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10.1371/journal.pone.0285916
PONE-D-23-13244
Study Protocol
Research and Analysis Methods
Database and Informatics Methods
Database Searching
Medicine and Health Sciences
Health Care
Health Services Administration and Management
Medicine and Health Sciences
Epidemiology
Medicine and Health Sciences
Health Care
Health Care Policy
Health Systems Strengthening
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Epidemiology
Pandemics
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Medical Conditions
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Covid 19
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Public and Occupational Health
Medicine and Health Sciences
Epidemiology
Disease Surveillance
Short-term health system responses to epidemics across hard to reach areas in sub-Saharan Africa: A scoping review protocol
Short-term health system responses to epidemics across hard to reach areas in SSA: A scoping review protocol
https://orcid.org/0000-0003-0348-8251
Murunga Annette A. Conceptualization Data curation Formal analysis Funding acquisition Investigation Methodology Project administration Writing – original draft *
Ngoye Ben Funding acquisition Investigation Project administration Supervision Validation Writing – review & editing
Wafula Francis P. Conceptualization Funding acquisition Supervision Writing – review & editing
Kokwaro Gilbert O. Funding acquisition Project administration Supervision Writing – review & editing
Institute of Healthcare Management, Strathmore University Business School, Nairobi, Kenya
Inocencio da Luz Raquel Editor
Institute of Tropical Medicine: Instituut voor Tropische Geneeskunde, BELGIUM
Competing Interests: The authors have declared that no competing interests exist.

* E-mail: amurunga@strathmore.edu
18 9 2024
2024
19 9 e028591623 5 2023
29 7 2024
© 2024 Murunga et al
2024
Murunga et al
https://creativecommons.org/licenses/by/4.0/ This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Epidemics and Pandemics (disease outbreaks) are the occurrence of cases of disease in excess of what would be normally expected. Epidemic-prone diseases, including emerging and re-emerging diseases, constitute the greatest threat to public health security and disruption of social and economic development. When outbreaks are diagnosed in specific areas, an outbreak response is triggered to stop the spread rapidly. In the past 20 years, the sub-Saharan region has witnessed a marked increase in the number of outbreaks in pandemics, such as cholera, dengue, A/H5N 1 influenza among others. While efforts toward containment have been individually studied, we have no recent studies that examine them collectively in order to draw appropriate comparisons, no recent studies that have especially focused on hard-to-reach areas, and none that have applied a health systems lens. This study thus details a scoping review of short-term health system responses to epidemics across hard-to-reach areas in sub-Saharan Africa. The scoping review will be undertaken following PRISMA guidelines. A modified Donabedian framework will be used to understand the different approaches used while responding to epidemics. The review will focus on published and unpublished studies that report short-term health systems responses to epidemics in hard to reach areas. These will be gleaned from PubMed, google scholar and Cochrane, supplemented by a Google advanced search. In addition, manual searches will be carried out through related articles and websites. Data will be charted, coded, and narratively synthesized. our exclusion criteria will include; protocols, book chapters and countries not identified as hard to reach areas in SSA. We anticipate developing a document that will show the different approaches health systems in different countries used when responding to epidemics. The information generated will contribute to strengthening future epidemic responses by identifying best practices and innovative ideas as well as highlighting knowledge gaps.

http://dx.doi.org/10.13039/501100000265 Medical Research Council MR/T022078/1 Kokwaro Gilbert O. 1. A. M- Wellcome (UKAid), Economic and Social Research Council, Medical Research Council- Grant Number MR/T022078/1 2. B.N- Wellcome (UKAid), Economic and Social Research Council, Medical Research Council- Grant Number MR/T022078/1 3. F.W- Wellcome (UKAid), Economic and Social Research Council, Medical Research Council- Grant Number MR/T022078/1 4. G.K- Wellcome (UKAid), Economic and Social Research Council, Medical Research Council- Grant Number MR/T022078/1 https://www.ukri.org/councils/mrc/. Data AvailabilityNo datasets were generated or analysed during the current study. All relevant data from this study will be made available upon study completion.
Data Availability

No datasets were generated or analysed during the current study. All relevant data from this study will be made available upon study completion.
==== Body
pmcIntroduction

The COVID-19 pandemic in 2019 led the world to experience a significant global public health threat that pushed the world to the brink of a social and economic meltdown. This threat triggered questions about how well the global public health community is prepared to handle major epidemics and pandemics. The COVID-19 pandemic forced countries to adopt drastic response measures, which included imposing total lockdowns due to its rapid person-to-person transmission rates. This was further exacerbated by weak and poorly resourced health systems with inequities especially across low- and middle-income settings most of which are in sub-Saharan Africa put the whole world at risk. Most of these countries also possess pockets of hard-to-reach areas that are described as places where it would be hardest or take the longest for someone to access basic humanitarian services (such as health clinics and hospitals). This access is further compounded by a lack of functioning transport links and infrastructure, as well as terrain difficulty [1].

To contextualize the epidemic challenge better, it is important to realize that health systems in Low-and Middle-Income Countries (LMICs) are barely able to handle health systems challenges in high-access areas such as urban and more affluent areas. Major gaps exist in key areas like surveillance, emergency preparedness and response, risk communication and effective control and management of points of entry [2]. A WHO evaluation reported that most Sub-Saharan Africa (SSA) countries are not equipped to respond to sudden shocks to health systems, yet the region often suffers isolated disease outbreaks [3]. Worse still, broader dynamics continue to contribute to the emergence and re-emergence of outbreaks of new diseases and antimicrobial resistance [4]. Despite the fact that outbreaks such as Severe Acute Respiratory System (SARS), cholera, chikungunya, dengue fever, Rift Valley Fever and Ebola provided warning signs and tested countries’ ability to respond [5], COVID-19 still found most LMICs unprepared. And the poor emergency response strategy was made worse by inadequate laboratory and epidemiological surveillance systems and economic, social and political disincentives to case reporting [6].

While COVID-19 presented a particularly unique challenge for most countries, it is pertinent to revert to understanding how SSA countries have been responding to other types of outbreaks. We are particularly keen to document immediate (short-term) responses in order to better understand policy agility and capacity to learn, adapt and change when the need does not seem/appear to be urgent. We know that because most SSA countries focus on urgent rather than important matters, their ability to handle COVID-19, which is both an urgent and important matter, was compromised. We argue that by understanding immediate policy response to outbreaks in low-priority areas, we may be able to characterize and deal with the pain points that prevent countries from prioritizing and establishing mechanisms to nip outbreaks in the bud before the major calamity. We also argue that while effort has gone towards examining health sector responses to specific outbreaks, not enough attention has gone towards characterizing commonalities in immediate response to the disease of different kinds and how the immediate actions translate into (or fail to translate into) medium- and longer-term strategies. Examining the causal relationships between the response activities and the broader health system change is crucial if the global health community is to find a lasting solution to disease outbreaks. Moreover, successful strategies for pandemic response and preparedness over the years have been viewed from a vertical lens that is disease-specific, yet it is plausible that if the response was looked at from a health system lens, the response would be quick and more effective. This explicit linkage appears under-addressed by existing literature.

Our scoping review, therefore, aims to provide an overview of existing evidence on immediate health system responses to epidemics in hard to reach areas in SSA and attempt to answer: what is the context of the health system (Service Delivery, Health workforce, Leadership and Governance, Health financing, Medical products and technology, and Health Information Systems) with regards to pandemic preparedness and management in SSA? What is the diversity of approaches in terms of policies, protocols, communication, community participation, and surveillance that were used to manage disease outbreaks? And what were the outcomes of the various approaches and models in the early detection of diseases, reduced disease impact on the population, change in health behavior, and strengthened health system?

The rationale for the scoping review

A scoping review utilizes a systematic and iterative approach to identify and synthesize existing literature or emerging literature on a given topic. For this study, a scoping review will be used to understand the scope of the existing literature on the topic, identify the concepts and definitions used, as well as identify gaps in literature for future areas of scholarship. The scoping review will also be used to examine emerging evidence on short term responses to disease outbreaks.

Limitations of a scoping review

Limitations in the use of scoping reviews includes, first developing search terms for a comprehensive search strategy may be difficult since the area of discussion is an emerging area with less well-known information, secondly some of the topical areas or terms such as hard to reach are ill defined and can lead to different definitions for the same topic, thirdly the terms used may not be indexed as Medical Subject Headings may be difficult to find in published literature.

Conceptual framework for the scoping review

A conceptual framework has been developed using the Donabedian framework [7] of structure, processes and outcomes as illustrated in (Fig 1). The framework is commonly used to assess the quality of health services. For this review, a modified framework will be used to help in understanding approaches used in the immediate health system responses to disease outbreaks. For the review, Structures will describe the context of the health system and includes the WHO building blocks of Service Delivery, Human Resource for health (HRH), Leadership Management and Governance (LMG), Health financing, Medical products and technology, Health Information Systems (HMIS) [8]. The process will include the functions and the surveillance, policies how to conduct contact tracing, community engagement, and vaccination campaigns, protocols on health messaging and data collection processes, and communication between partners, and outcomes will include surveillance and early detection of disease outbreaks, supply chain management, treatment centers, community engagement, contact tracing, rapid response teams, public health messaging, data collection and analysis, Vaccination campaigns (if applicable), coordination between institutions and different organizations (national, International, NGOs).

10.1371/journal.pone.0285916.g001 Fig 1 Modified Donabedian framework for the scoping review.

Aided by this modified framework, we focus on the following review questions:

Context of the health system building block: What contextual forces are shaping the health system, and what are the key challenges faced by countries hard to reach areas in SSA?

Processes (functions and activities) of the health system: What are the main functions and activities of the health system hard to reach areas in SSA, and what diversity of approaches, models, innovations and tools were used to manage epidemics?

Outcomes of the health system: How successful are the various approaches and models in improving preventing and managing disease epidemics hard to reach areas in SSA?

Methodology

The review seeks to describe the short-term health system responses to epidemics across hard-to-reach areas in sub-Saharan Africa. Like other scoping reviews, the purpose is to broadly describe a phenomenon (what is known and what isn’t) and characterize it in ways that contribute towards a more detailed understanding and/or further research. Consequently, we seek to identify and map available evidence from a wide variety of sources, including published and unpublished material. We follow Arksey and O’Malley’s five-stage scoping review framework [9], which proposes the following five stages: identifying the research question, finding the articles, selecting appropriate articles, charting the data, and collating and summarizing the data into meaningful themes.

Stage 1: Identifying the research question

The research question in this review is based on the Joanna Briggs Institute PCC (Population-concept-context) model [10]. An overarching research question was developed to guide the search strategy: “What are the short-term health system responses to epidemics across hard to reach areas in sub-Saharan Africa?”. The question allows us to capture appropriate existing literature and also provides an opportunity for research questions to be added or modified in the course of the study.

Stage 2: Identifying relevant studies

Our approach will include a systematic search of peer-reviewed studies from electronic databases—PubMed, Google Scholar and Cochrane, snowballing from article reference lists to include additional studies that may not have been indexed. We will also search gray literature using Google. Literature search strategies will be developed using medical subject headings (MeSH-terms) and text words related to the population, geographical terms where countries identified as hard to reach areas will be analyzed and phenomenon of interest/intervention, as shown in Table 1.

10.1371/journal.pone.0285916.t001 Table 1 Search terms used in searching Pub-Med electronic database.

Group A: Target population terms (combined by ‘OR’)	Group B: Geographical terms (combined by ‘OR’)	Group C: intervention (combined by ‘OR’)	
AND
cholera OR diarrhoea OR diarrhoea OR dysentery OR Covid-19 OR leishmaniasis OR kala azar OR trypanosomiasis OR sleeping sickness OR malaria OR polio OR measles OR mumps OR meningitis OR chikungunya OR yellow fever OR dengue OR Ebola OR SARS OR MERS OR influenza OR Zika OR epidemic	AND
Angola OR Benin OR Burkina Faso OR Burundi OR Central African Republic OR Chad OR Comoros OR the Democratic Republic of Congo OR Djibouti OR Equatorial Guinea OR Eritrea OR Ethiopia OR Gambia OR Guinea OR Guinea-Bissau OR Lesotho OR Liberia OR Madagascar OR Malawi OR Mali OR Mozambique OR Niger OR Sao Tome and Principe OR Senegal OR Sierra Leone OR Somalia OR Sudan OR Tanzania OR Togo OR Uganda OR Zambia OR OR Rwanda OR Congo OR Côte d’Ivoire OR Ivory Coast OR Ghana OR Zimbabwe OR Namibia OR Swaziland OR Botswana OR Gabon OR Mauritius OR Kenya OR Sub-Saharan Africa OR less developed countries in Sub-Saharan Africa	Health systems impact OR Health systems resilience OR Health systems performance OR Health systems response OR Health system assessment, OR Immediate health system response, OR Short-term health system response	

Stage 3: Selecting articles.

A three-step search strategy will be undertaken. An initial search of three databases will be used that is PubMed, google scholar and Cochrane gray literature will also be accessed through google, this will be followed by an analysis of the text words contained in the title and abstract and the index terms used. The second step will include using all identified keywords and index terms in all the included databases and gray literature. The third step will include a manual review of the reference list of all the studies for additional articles that may have been left out during the initial search. This will be done firstly by searching through the reference lists of all included articles, secondly citation tracking in which we shall track selected articles that cite each one of the included articles, and thirdly similar to the citation tracking, we will follow all “related to” or “similar” articles where data collected does not have the word hard to reach areas, data will be collected based on countries included in the study.

Inclusion criteria

The inclusion criteria will include empirical studies with either qualitative or quantitative data published in English as well as countries termed as less developed countries by the United Nations. Systematic and scoping reviews will also be considered. Full text English papers from between 2010 to 2024 will be considered. This period is critical because majority of the major disease outbreaks occurred during this period.

Exclusion criteria

The scoping review will exclude all types of reviews, protocols, book chapters and countries not identified as hard to reach areas in SSA

MeSH terms used to search for CAB Direct included: Epidemic OR disease outbreak, AND Health system response AND hard to reach Countries AND Sub-Saharan Africa; and for Google Scholar, Health system response to epidemics AND hard to reach AND Sub-Saharan Africa

Following the search strategy above, all identified articles will be uploaded onto Zotero, where all duplicates will be removed.

The first screening process will include reading the title and the abstracts to reach the following decisions: (1) if at least one reviewer agrees to include or consider the abstract or title to be inconclusive, the study will be moved to the next level of screening; (2) for any of the studies if both reviewers agree for an article to be excluded, the article will be excluded. All studies at this level will be charted in an Excel sheet.

In the second level of screening, the full texts will be assessed by two independent reviewers. Reasons for any exclusion will be recorded and reported in the scoping review. Any disagreements will be resolved through discussions or with a third reviewer. The results of the search and study selection will be reported in a Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) as illustrated in the flow diagram (Fig 2).

10.1371/journal.pone.0285916.g002 Fig 2 Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram.

Stage 4: Charting data

To answer the research question, a data charting form in Excel with the following features will be created: authors, year of publication, study title, study design, the aim of the study, country of the study, and key findings relevant to the review objective. A draft charting table is provided (S1 Appendix). As a preliminary step, the reviewers will independently extract data from the first five articles using the data-charting table and meet to determine whether the approach to data extraction is consistent with the purpose of the study. The draft data extraction tool will be modified and revised as necessary during the extraction process. Modifications will be detailed in the full scoping review article.

Stage 5: collating, summarizing and reporting the results

The data from stage 4 will be collated, summarized and reported in a manner that aligns with the study objectives. Tabular and graphical representations of the data may be used to illustrate the identified results and will be supported by narrative descriptions of the data. The meaning of the findings and implications for future research and practice will be discussed.

Patient and public involvement

Patients and the public will not be involved in the design and conception of the study.

Ethics and dissemination

The proposed scoping review does not require ethical approval as data will be collected through published peer-reviewed literature and grey literature. This scoping review will provide a comprehensive overview of existing evidence in the field and will be disseminated to relevant public health offices, during conferences and stake holder meetings.

Supporting information

S1 Appendix (DOCX)

10.1371/journal.pone.0285916.r001
Decision Letter 0
Shyaka Anselme Academic Editor
© 2024 Anselme Shyaka
2024
Anselme Shyaka
https://creativecommons.org/licenses/by/4.0/ This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Submission Version0
13 Sep 2023

PONE-D-23-13244Short-term health system responses to epidemics across hard-to-reach areas in sub-Saharan Africa: A scoping review protocolPLOS ONE

Dear Ms. Murunga,

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.

==============================

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Review and discuss your choice to search only a few databases while leaving out other important sources for biomedical literature and research.

Discuss any anticipated limitations to the method selected for your scoping review. Please include a section on the limitations and discuss any challenges that could limit a comprehensive retrieval of the literature (e.g., the review will consider manuscripts published in English only, only a few databases to be used for manuscript search, etc.)

==============================

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3. 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.

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Does the manuscript provide a valid rationale for the proposed study, with clearly identified and justified research questions?

The research question outlined is expected to address a valid academic problem or topic and contribute to the base of knowledge in the field.

Reviewer #1: Yes

********** 

2. Is the protocol technically sound and planned in a manner that will lead to a meaningful outcome and allow testing the stated hypotheses?

The manuscript should describe the methods in sufficient detail to prevent undisclosed flexibility in the experimental procedure or analysis pipeline, including sufficient outcome-neutral conditions (e.g. necessary controls, absence of floor or ceiling effects) to test the proposed hypotheses and a statistical power analysis where applicable. As there may be aspects of the methodology and analysis which can only be refined once the work is undertaken, authors should outline potential assumptions and explicitly describe what aspects of the proposed analyses, if any, are exploratory.

Reviewer #1: Yes

********** 

3. Is the methodology feasible and described in sufficient detail to allow the work to be replicable?

Descriptions of methods and materials in the protocol should be reported in sufficient detail for another researcher to reproduce all experiments and analyses. The protocol should describe the appropriate controls, sample size calculations, and replication needed to ensure that the data are robust and reproducible.

Reviewer #1: Yes

********** 

4. Have the authors described where all data underlying the findings will be made available when the study is complete?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception, at the time of publication. 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

********** 

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

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Reviewer #1: Yes

********** 

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above and, if applicable, provide comments about issues authors must address before this protocol can be accepted for publication. You may also include additional comments for the author, including concerns about research or publication ethics.

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(Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Overall, this scoping review protocol appears well-structured and comprehensive, and it provides a clear outline of how the study will be conducted.

However, here some proposed areas for improvement:

Major comment:

P.7 - There should be an alignment between the title – main objective - and the methodology. The methodology outlines a clear and well-structured approach for conducting a scoping review and provides details on the research questions, search strategy, data selection, and data extraction. However, it is unclear how the search approach proposed will collect data on hard-to-reach areas specifically. Details on specific search for these areas should be defined. This is important since these areas may not necessarily be characterized as ‘hard - to- reach' in literature.

Minor comments

Abstract & P.3 - The use of the word ‘outbreak’ should be reviewed. This is a general term that englobes both ‘epidemic’ and ‘pandemic’. Ensure you use it appropriately and replace it epidemics and/or pandemics whenever applicable.

Abstract - There is contradiction in this sentence. If the objective is to stop infection, the target is MANY people, not few. But this sentence can be better formulated. Suggestion: use the term 'minimize infections'.

Abstract - Avoid starting sentences with 'And'.

Abstract - This abstract should briefly mention the methodology.

P.3 - Provide more details and clarification on how the manual search will be carried out.

P. 4 - The use of 'short-term' two times in one sentence is redundant. Reformulate.

P.5 - Capitalize ‘COVID-19’

P.5 - Explain the full meaning of abbreviations the first time they are used (eg: SSA, LMICs, SARS, etc). They can simply be used as abbreviations afterwards.

P.6 - Reformulate this sentence ‘To contextualize the challenge better, though, it is important to realize that health systems in LMICs are barely able to handle those in high-access areas such as urban and more affluent Areas.’ It is unclear what ‘those’ is replacing.

P.6 - 7. The rationale for scoping review as it is presented gives a broad definition of scoping review and a difference between scoping review and systematic review. Define the rationale specifically for this specific scoping review; the needs and expected outcomes.

P.7- This part - as for others - should be aligned with the short-term aspect of your research project. Some of the outcomes mentioned here are long-term. Short-term health system responses include:

-Surveillance and early detection

-Rapid response teams

-Treatment Centers

- Public Health Messaging

- Supplying Chain Management

- Community Engagement

- Contact Tracing

- Data Collection and Analysis

- Vaccination campaigns (if applicable)

- Coordination between institutions and different organizations (national, International, NGOs).

- Explore ways of incorporating these in the Process.

P. 8- It is unclear what will be done in this step of screening the reference list. Provide more details.

P.10 - Define inclusion and exclusion criteria.

********** 

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.

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Reviewer #1: No

**********

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Attachment Submitted filename: PONE-D-23-13244.pdf - revised.pdf

10.1371/journal.pone.0285916.r002
Author response to Decision Letter 0
Submission Version1
8 Feb 2024

1. Review and discuss your choice to search only a few databases while leaving out other important sources for biomedical literature and research.

Ans: The study focused on three databases that is PubMed, Google Scholar and Cochrane. The databases were selected on the basis that 1) Google Scholar has a wide variety of articles and is also very comprehensive that is it includes literature that goes beyond biomedical research. The data base also provides provision for gray literature. PubMed on the other hand has a free search interface and provides access to more than 26million citations covering biomedical literature. The literature provided dates back from 1946 in MEDLINE AND PreMEDLINE. The database also includes publisher-supplied records (including electronic publications ahead of print) (1).

2. Discuss any anticipated limitations to the method selected for your scoping review. Please include a section on the limitations and discuss any challenges that could limit a comprehensive retrieval of the literature (e.g., the review will consider manuscripts published in English only, only a few databases to be used for manuscript search, etc.)

Limitations in the use of scoping reviews includes, first developing search terms for a comprehensive search strategy may be difficult since the area of discussion is an emerging area with less well-known information, secondly some of the topical areas or terms such as hard to reach are ill defined and can lead to different definitions for the same topic, thirdly the terms used may not be indexed as Medical Subject Headings may be difficult to find in published literature.

P.7 - There should be an alignment between the title – main objective - and the methodology. The methodology outlines a clear and well-structured approach for conducting a scoping review and provides details on the research questions, search strategy, data selection, and data extraction. However, it is unclear how the search approach proposed will collect data on hard-to-reach areas specifically. Details on specific search for these areas should be defined. This is important since these areas may not necessarily be characterized as ‘hard - to- reach' in literature.

Ans: Thank you for taking note of this. The term hard to reach areas has now been defined are as places where it would be hardest or take the longest for someone to access basic humanitarian services (such as health clinics and hospitals). This access is further compounded by a lack of functioning transport links and infrastructure, as well as terrain difficulty. The countries to be included in this category include:

Angola Ethiopia Rwanda

Benin Gambia São Tomé and Príncipe

Burkina Faso Guinea Senegal

Burundi Guinea-Bissau Sierra Leone

Central African Republic Lesotho Somalia

Chad Liberia Sudan

Comoros Madagascar Tanzania

Democratic Republic of the Congo Malawi Togo

Djibouti Mali Uganda

Equatorial Guinea Mauritania Zambia

Eritrea Mozambique Rwanda

Niger São Tomé and Príncipe

Abstract & P.3 - The use of the word ‘outbreak’ should be reviewed. This is a general term that englobes both ‘epidemic’ and ‘pandemic’. Ensure you use it appropriately and replace it epidemics and/or pandemics whenever applicable.

Ans Replaced with Epidemic

Abstract - There is contradiction in this sentence. If the objective is to stop infection, the target is MANY people, not few. But this sentence can be better formulated. Suggestion: use the term 'minimize infections'-this has been done.

Abstract - Avoid starting sentences with 'And'-this has been corrected

Abstract - This abstract should briefly mention the methodology-this has been corrected and added

P.3 - Provide more details and clarification on how the manual search will be carried out.

The third step will include a manual review of the reference list of all the studies for additional articles that may have been left out during the initial search. This will be done firstly by searching through the reference lists of all included articles, secondly citation tracking in which we shall track selected articles that cite each one of the included articles, and thirdly similar to the citation tracking, we will follow all “related to” or “similar” articles where data collected does not have the word hard to reach areas, data will be collected based on countries included in the study.

P. 4 - The use of 'short-term' two times in one sentence is redundant. Reformulate this has been reformulated

Our scoping review, therefore, aims to provide an overview of existing evidence on immediate health system responses to epidemics in hard to reach areas in SSA and attempt to answer: what is the context of the health system (Service Delivery, Health workforce, Leadership and Governance, Health financing, Medical products and technology, and Health Information Systems) with regards to pandemic preparedness and management in SSA? What is the diversity of approaches in terms of policies, protocols, communication, community participation, and surveillance that were used to manage disease ou

tbreaks? And what were the outcomes of the various approaches and models in the early detection of diseases.

P.5 - Capitalize ‘COVID-19-Done

P.5 - Explain the full meaning of abbreviations the first time they are used (eg: SSA, LMICs, SARS, etc). They can simply be used as abbreviations afterwards. Done

P.6 - Reformulate this sentence ‘To contextualize the challenge better, though, it is important to realize that health systems in LMICs are barely able to handle those in high-access areas such as urban and more affluent Areas.’ It is unclear what ‘those’ is replacing.

To contextualize the epidemic challenge better, it is important to realize that health systems in Low-and Middle-Income Countries (LMICs) are barely able to handle health systems challenges in high-access areas such as urban and more affluent areas.

P.6 - 7. The rationale for scoping review as it is presented gives a broad definition of scoping review and a difference between scoping review and systematic review. Define the rationale specifically for this specific scoping review; the needs and expected outcomes.

A scoping review utilizes a systematic and iterative approach to identify and synthesize existing literature or emerging literature on a given topic. For this study, a scoping review will be used to understand the scope of the existing literature on the topic, identify the concepts and definitions used, as well as identify gaps in literature for future areas of scholarship.

P.7- This part - as for others - should be aligned with the short-term aspect of your research project. Some of the outcomes mentioned here are long-term. Short-term health system responses include:

-Surveillance and early detection

-Rapid response teams

-Treatment Centers

- Public Health Messaging

- Supplying Chain Management

- Community Engagement

- Contact Tracing

- Data Collection and Analysis

- Vaccination campaigns (if applicable)

- Coordination between institutions and different organizations (national, International, NGOs).

- Explore ways of incorporating these in the Process

This has been done.

p.10-Define the inclusion and exclusion criteria.

Inclusion criteria

The inclusion criteria will include empirical studies with either qualitative or quantitative data published in English as well as countries termed as less developed countries by the United Nations. Systematic and scoping reviews will also be considered. Full text English papers from between 2010 to 2024 will be considered. This period is critical because majority of the major disease outbreaks occurred during this period.

Exclusion criteria

The scoping review will exclude all types of reviews, protocols, book chapters and countries not identified as hard to reach areas in SSA

Attachment Submitted filename: Response to reviewers.docx

10.1371/journal.pone.0285916.r003
Decision Letter 1
Inocencio da Luz Raquel Academic Editor
© 2024 Raquel Inocencio da Luz
2024
Raquel Inocencio da Luz
https://creativecommons.org/licenses/by/4.0/ This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Submission Version1
30 Jul 2024

Short-term health system responses to epidemics across hard to reach areas in sub-Saharan Africa: A scoping review protocol

PONE-D-23-13244R1

Dear Authors

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Reviewers' comments:

10.1371/journal.pone.0285916.r004
Acceptance letter
Inocencio da Luz Raquel Academic Editor
© 2024 Raquel Inocencio da Luz
2024
Raquel Inocencio da Luz
https://creativecommons.org/licenses/by/4.0/ This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
2 Aug 2024

PONE-D-23-13244R1

PLOS ONE

Dear Dr. Murunga,

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