of the online submission form. -->-->Please remove any funding-related text from the manuscript and let us know how you would like to update your Funding Statement. Currently, your Funding Statement reads as follows: -->-->This study was supported by the National Heart, Lung, and Blood Institute of the National Institutes of Health under Award Number D43TW012466. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. -->--> -->-->Please include your amended statements within your cover letter; we will change the online submission form on your behalf.-->--> -->-->5. Thank you for uploading your study's underlying data set. Unfortunately, the repository you have noted in your Data Availability statement does not qualify as an acceptable data repository according to PLOS's standards.-->--> -->-->At this time, please upload the minimal data set necessary to replicate your study's findings to a stable, public repository (such as figshare or Dryad) and provide us with the relevant URLs, DOIs, or accession numbers that may be used to access these data. For a list of recommended repositories and additional information on PLOS standards for data deposition, please see https://journals.plos.org/plosone/s/recommended-repositories.-->--> -->-->6. Your ethics statement should only appear in the Methods section of your manuscript. If your ethics statement is written in any section besides the Methods, please delete it from any other section.-->--> -->-->7. We notice that your supplementary tables are included in the manuscript file. Please remove them and upload them with the file type 'Supporting Information'. Please ensure that each Supporting Information file has a legend listed in the manuscript after the references list.-->--> -->-->8. 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. Additional Editor Comments: Please re-check the design which you call a cross-sectional sectional design right from the title. You might have to re-consider giving it the appropriate name as a matched case control study right from the title because this is what you did. The authors should highlight key limitations of a case control study which readers should be aware of. The discussion, try to show how your work adds to the global discourse around SCD beyond the local study setting. Lastly, the entire still needs proof-reading to correct obvious language errors. -->--> -->-->[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: Partly ******** -->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? 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 ****** -->4. 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 #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: This is a well written manuscript describing a cross-sectional study of school absenteeism in school-aged children with SCD compared to age-matched siblings or peers without SCD. The recruitment and data collection are appropriate and well described. The results are clearly presented in text and Tables. The statistical approach is appropriate. The conclusions and limitations suggested appropriately reflect the study results. Literature from both high and low-middle income countries are provided for comparison. Questions for the authors: 1. please define a school "term" and it's typical duration. 2. The need for or lack thereof for transportation to school can often be a barrier-was this a potential concern in this region or population? Any urban vs rural differences? 3. Please elaborate on availability of online/virtual schooling or tutoring services Reviewer #2: The authors performed a cross-sectional comparative observational study on patients with sickle cell disease and matched peers. The aim of interest was the prevalence of chronic school absenteeism and the associated factors. The manuscript is well written and easy to read and addresses a very important topic. There are however some important things to be considered for improvement. 1. In the abstract and the manuscript, the authors use the words "predictors" and "associated factors" interchangeably. However, this is not acceptable. Predictors are only measurable in a cohort design only as opposed to associated factors that can be measured cross-sectionally. 2. In essence, this is a matched case control study and should be presented as such right from the title and the body. The SCD participants are the cases and the matched peers are the controls. 3. In the sample size calculation, it is not clear what "q1" and "q2" stand for. Sample size for two proportion comparison study requires only "p1" (Expected proportion of chronic absenteeism in the SCD participants) and "p2" (Expected proportion of chronic absenteeism in the controls). 4. In the same sample size calculation, there is no reference or explanation for how the p1 and p2 were obtained since these were supposed to be predetermined. 5. In the results, table one should strictly contain baseline demographic characteristics and should not contain the "results". Eg number of school days missed, reasons for missing school etc. 6. I see no use of table 2 in the results, which objective is this answering? We need results on the following - Prevalence of chronic absenteeism in the two groups with their 95%CI and the comparison (prevalence ratio or OR with CI) -Bi-variate and multivariate logistic regression on the associated factors (And this should be limited to only the SCD group since its entirely exploratory and the study is not powered for a comparison between the cases and controls). 7. Table 4 can be improved significantly, the crude and adjusted odds ratios can be presented concurrently in the same table (Again forget about the comparison as this is not useful), and on the rows, only present the positive (Yes) instead of one row for "Yes" and another row for "no' for the same variable eg only one row for "ever repeated a class?" 8. Limit the discussion and conclusion mostly for what the study is powered for. 9. Limitations: Please report the traditional limitations for case control study, and in your study, the cases were more likely to remember or have records as regards chronic absenteeism. ****** -->6. 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 #1: Yes: Carlton Dampier MD Reviewer #2: Yes: Conrad K Muzoora ******** [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. https://doi.org/10.1371/journal.pone.0350308.r001
Revision 1
28 Feb 2026 Author Response Dear Dr. Mubuuke, On behalf of my co-authors, I hereby submit the responses to the reviewers’ comments for the manuscript titled “School absenteeism among children and adolescents aged 6–19 years with sickle cell disease in Uganda: a comparative cross-sectional study” (Manuscript ID: PONE-D-25-63605). We thank the reviewers for the careful review of our manuscript and for the constructive guidance provided. We have addressed each comment in detail below and revised the manuscript accordingly. JOURNAL REQUIREMENTS Journal Requirement 1: PLOS ONE Style and File Naming Comment: 1. When submitting your revision, we need you to address these additional requirements. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf Response: We confirm that the manuscript has been revised to fully comply with PLOS ONE formatting and style requirements, using the official PLOS ONE templates for the main body and title page. File naming conventions have also been updated in accordance with journal guidelines. All submitted files, including the revised manuscript with tracked changes, the clean manuscript, and its supporting information. In addition, we have adhered to the required naming and formatting standards. Journal Requirement 2: Funding Statement - Completeness Comment 2. Thank you for stating in your Funding Statement: This study was supported by the National Heart, Lung, and Blood Institute of the National Institutes of Health under Award Number D43TW012466. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. Please provide an amended statement that declares all the funding or sources of support (whether external or internal to your organization) received during this study, as detailed online in our guide for authors at http://journals.plos.org/plosone/s/submit-now. Please also include the statement “There was no additional external funding received for this study.” in your updated Funding Statement. Please include your amended Funding Statement within your cover letter. We will change the online submission form on your behalf. Response: The Funding Statement has been amended to declare all sources of support and now explicitly includes the statement indicating that no additional external funding was received. Revised text: Cover letter “This study was supported by the National Heart, Lung, and Blood Institute of the National Institutes of Health under Award Number D43TW012466. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. There was no additional external funding received for this study.” Journal Requirement 3: Role of the Funder Comment 3. Thank you for stating the following financial disclosure: This study was supported by the National Heart, Lung, and Blood Institute of the National Institutes of Health under Award Number D43TW012466. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. Please state what role the funders took in the study. If the funders had no role, please state: "The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript." If this statement is not correct you must amend it as needed. Please include this amended Role of Funder statement in your cover letter; we will change the online submission form on your behalf. Response: We confirm that the funders had no role in the conduct of the study. The Role of the Funder statement has been clarified accordingly. Revised text: Cover letter “The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.” Journal Requirement 4: Funding Information in Acknowledgments Comment 4. Thank you for stating the following in the Acknowledgments Section of your manuscript: I thank the research participants and clinical staff at the Sickle Cell Clinic at Mulago Hospital. I am grateful to the research assistants for collecting the data. Special thanks to Mirembe Vanessa and Kataike Peace for their commitment and hard work. I also appreciate the ENRICH program for the guidance and financial resources throughout this journey. We note that you have provided funding information that is not currently declared in your Funding Statement. However, funding information should not appear in the Acknowledgments section or other areas of your manuscript. We will only publish funding information present in the Funding Statement section of the online submission form. Please remove any funding-related text from the manuscript and let us know how you would like to update your Funding Statement. Currently, your Funding Statement reads as follows: This study was supported by the National Heart, Lung, and Blood Institute of the National Institutes of Health under Award Number D43TW012466. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. Please include your amended statements within your cover letter; we will change the online submission form on your behalf. Response: We agree and have removed all funding-related text from the Acknowledgments section. The Acknowledgments now include only expressions of gratitude to participants, clinical staff, and research assistants. All funding information is presented exclusively in the Funding Statement, as per PLOS ONE policy. Revised text: Section: Acknowledgements, pages-21, lines 408-410 “We thank the research participants and clinical staff at Mulago Hospital’s Sicklecell clinic. In addition, we are grateful to the research assistants for collecting the data. Special thanks to Mirembe Vanessa and Kataike Peace for their commitment and hard work.” Journal Requirement 5: Data Availability and Repository Comment 5. Thank you for uploading your study's underlying data set. Unfortunately, the repository you have noted in your Data Availability statement does not qualify as an acceptable data repository according to PLOS's standards. At this time, please upload the minimal data set necessary to replicate your study's findings to a stable, public repository (such as figshare or Dryad) and provide us with the relevant URLs, DOIs, or accession numbers that may be used to access these data. For a list of recommended repositories and additional information on PLOS standards for data deposition, please see https://journals.plos.org/plosone/s/recommended-repositories. Response: We thank the journal for this guidance. The minimal dataset required to replicate the study findings has now been deposited in a stable, public repository compliant with PLOS ONE standards, Figshare. The Data Availability Statement has been updated to include the correct repository name and DOI/URL. Revised text: Availability of data and materials and references, pages: 20, lines-390 ‘’The data described in this article can be freely and openly accessed at the Figshare repository (Nattimba, Juliane Peninah (2026). School absenteeism and associated factors among children and adolescents attending sickle cell clinic, Mulago National Referral hospital, Kampala district.. figshare. Dataset. https://doi.org/10.6084/m9.figshare.31290772.v1)’’ Journal Requirement 6: Ethics Statement Location Comment 6. Your ethics statement should only appear in the Methods section of your manuscript. If your ethics statement is written in any section besides the Methods, please delete it from any other section Response: We confirm that the ethics statement now appears only in the Methods section. Any duplicate ethics-related text appearing elsewhere in the manuscript has been removed. Journal Requirement 7: Supporting Information Files Comment 7. We notice that your supplementary tables are included in the manuscript file. Please remove them and upload them with the file type 'Supporting Information'. Please ensure that each Supporting Information file has a legend listed in the manuscript after the references list. Response: All supplementary tables have been removed from the main manuscript and uploaded as separate Supporting Information files. Each Supporting Information file is now referenced appropriately in the manuscript, with legends listed after the references section. Journal Requirement 8: Reviewer-Recommended Citations Comment 8. 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: We have now included an appropriate citation in the Methods section to support the statistical approach used for the sample size calculation. The reference has been added to clarify the methodological basis and improve the transparency and reproducibility of the study design. The data repository from which relevant comparative or contextual data were obtained has also been appropriately referenced. The reviewers recommended no additional citations. Revised text: Methods- Data analysis- Page8, Lines 184-186, Availability of data and Materials-Page 20, Lines 390-391 “The assumed proportions (p₁ and p₂) were informed by prior studies reporting school absenteeism among children with SCD and comparison groups in similar contexts. (12)” EDITORIAL COMMENTS Editor Comment 1: Please re-check the design which you call a cross-sectional design right from the title. You might have to reconsider giving it the appropriate name as a matched case-control study because this is what you did. Response: We respectfully maintain that the study is appropriately classified as a comparative cross-sectional study and not a case-control study. We recognize that the inclusion of two groups may resemble a case-control structure; however, the recruitment process and analytical framework align with cross-sectional methodology. Participants were recruited based on exposure status (presence or absence of sickle cell disease) rather than outcome status (chronic absenteeism). Children with SCD were consecutively enrolled from the Sickle Cell Clinic during routine visits. For each enrolled child with SCD, a sibling or peer without SCD of similar age was recruited as a comparison participant. Importantly, participants were not selected based on whether they had chronic absenteeism, and absenteeism status was unknown at the time of enrollment. Both exposure (SCD status) and outcome (chronic absenteeism during the previous school term) were assessed concurrently at a single point in time. No retrospective identification of cases and controls based on absenteeism occurred, and no matching or conditional analytical techniques typical of case-control designs were applied. Revised text: Section: Methods - Study design and setting, Page:5, Lines:95-99 “This was a comparative cross-sectional study conducted among children aged 6–19 years. Participants were recruited based on sickle cell disease (SCD) status rather than absenteeism status. Children with SCD were consecutively enrolled during routine clinic visits at the national referral hospital’s Sickle Cell Clinic. For each enrolled child with SCD, a sibling or age-comparable peer without SCD was recruited from the same household or community. Chronic absenteeism was assessed at the time of the interview based on school attendance during the previous term. Participants were not selected based on absenteeism status, and no retrospective identification of cases and controls was performed.” Editor Comment 2: The authors should highlight key limitations of a case-control study which readers should be aware of. Response: We agree with the Editor that clearly articulating study limitations is essential. While this study is cross-sectional, we recognize that several limitations commonly discussed in observational and case-control studies are relevant. We have therefore expanded the Limitations subsection to address potential sources of bias, including recall bias, lack of temporality, and selection bias. In particular, we discuss the possibility of differential recall of school absenteeism among caregivers of children with sickle cell disease, as well as the exclusion of children who may have permanently withdrawn from school. Revised text: Section: Discussion - Limitations, Pages: 18-19, Lines:344-362 “First, the cross-sectional design limits the ability to establish temporal relationships between associated factors and chronic absenteeism; therefore, causal inferences cannot be made. Second, school absenteeism was assessed using caregiver or participant self-report for the previous school term, which may be subject to recall bias and misclassification. Caregivers of children with sickle cell disease may recall illness-related absences more readily than caregivers of comparison participants, potentially resulting in differential recall. Third, as with many observational studies, residual confounding from unmeasured variables cannot be excluded despite multivariable adjustment. Factors such as school-level support systems, teacher perceptions, or household socioeconomic dynamics not fully captured in the study may influence absenteeism patterns. Finally, participants were recruited from a clinical setting and included only children currently enrolled in school. Children with sickle cell disease who had permanently withdrawn from school were not captured, which may have led to underestimation of the true extent of absenteeism among the children with SCD at the Mulago Hospital Sickle Cell clinic.” Editor Comment 3: The discussion, try to show how your work adds to the global discourse around sickle cell disease beyond the local study setting. Response: The Discussion has been substantially strengthened to situate our findings within the broader global literature on sickle cell disease and educational outcomes. We now compare our findings with studies from both high-income and low- and middle-income countries and highlight how structural constraints, such as limited access to remote learning and frequent healthcare utilization, may amplify educational disadvantage in resource-limited settings. We further emphasize that school absenteeism among children with sickle cell disease is a global concern, but one that manifests differently depending on health system capacity, educational infrastructure, and social support mechanisms. This framing enhances the relevance of our findings beyond Uganda. Revised text: Section: Discussion, Page: 15–16, Lines:283-295 “The findings of this study contribute to the growing global discourse on the educational implications of sickle cell disease (SCD). Across both high-income countries and low- and middle-income countries, children living with SCD consistently experience higher levels of school absenteeism compared to their peers (1,2,22). However, the magnitude and consequences of absenteeism are shaped by contextual factors, including healthcare access, availability of school-based accommodations, and broader social support systems (2). In high-income settings, structured educational support services, individualized learning plans, and access to remote learning options may mitigate some of the academic disruption associated with recurrent illness and hospitalization (1). In contrast, in many resource-limited settings, including Uganda, limited access to compensatory academic support and fewer school-based health accommodations may amplify the afore reported cases of absenteeism among children with SCD in Africa. “ Editor Comment 4: Lastly, the entire manuscript still needs proofreading to correct obvious language errors. Response: The entire manuscript has undergone thorough proofreading to corre Attachments Attachment Submitted filename: Response to Reviewers.docx https://doi.org/10.1371/journal.pone.0350308.r002
17 Apr 2026 Decision Letter - Aloysius Gonzaga Mubuuke, Editor -->PONE-D-25-63605R1-->-->School absenteeism among children and adolescents aged 6-19 years with sickle cell disease in Uganda: a comparative cross-sectional study-->-->PLOS One Dear Dr. Nattimba, 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. ============================== ACADEMIC EDITOR: -->-->The paper has significantly improved and is benefit to the readership of PLOS ONE. The discussion has been strengthened. However, before the authors explain the strengths and limitations of the study towards the end of the discussion, they should include some key implications of the findings from this study first to clinicians who take care of these children with SCD and second, to the school administration authorities especially that they deal with these children while in school. -->-->============================== Please submit your revised manuscript by Jun 01 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. Please include the following items when submitting your revised manuscript:--> A 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. As the corresponding author, your ORCID iD is verified in the submission system and will appear in the published article. PLOS supports the use of ORCID, and we encourage all coauthors to register for an ORCID iD and use it as well. Please encourage your coauthors to verify their ORCID iD within the submission system before final acceptance, as unverified ORCID iDs will not appear in the published article. Only the individual author can complete the verification step; PLOS staff cannot verify ORCID iDs on behalf of authors. We look forward to receiving your revised manuscript. Kind regards, Aloysius Gonzaga Mubuuke 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 : The paper has significantly improved and is benefit to the readership of PLOS ONE. The discussion has been strengthened. However, before the authors explain the strengths and limitations of the study towards the end of the discussion, they should include some key implications of the findings from this study first to clinicians who take care of these children with SCD and second, to the school administration authorities especially that they deal with these children while in school. [Note: HTML markup is below. Please do not edit.] Reviewers' comments: Reviewer's Responses to Questions -->Comments to the Author 1. 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Revision 2
23 Apr 2026 Author Response MAKERERE UNIVERSITY COLLEGE OF HEALTH SCIENCES SCHOOL OF MEDICINE DEPARTMENT OF PEDIATRICS AND CHILD HEALTH 23rd April 2026 Dr. Aloysius Gonzaga Mubuuke Academic Editor PLOS One Dear Dr. Mubuuke, On behalf of my co-authors, I am pleased to submit our responses to the reviewers’ comments for the manuscript titled “School absenteeism among children and adolescents aged 6–19 years with sickle cell disease in Uganda: a comparative cross-sectional study” (Manuscript ID: PONE-D-25-63605). We sincerely thank the Academic Editor and reviewers for their careful evaluation of our manuscript and for their valuable and constructive comments. We have carefully addressed each comment in detail below and revised the manuscript accordingly. EDITOR COMMENTS Comment 1: The paper has significantly improved and is benefit to the readership of PLOS ONE. The discussion has been strengthened. However, before the authors explain the strengths and limitations of the study towards the end of the discussion, they should include some key implications of the findings from this study first to clinicians who take care of these children with SCD and second, to the school administration authorities especially that they deal with these children while in school. Response: We have revised the Discussion section to include a new paragraph on the practical implications of our findings before the strengths and limitations section. Specifically, we added implications for clinicians caring for children and adolescents with sickle cell disease (SCD), emphasizing routine screening for school absenteeism, early management of pain crises and hospitalizations, caregiver counseling, and psychosocial support. We also included implications for school administrators and education authorities, highlighting the need for flexible attendance policies, teacher sensitization, improved communication between schools and families, and academic support for learners with SCD. Revised text: Discussion section, page 18-19, lines 341-360 “These findings have important implications for clinicians caring for children and adolescents with sickle cell disease. Routine clinical care should include screening for school absenteeism as part of holistic patient assessment, since frequent absence may signal worsening disease severity, psychosocial distress, or barriers to treatment adherence. Early identification and management of pain crises, infections, and other complications that lead to hospitalization may help reduce school disruption. Clinicians should also counsel caregivers on the importance of sustained school attendance and work with families to schedule routine clinic visits, where possible, outside critical school periods. Strengthening psychosocial support and referral systems for learners with repeated absenteeism may further improve both health and educational outcomes. The findings also have important implications for school administrators and education authorities. School administrators should recognize sickle cell disease as a chronic health condition requiring flexible and supportive attendance policies rather than punitive responses to repeated absence. Improved communication between schools, caregivers, and healthcare providers may help schools better understand illness-related absenteeism and support timely academic catch-up. Teacher sensitization on the challenges faced by learners with SCD is important to reduce stigma, improve classroom support, and encourage retention in school. Where feasible, schools should strengthen school health programs and provide reasonable accommodations such as flexible assessment schedules, remedial learning support, and referral pathways for children experiencing frequent illness-related interruptions in learning.” We hope we have satisfactorily addressed all comments from the Academic Editor and reviewers, and that the revised manuscript is now suitable for publication in PLOS ONE. We are sincerely grateful for the valuable suggestions, which have helped improve the clarity, interpretability, and overall quality of our manuscript. Sincerely, Nattimba Juliane Peninah Corresponding author Attachments Attachment Submitted filename: Response_to_Reviewers_auresp_2.docx https://doi.org/10.1371/journal.pone.0350308.r004
13 May 2026 Decision Letter - Aloysius Gonzaga Mubuuke, Editor School absenteeism among children and adolescents aged 6-19 years with sickle cell disease in Uganda: a comparative cross-sectional study PONE-D-25-63605R2 Dear Dr. Nattimba, 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, Aloysius Gonzaga Mubuuke Academic Editor PLOS One Additional Editor Comments (optional): The paper reads well and will be of importance to the journal readership Reviewers' comments: https://doi.org/10.1371/journal.pone.0350308.r005
Formally Accepted
Acceptance Letter - Aloysius Gonzaga Mubuuke, Editor PONE-D-25-63605R2 PLOS One Dear Dr. Nattimba, 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. Aloysius Gonzaga Mubuuke Academic Editor PLOS One https://doi.org/10.1371/journal.pone.0350308.r006

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