Evaluating the effect of a community score card among pregnant and breastfeeding women living with HIV in two districts in Malawi.

Malawi faces challenges with retaining women in prevention of mother-to-child HIV transmission (PMTCT) services. We evaluated Cooperative for Assistance and Relief Everywhere, Inc. (CARE's) community score card (CSC) in 11 purposively selected health facilities, assessing the effect on: (1) retention in PMTCT services, (2) uptake of early infant diagnosis (EID), (3) collective efficacy among clients, and (4) self-efficacy among health care workers (HCWs) in delivering quality services. The CSC is a participatory community approach. In this study, HCWs and PMTCT clients identified issues impacting PMTCT service quality and uptake and implemented actions for improvement. A mixed-methods, pre- and post-intervention design was used to evaluate the intervention. We abstracted routine clinical data on retention in PMTCT services for HIV-positive clients attending their first antenatal care visit and EID uptake for their infants for 8-month periods before and after implementation. To assess collective efficacy and self-efficacy, we administered questionnaires and conducted focus group discussions (FGDs) pre- and post-intervention with PMTCT clients recruited from CSC participants, and HCWs providing HIV care from facilities. Retention of HIV-positive women in PMTCT services at three and six months and EID uptake was not significantly different pre- and post-implementation. For the clients, the collective efficacy scale average improved significantly post-intervention, (p = 0.003). HCW self-efficacy scale average did not improve. Results from the FGDs highlighted a strengthened relationship between HCWs and PMTCT clients, with clients reporting increased satisfaction with services. However, the data indicated continued challenges with stigma and fear of disclosure. While CSC may foster mutual trust and respect between HCWs and PMTCT clients, we did not find it improved PMTCT retention or EID uptake within the short duration of the study period. More research is needed on ways to improve service quality and decrease stigmatized behaviors, such as HIV testing and treatment services, as well as the longer-term impacts of interventions like the CSC on clinical outcomes.

Introduction

There has been significant progress in prevention of mother-to-child HIV transmission (PMTCT) in Malawi; from 2010 to 2018, the number of new HIV infections in children 0–14 years declined from more than 15,000 to under 3,500 [1]. However, further progress must be made to reach elimination of mother-to-child HIV transmission (MTCT). The MTCT rate at the end of breastfeeding was estimated to be 7.8% in Malawi in 2018 [2].

Malawi faces ongoing challenges with retention of mothers and infants in PMTCT care. A study completed after the national roll-out of universal lifelong antiretroviral therapy (ART) for pregnant and breastfeeding women found that 17% of women were lost to follow-up within six months of initiating ART [3]. Further, women who initiated ART during pregnancy were five times more likely than women who were initiated on ART when not pregnant to never return to the health facility [3]. Additionally, only 75% of HIV-exposed infants (HEIs) received a DNA PCR test for early infant diagnosis (EID) by two months of age in 2018 [4], highlighting significant losses to follow-up of mothers and infants during the breastfeeding period.

Studies examining PMTCT retention among pregnant and breastfeeding mothers on lifelong ART in Malawi demonstrate several common barriers including low male involvement in PMTCT, fear of disclosure to one’s partner, stigma, and poor interactions with some health care workers (HCWs) [5-10]. Studies have found that improved quality of care, including perceived quality of care, improves health-seeking behaviors, retention in care, and ART adherence [11-13]. One means of addressing persistent and modifiable barriers to quality care is using social accountability approaches to empower clients and communities [14,15].

In the health sector, social accountability approaches are participatory practices that reinforce the complementary responsibilities and shared accountability of citizens, HCWs, and governments in the provision of quality health services. They empower service users to voice their needs and concerns, hold service providers and government to account, and create space for collective action to improve public sector performance. One social accountability approach is the community score card (CSC) © developed by Cooperative for Assistance and Relief Everywhere, Inc. (CARE). The CSC is a social accountability approach which uses a two-way, ongoing participatory approach for assessment, planning, monitoring, and evaluating public services. The CSC brings together the demand side (i.e., ‘client’) and the supply side (i.e., ‘HCWs’) of a service or program to jointly analyze issues underlying service delivery problems, find a common and shared way of addressing those issues, and continuously track commitments toward the implementation of those solutions in an ongoing process of quality improvement [15].

A review of eight CSC projects in five countries found evidence suggesting increased citizen empowerment, service provider and power-holder effectiveness, and improvements in services [16]. A cluster randomized controlled evaluation of the CSC’s effectiveness in improving reproductive health-related outcomes in Malawi found that clinic catchment areas implementing the CSC had higher rates of home visits, increased postnatal care, and improved service satisfaction compared to control areas [17].

The CSC approach has shown promising results in maternal, neonatal, child, and other health services domains, but prior to this study it had not been used in an HIV service delivery setting or to assess patient outcomes, such as retention in care. The US Centers for Disease Control and Prevention (CDC), CARE, the Malawi Ministry of Health (MOH), and the Elizabeth Glaser Pediatric AIDS Foundation (EGPAF) collaborated to adapt, implement, and evaluate the CSC approach for PMTCT services at 11 facilities in the Dedza and Ntcheu districts of Malawi. In 2015–2016, Malawi‘s HIV prevalence overall was 10.6%, but varied by region [18]. The Ntcheu and Dedza districts of Malawi’s central region were priority districts within the national HIV response, and EGPAF supported the MOH facilities as an implementing partner. The average proportion of HIV-positive pregnant women retained at six months in these districts was 75%, with 64–71% of HEIs returning at six weeks for EID.

The adaptation and implementation of the CSC within PMTCT settings aimed to improve clinical outcomes for HIV-positive pregnant and breastfeeding women and their families by strengthening community engagement in HIV service delivery. In this paper, we assess the effect of the CSC on women’s retention in PMTCT services, EID uptake, collective efficacy among the clients (the extent to which the women believed that the community could work together to improve care), and self-efficacy among HCWs in delivering quality services and community participation.

Methods

Intervention description

The CSC approach is a participatory forum that consists of five core phases (illustrated in Fig 1 and described in detail elsewhere [16,17]), four of which are repeated on a regular basis (called “rounds”), during which service users and service providers separately identify issues and then jointly propose solutions and monitor implementation of the solutions. For this project, CARE-Malawi staff implemented three rounds of issue identification and implementation periods of four months duration from September 2017-September 2018. This project adapted elements of the CSC approach originally aimed at broad-based community engagement to focus on engaging HCWs and clients of PMTCT clinical services to identify and solve PMTCT-related issues. The adaptation process and lessons learned are described elsewhere [19]. HCWs were recruited from the intervention clinics and PMTCT clients were identified through the intervention clinics and associations of people living with HIV within the catchment areas surrounding the intervention clinics and invited to participate in the CSC intervention. For the first round, HCWs and PMTCT clients separately identified the issues and barriers most impacting their ability to successfully deliver and access quality PMTCT services, then grouped these issues into indicators. These indicators were then scored by both HCWs and PMTCT clients and used to develop the individual score cards. HCWs and PMTCT clients then came together with other community and government leaders to present their scores and develop, implement, and monitor specific actions for improving PMTCT service delivery and access. Examples of specific actions identified were increasing the availability of trained HCWs providing PMTCT services and adequate infrastructure, supplies, and equipment. In subsequent rounds, previous issues were revisited in order to assess progress made as a result of the action period and re-scored, and action plans were updated. In the CSC approach, participants’ perception of the quality of services meaningfully affects health-seeking behavior including decisions to remain in care [20,21]. A total of 822 PMTCT clients and 64 HCWs participated in the intervention, with participation varying by round.

Fig 1

Core phases of the community score card approach.

Study setting

The 11 health facilities in Ntcheu and Dedza districts (9 health centers and 2 district hospitals), were selected based on several criteria, including: 1) at least 25 HIV-positive women receiving HIV services annually; 2) less than 85% retention of HIV-positive pregnant and breastfeeding women in PMTCT services at six months after ART initiation; and 3) lower than national average uptake of EID. Ntcheu and Dedza district hospitals were included to test the CSC intervention in a setting with high patient volume.

Study design

We used a mixed methods, pre- and post-intervention cross-sectional design to assess four key outcomes: (1) retention in PMTCT services, (2) uptake of EID, (3) collective efficacy among clients, and (4) self-efficacy among HCWs in delivering quality services.

To assess the effect of the CSC intervention on clinical outcomes (early retention in PMTCT for newly and previously diagnosed HIV-positive pregnant women and EID uptake), we abstracted data from routine health records maintained by the clinics in the study. The study used clinical records to determine retention in PMTCT services for HIV-positive pregnant and breastfeeding women and EID uptake for their HEIs in the periods before and after implementation of the intervention. Women did not have to participate in the CSC intervention to be included in the abstraction, as it was hypothesized that CSC-related clinical improvements may affect the quality of care, PMTCT retention, and EID uptake for all PMTCT clients.

To assess changes in collective efficacy and self-efficacy among the women and HCWs, we administered quantitative questionnaires and conducted pre- and post-intervention focus group discussions (FGDs) with PMTCT clients and HCWs engaged with the CSC intervention. We selected this mixed methods approach in recognition of the complex theories of change behind social accountability interventions [22]. Each component was conducted to provide unique information on the effectiveness of the intervention. By examining these findings together in one paper, we attempt a complete examination and discussion of the entirety of the findings to better understand the complex model of change.

Study participants and sample size

Clinical data abstraction

In accordance with the MOH guidelines at the time of the study, pregnant women underwent “opt-out” HIV testing (default testing unless the woman refused testing) at first antenatal care (ANC) visit or delivery, and were immediately offered ART if found to be HIV-positive [23]. HIV-positive pregnant or breastfeeding women obtained monthly ART refills from maternal and child health or HIV clinics. HEIs were offered DNA PCR testing at 6–8 weeks of age.

For the abstraction of data from existing clinical records, women were eligible for inclusion if they were HIV-positive (newly or previously diagnosed), aged 15 years or older, and attended their first ANC appointment and received ART between August 2016-March 2017 (pre-intervention) and between August 2017-March 2018 (post-intervention) in one of the 11 selected facilities. All eligible women were identified using the clinic’s ANC register and assigned a unique study identifier. All documented live births of the identified women were eligible for inclusion and listed with a linking identifier. We targeted a sample size of women and infants to detect a 10% change in six-month retention in PMTCT services and uptake of EID at 6–8 weeks, from baseline rates of 74% and 56% respectively. Given the hypothesized effect size, our power analysis determined a sample size of 481 women and 481 infants at pre- and post-intervention (power = 0.80, 2-tailed, α = 0.05, potential attrition = 20%) across the 11 sites was needed.

Surveys and FGDs

Surveys and FGDs were administered to CSC participants. PMTCT clients were eligible for inclusion if they were HIV-positive (newly or previously diagnosed), aged 15 years or older, and were currently pregnant or breastfeeding. All eligible PMTCT clients were approached and briefed about the survey at the first and last CSC meetings. Those who expressed interest were administered a consent script in a private place. Women who consented were invited to participate in the survey on the same day as the CSC meeting.

Participants for the FGDs were selected from CSC meetings using a lottery method. Attendees of the CSC meetings were provided with a number, and those who received numbers 2–6 were invited to participate in an FGD. Three FGDs with HCWs and three FGDs with the women were conducted in each of the two districts for the pre and post period. Those interested were given further details of the FGD. On the day of the FGD, eligibility criteria were reviewed for the women who came. Eligible women provided written consent.

HCWs were eligible for inclusion in the surveys and FGDs if they were 18 years and older and were working in HIV care in one of the selected facilities for at least one month. Eligible HCWs were recruited through the facilities. All eligible HCWs were invited to participate in the collective action survey and the FGDs. Booking for interviews and FGDs was conducted simultaneously, and consent was administered prior to each activity. With expected attendance of 300 PMTCT clients at CSC sessions and 65 eligible HCWs, we determined we would have at least 90% power to detect a 5% change in empowerment indicators in the survey. The subsets of these groups who participated in the FGDs were deemed sufficient in size to reach thematic saturation.

Data collection

Trained research assistants abstracted clinical data from the ANC, ART, and maternity registers, as well as from the facility-maintained patient files documenting ART treatment for all eligible PMTCT clients. Information abstracted included sociodemographic characteristics, pregnancy information, birth outcomes, and visit information from up to seven ART visits recorded in the ART register. All HEIs of eligible PMTCT clients had their clinical information abstracted from the EID DNA PCR logbook and infant patient files. Information abstracted included gender, birth weight, up to six months of visit information, and HIV testing and results. Abstraction for both populations was conducted from November 2017-January 2018 (pre-intervention) and October 2018-December 2019 (post-intervention). Research assistants recorded abstracted data on a paper form, which was then entered into an Epi Info v7.2 database.

Research assistants orally administered the surveys in Chichewa or English. The PMTCT client survey included questions on sociodemographic variables, collective efficacy, and at post-intervention only, participation in the CSC intervention. The HCW survey included questions on sociodemographic variables, work responsibilities, self-efficacy for collective action, social cohesion (mutual aid, trust, connectedness, and social support), work attachment, social participation, collective efficacy, and mutual responsibility. Seven research assistants were trained and responsible for conducting the FGDs in the role of moderator or notetaker. Research assistants recorded the responses on paper forms, which were then entered into an Epi Info database.

Research assistants facilitated the FGDs in Chichewa for PMTCT clients and English for HCWs. PMTCT client FGDs explored satisfaction with and perceived quality of health services, and relationship and trust with HCWs. HCW FGDs explored service challenges and accountability, and relationship and trust with clients. To reduce social desirability bias, the FGDs used anecdotal scenarios called “vignettes” to talk about the experience of new PMTCT clients and new HCWs. The vignettes focus on a young woman pregnant for the first time, attending her first ANC visit, and her experiences at the health facility, from her reception to her HIV-positive test, counseling, and drug pick-up. The scenario includes her perception of the services, and treatment by HCWs. At post-intervention, both populations were asked about the effect of the CSC on services. Prior to each discussion, FGD facilitators presented discussion guidelines, according to the standard operating procedures. In addition to assurances of the confidentiality of the discussions, the guidelines included the importance of confidentiality and the discouragement of sharing of personal information, especially for PMTCT clients. FGDs were audio recorded, transcribed, and for PMTCT client FGDs, translated to English.

Ethical approval

Ethical approval was received from the Malawi National Health Sciences Research Committee, Advarra Institutional Review Board (IRB), and the CDC IRB. We obtained a waiver of informed consent for clinical data abstraction, as data was collected as part of routine care and it was not feasible to seek client permission. Informed consent was obtained from the clients and HCWs who participated in the questionnaire surveys and FGDs. In Malawi, pregnant women aged 15–17 years are emancipated minors and thus can provide informed consent for themselves and their infants. Clients provided written consent or a thumbprint if they were unable to sign their names, while HCWs provided written consent.

Measures

We adapted validated measures from the “Women’s and Health Worker Voices in Open, Inclusive Communities and Effective Spaces (VOICES): Measuring Governance Outcomes in Reproductive and Maternal Health Programmes” [24] to make them more explicitly related to PMTCT services. We adapted measures of collective efficacy for PMTCT clients, and self-efficacy, social cohesion, work attachment, collective efficacy, and mutual responsibility for and support of services for HCWs [25,26]. The modified collective efficacy scale consisted of four items: How sure are you that the community can work together to (1) obtain government services and entitlements; (2) improve PMTCT services in this community; (3) improve how HIV -positive pregnant and postpartum women are treated at the health facility; and (4) improve the health and well-being of HIV-positive pregnant and postpartum women and their children. Collective efficacy was measured on a 5-point unipolar Likert scale from not at all sure to completely sure. The Cronbach alpha for the modified measure was 0.76, demonstrating sufficient internal consistency and scale reliability [27].

Self-efficacy for delivering quality health/PMTCT services was measured with two (modified) items: (1) how sure are you that you personally can do things to improve your own performance at work; and (2) how sure are you that you personally can do things to improve the quality of PMTCT services in the health facility and the catchment area. Self-efficacy for participation was measured with three items: (1) how sure are you that you can speak up in the community or health facility meetings about things that need improvement; (2) how sure are you that you can ask people in the community what HIV/PMTCT services their community needs; and (3) how sure are you that you can answer questions and share information with the community about PMTCT services available. All were measured on a 5-point unipolar Likert scale from not at all sure to completely sure. The Cronbach alpha for self-efficacy for delivering quality PMTCT services was 0.78 and 0.81 for participation.

Social participation was essentially an indicator of participation in the CSC process with questions on whether, in the past six months, they had met with the Village Health Committee, Health Center Committee, or community members to discuss and work on PMTCT issues. Participants were also asked if, in the past six months, they had meetings between the community, HCWs, and district government authorities where problems or other issues with health services were discussed, and plans for improving health services had been made to assess whether the collective action process had been implemented in full.

Quantitative analysis

Abstracted clinical data were analyzed by calculating the percent of women retained in PMTCT services by timing of diagnosis (newly or previously diagnosed) and duration of time on ART (three or six months). Retention for this study was defined as having attended the most recent scheduled ART visit before the specified time (three or six months from first ANC), with a seven-day grace period. Chi square tests and logistic regression modeling were performed to examine the relationship between timing of diagnosis at both pre- and post-intervention and to compare PMTCT retention before and after the CSC intervention. We adjusted for type of health facility (i.e., hospitals or health centers) in the analysis. Similarly, the percent of HEIs tested with DNA PCR by eight weeks of age was calculated for pre- and post-intervention and compared. EID uptake was defined as having a recorded DNA PCR test in the infant’s patient file or the EID DNA PCR logbook. We used generalized estimating equation (GEE) modeling to examine potential clustering. To account for the clustering of individuals within sites, we considered a compound symmetry working correlation structure in the GEE model. The correlation coefficient was negligible (close to 0), so we decided to proceed with logistic regression modeling and chi square tests. All statistical tests were conducted on the combined data for all sites and used p < .05 as the significance level.

The collective and self-efficacy measures were composed of items presented as questions that employed Likert scales with positively and negatively worded statements. These data were analyzed by summing the values for each item (a measure was composed of one or more items) and dividing by the number of items. For each measure, at both pre- and post-intervention, a mean and standard deviation (SD), and median and interquartile range (IQR), were determined. We assessed pre-/post-intervention differences using the Wilcoxon-Rank Sum test, as we found that the data were not normally distributed. Analyses were conducted using STATA v12 and SAS v9.4.

Qualitative analysis

FGDs were transcribed and translated into Word documents and uploaded into the qualitative analysis software program MaxQDA v12. A detailed code list was developed by the study team and used in the analysis of the pre- and post-intervention data. The pre-intervention data was analyzed after the first round of data collection, the post-intervention data was analyzed after the post-intervention data were collected, and then a comparison analysis was done to compare the results of the pre-/post-intervention data. This was done by comparing the data reduction and summary tables (matrices). The matrices compared the perspectives of the two populations at the two different time points. Data were compared pre- and post-intervention and changes in service quality, client satisfaction, and HCW-PMTCT client relationships were summarized, including specific changes attributed to the CSC intervention and process.

Data were coded by two research assistants for the pre-post analysis. For the comparison analysis, the study team reviewed the matrices and identified the changes pre-/post-intervention together. Reviews of coded transcripts were conducted throughout the coding process to ensure inter-coder reliability. This was done by comparing the coding of the same transcripts by the two research assistants.

Results

Clinical outcomes: Early retention of HIV-positive women enrolled in PMTCT and EID uptake

A total of 627 women at pre-intervention and 606 women at post-intervention enrolled in ANC were identified as eligible for data abstraction and had their records abstracted. All women had ANC information available, but ART and maternity information was not available for all women due to clients seeking health services at more than one health facility, poor documentation, and/or transfers, defaults, and deaths. At pre-intervention, 370 HEIs (59.0%) were identified for the 627 women, and at post-intervention, 448 HEIs (73.9%) were identified for the 606 women; not all HEIs were identified due to gaps in record documentation and linking systems.

Of the 627 HIV-positive women whose records were abstracted at pre-intervention, 43.4% (272) were newly diagnosed with HIV at their first ANC visit. At post-intervention, of the 606 HIV-positive women 38.6% (234) were newly diagnosed with HIV (Table 1). The mean ages of the women were 29 and 28 years at pre- and post-intervention, respectively. Women newly diagnosed with HIV tended to be younger compared to previously diagnosed women. Mean gestational age at first ANC visit was similar between women previously and newly diagnosed with HIV and both pre- and post-intervention (Table 1). A greater proportion of birth outcome data were available post-intervention.

Table 1

Characteristics of the women attending PMTCT and birth outcomes pre- and post- intervention.

	Pre-intervention				Post-intervention
	New HIV+ (n = 272)	Previous HIV+ (n = 355)	Total (n = 627)	New HIV+ (n = 234)		Previous HIV+ (n = 372)	Total (n = 606)
	N (%)	N (%)	N (%)	N (%)		N (%)	N (%)
Age at first ANC visit (years)
15–19	35 (12.9)	10 (2.8)	45 (7.2)	29 (12.4)		13 (3.5)	42 (6.9)
20–24	86 (31.6)	67 (18.9)	153 (24.4)	79 (33.8)		67 (18.0)	146 (24.1)
25–29	64 (23.5)	79 (22.3)	143 (22.8)	63 (26.9)		98 (26.3)	161 (26.6)
30–34	59 (21.7)	102 (28.7)	161 (25.7)	38 (16.2)		95 (25.5)	133 (21.9)
35+	28 (10.3)	97 (27.3)	125 (19.9)	25 (10.7)		99 (26.6)	124 (20.5)
Total	272 (100.0)	355 (100.0)	627 (100.0)	234 (100.0)		372 (100.0)	606 (100.0)
Gestational age at first ANC visit (weeks)
Mean (SD)	20.7 (6.6)	20.6 (6.7)	20.7 (6.7)	21.9 (6.2)		21.8 (6.5)	21.8 (6.3)
Birth outcomes
Alive	147 (54.0)	223 (62.8)	370 (59.0)	146 (62.4)		302 (81.2)	448 (73.9)
Still birth/ perinatal death	0 (0.0)	0 (0.0)	0 (0.0)	1 (0.4)		1 (0.3)	2 (0.3)
Missing	125 (46.0)	132 (37.2)	257 (41.0)	87 (37.2)		69 (18.5)	156 (25.7)
Total	272 (100.0)	355 (100.0)	627 (100.0)	234 (100.0)		372 (100.0)	606 (100.0)

Early retention of HIV-positive women enrolled in PMTCT at three and six months was not significantly different at pre- and post-implementation of the CSC intervention (Table 2). Of the 627 eligible women in the pre-intervention cohort, 476 (75.9%) and 475 (75.8%) had data available for 3-month and 6-month retention, respectively; out of 606 eligible women in the post-intervention cohort, 574 (94.7%) and 569 (93.9%) had data available for 3-month and 6-month retention, respectively. Pre-intervention, 362/476 (76.1%) HIV-positive women enrolled in PMTCT were retained at three months, while post-intervention, 446/574 (77.7%) were retained at three months, p = 0.527. At six months, 352/475 (74.1%) were retained pre-intervention, and 431/569 (75.8%), post-intervention, p = 0.542. At both time periods, previously diagnosed HIV-positive women were more likely to be retained compared to newly diagnosed women (at 3 months, relative risk [RR] 3.73, 95% confidence interval [CI] 2.75–5.05; at 6 months RR 3.50, 95% CI 2.83–5.12).

Table 2

Number and percentage of HIV-positive pregnant women (newly and previously diagnosed) retained in PMTCT services at 3 and 6 months after their first ANC visit and infant DNA/PCR test at 6–8 weeks or >8 weeks of age, pre- and post-intervention.

	Pre-intervention			Post-intervention			P-value pre/post intervention
PMTCT retention1 period	New HIV+	Prev. HIV+	Total	New HIV+	Prev. HIV+	Total
	N (%)	N (%)	N (%)	N (%)	N (%)	N (%)
3 mo.	126 (61.5)	236 (87.1)	362 (76.1)	146 (65.0)	300 (86.0)	446 (77.7)	0.527
6 mo.	118 (57.8)	234 (86.4)	352 (74.1)	140 (62.8)	291 (84.1)	431 (75.8)	0.542
DNA/PCR test2	N (%)			N (%)			0.678
6–8 weeks	257 (78.8)			325 (77.6)
>8 weeks	69 (21.2)			94 (22.4)

1Retention in PMTCT services is defined as having attended a clinic visit before the specified time (3- or 6-months after first ANC visit) and having a scheduled clinic visit after the specified time. A seven-day window was given to account for individuals with a clinic visit within one week before or after. Adjustments and exclusions were made to account for transfers and deaths. We excluded those for whom ART visit information was missing in pre- (n = 145) and post-intervention (n = 21) data sets.

2Excluding missing data; pre-intervention (n = 40) and post-intervention (n = 27).

Complete HIV testing was available for 326/370 (88.1%) of HEIs in the pre-intervention cohort and out of 419/480 (87.3%) HEIs in the post-intervention cohort. No significant differences in EID uptake were observed pre- and post-intervention, with EID uptake by eight weeks of age at 78.8% (257/326) pre-intervention and 77.6% (325/419) post-intervention, p = 0.678 (Table 2).

Collective action surveys

A total of 596 PMTCT clients (295 pre-intervention and 300 post-intervention) and 128 HCWs (64 pre- and 64 post-intervention) participated in the collective action surveys. The characteristics of the PMTCT clients at pre- and post-intervention were similar, as shown in Table 3. The mean age and SD of the PMTCT clients were similar pre- and post-intervention at ages 30 (6) and 30 (7) years respectively. Similar proportions of clients attended primary school or less; 79.7% (235/295), and 80.7% (242/300) respectively. The mean time (SD) since HIV diagnosis was 4.3 (3.9) months for the pre-intervention clients and 5.1 (4.0) months for the post-intervention clients. Newly and previously diagnosed PMTCT clients’ demographics were also similar.

Table 3

Characteristics of PMTCT clients completing collective action surveys, pre- and post- intervention.

	Pre-intervention (n = 295)	Post-intervention (n = 300)
	N (%)	N (%)
Age (years)
15–19	8 (2.7)	4 (1.3)
20–24	46 (15.6)	47 (15.7)
25–29	82 (27.8)	71 (23.7)
30–34	73 (24.8)	76 (25.3)
35+	86 (29.2)	102 (34.0)
Education level
None	41 (13.9)	48 (16.0)
Primary	194 (65.7)	194 (64.7)
Secondary	60 (20.3)	58 (19.3)
Time since HIV diagnosis
Mean, SD	4.3, 3.9	5.1, 4.0

Most of the HCWs interviewed were nurses or midwives (39.1% and 37.5% pre- and post-intervention, respectively). Most of the providers were from health centers (78.1% at pre- and post-intervention), as shown in Table 4. The majority had graduated more than four years prior and had at least 2 years of experience in their current role (data not shown).

Table 4

Characteristics of HCWs completing collective action surveys, pre- and post- intervention.

	Pre-intervention (n = 64)	Post-intervention (n = 64)
	N (%)	N (%)
Type of health facility
Health center	50 (78.1)	50 (78.1)
Hospital	14 (21.9)	14 (21.9)
Type of health worker *
Doctor/clinical officer	3 (4.7)	3 (4.7)
Nurse/midwife	25 (39.1)	24 (37.5)
Client attendant	1 (1.6)	1 (1.6)
Health Surveillance Assistant	13 (20.3)	9 (14.1)
Other#	21 (32.8)	27 (42.2)

*At pre-intervention, data on HCW type was missing for 1 participant.

# Medical assistant, nurse midwife technician, ART clerk.

Table 5 notes measures for collective and self-efficacy. The collective efficacy scale average demonstrated significant improvements for PMTCT clients at pre-/post-intervention, (p = 0.003). HCW self-efficacy scale average for delivering quality services and participation were high at baseline and did not improve post-intervention, p = 0.91 vs. p = 0.87.

Table 5

Medians, interquartile ranges, and p-values for the measures of collective efficacy for the PMTCT clients, and self-efficacy delivering quality health service for participation for HCWs, pre and post intervention.

	PMTCT clients			HCWs
	Pre-intervention (n = 295)	Post-intervention (n = 300)	p-value	Pre-intervention (n = 64)	Post-intervention (n = 64)	p-value
Collective efficacy	4.50 (4.0, 5.0)	4.75 (4.25, 5.0)	0.003
Self-efficacy delivering quality health services	N/A	N/A		4.00 (4.00, 4.00)	4.00 (4.00, 4.00)	0.91
Self-efficacy for participation	N/A	N/A		4.00 (3.67, 4.00)	4.00 (3.67, 4.00)	0.87

No significant changes were observed for HCWs at pre-/post-intervention for work responsibilities, social cohesion, work attachment, collective efficacy, and mutual responsibility (not shown; p>0.05). Social participation, however, did increase significantly at post-intervention (not shown; p = 0.021), as expected given the participation in the CSC intervention.

FGDs

A total of 126 PMTCT clients participated in 12 FGDs (six pre- and six post-intervention) and 135 HCWs participated in 12 FGDs (six pre- and six post-intervention). Tables 6 and 7 present the demographic characteristic of the PMTCT and HCW participants in the FGDs, respectively. Women in the post-intervention FGDs were older, reported more primary education, and were more likely to be divorced, widowed, or separated compared to the pre-intervention group.

Table 6

Characteristics of participants in PMTCT FGDs, pre- and post- intervention.

	Pre-intervention (n = 57)	Post-intervention (n = 69)
	N (%)	N (%)
Age (years)
15–19	7 (12.3)	3 (4.3)
20–24	11 (19.3)	12 (17.4)
25–29	16 (28.1)	14 (20.3)
30–34	7 (12.3)	18 (26.1)
35+	16 (28.1)	22 (31.9)
Education
None	12 (21.1)	6 (8.7)
Primary	32 (56.1)	50 (72.5)
Secondary	13 (22.8)	13 (18.8)
Relationship status
Married/live as married	49 (86.0)	50 (72.5)
Divorce/widowed/separated	4 (7.0)	17 (24.6)
Never married	4 (7.0)	2 (2.9)

Table 7

Characteristics of participants in HCW FGDs, pre- and post- intervention.

	Pre-intervention (n = 70)*	Post-intervention (n = 65)
	N (%)	N (%)
Gender
Male	38 (59.4)	32 (49.2)
Female	26 (40.6)	33 (50.8)
Type of facility
Hospital	12 (18.8)	16 (24.6)
Health center	52 (80.2)	49 (75.4)

*Six participants in the pre-intervention FGD elected not to share their demographic information.

Compared to the pre-intervention FGDs, there was a higher proportion of female and hospital based HCWs in the post-intervention FGDs.

Results from the FGDs highlighted a strengthened relationship among HCWs and PMTCT clients, with many clients reporting an increased satisfaction in services after implementation of the CSC intervention.

“It is true that there is now a great improvement on our relationship, because the meetings we had with CARE tried to establish causes of all misunderstandings we had previously, and how to address those misunderstandings.”

(PMTCT client, post-intervention).

A major finding from the FGDs was the reported improvement in clinic service provision and the HCW-PMTCT client relationship. During the pre-intervention FGDs, PMTCT clients reported that the quality of services and consultations were good, but also noted long wait times, insufficient staffing and clinic hours, lack of privacy for consultation, and stock outs of supplies. HCWs also raised issues with space and supplies, as well as long hours and challenging working conditions. One HCW stated,

“[There is a] shortage of equipment…there are few rooms to work in…and there is too much work every day…every day, it’s busy, working up at night and day…and it’s hard work.”

Further, in the pre-intervention data, both HCWs and PMTCT clients reported interactions that were sometimes unpleasant or uncomfortable. PMTCT clients described HCWs as “rude” and reported that they would yell at clients, especially if they attended ANC without their male partners. One PMTCT client explained prior to the intervention,

“I was yelled at uncontrollably for forgetting to go for a scale weigh before meeting the nurse during my third ANC visit. Uh the nurse got angry; I feel like she overreacted.”

HCWs felt that PMTCT clients were often dissatisfied and unappreciative of their work. One HCW stated, ‘It is true that that community members don’t appreciate what HCW do.’

Following the CSC, both PMTCT clients and HCWs reported substantial improvements in their communication and relationship with each other. A PMTCT client noted,

“Previously, it was very common for the health care workers to yell at clients or patients but now we have seen a great improvement. Nowadays it is very rare to experience that.”

At post-intervention, HCWs reported a greater understanding of clients’ feelings and their needs, and PMTCT clients became more aware of what services they could expect from the health facility and the challenges that the HCWs face in providing services. One HCW reported,

“…[CSC] has helped, because the HCWs they were thinking they were doing right, but after attending the CSC meetings, they saw that people were complaining, and they have seen their areas to improve, and we have seen the change.”

A PMTCT client explained,

“Previously, we had a lot of concerns which lacked a platform where they would be addressed the same with health care workers. However, with the introduction of CSC we had that platform to express ourselves. During these meetings we were able to understand other challenges that exist in the system.”

A similar positive impression of the CSC process was reported by an HCW,

“The process is good because we were able to see the gaps we have in offering the services based on the discussions we had. We were able to understand what community members expect from us, and also the community had a chance to know what we can offer based on what we have on the ground.”

This mutual understanding fostered respect and improved relationships between HCWs and clients. One PMTCT client expressed that following the start of the CSC intervention, HCWs have “started respecting us just as we respect them on their duty.” Many women also expressed improved respect and treatment of clients by HCWs. One PMTCT client described HCWs as “no longer harsh” and others reported feeling more welcome at the health facility.

Both HCWs and PMTCT clients also reported concrete actions that had been implemented as a result of the CSC to improve PMTCT services, such as changing ART pickup times to less busy clinic times to provide more privacy. HCWs and PMTCT clients also reported increased timeliness of HCWs and more flexibility in working hours.

PMTCT clients also noted changes resulting from the CSC intervention not only in the facilities but also in the communities, including pastors sharing correct information about HIV and ART with others. An unexpected result of the CSC expressed by multiple PMTCT clients was a felt sense of reduced discrimination towards people living with HIV within the community, which was attributed to others being more aware of the dangers of discrimination. A PMTCT client shared her experience,

“This program should continue because those who were discriminating others in the homes, relatives and communities have… stopped, because from the meetings, as for me… I was discriminated and they [parents] would not carry my baby. But now discrimination has ended.”

However, reduction in stigma was not universally expressed. Fear of disclosure of one’s HIV status to a partner or family member was mentioned in the pre- and post-intervention FGDs, although the fear was not mentioned as frequently in the post-intervention data.

Discussion

This study used multiple methods to assess the effect of the CSC on collective efficacy among PMTCT clients, self-efficacy among HCWs for delivering quality services, and perceived quality of care as well as key clinical PMTCT indicators including retention in PMTCT services and EID uptake. Improvements were seen in collective efficacy among PMTCT clients and perceived quality of care among both clients and HCWs. However, no significant changes were observed in HCW self-efficacy or in clinical PMTCT indicators.

The quantitative results from the collective action surveys showed a significant increase in women’s certainty that the community could work together to improve PMTCT services. The qualitative results corroborated these findings, indicating improvements in client satisfaction with services and HCW-client relationships, suggesting perceptions of improved quality of care. Overall, the CSC intervention was highly valued by HCWs and PMTCT clients as a mechanism for improving communications, identifying approaches to improve health services, and increasing social participation. Despite this, there appeared to be no change in the HCWs self-efficacy in delivering quality health services. This may be due to HCWs believing that they were already providing acceptable services.

Additionally, no change was observed in the key patient-level clinical outcome indicators of early maternal PMTCT retention and EID uptake that we hypothesized would improve based on improved perceived and actual PMTCT service quality. Retention was significantly higher among previously diagnosed clients compared to those who were newly diagnosed, consistent with other studies; this may be related to age as the previously diagnosed women were older, and comparatively younger women are less likely to be retained [28,29]. However, there was no significant effect of the intervention on either group.

One potential explanation for the lack of statistically significant improvement in these indicators is the shortened intervention period and window for follow-up. In actual practice, the CSC process typically includes multiple rounds with longer action periods between rounds over the course of multiple years. These longer implementation and action periods and additional rounds may be needed for clients, HCWs and governments to effectively mobilize and implement transformative solutions, particularly operational mechanisms and procedures at the facility-level, and for these to translate into changes in behaviors and practices. In addition, some clients in the abstraction sample reached their three- and six-month retention windows and recommended EID uptake prior to the completion of all action periods for the CSC. With a longer period to make changes and to measure outcomes, significant improvements may have been observed.

A second explanation as to why statistically significant improvements in clinical outcomes were not observed could be that some barriers to PMTCT retention and EID are not particularly well suited to social accountability approaches. While the CSC intervention addressed some of the known barriers to PMTCT retention, particularly those related to patient-centered elements of quality [7] (e.g., the poor relationship between HCWs and clients), it was not as successful or well-suited at addressing health system and individual-level barriers such as a lack of integrated care, self-stigma, and partner disclosure [30]. A systematic review and series of meta-analyses on the relationship between HIV-related stigma and health identified a link between self-stigma and lower ART adherence and social support [30]. Self-stigma and fear of stigmatization as expressed in the FGDs may have inhibited women from disclosing their status and accessing services. Few documented social accountability projects have specifically engaged stigmatized populations, so it is unclear how community-based approaches function for these populations or how well approaches based on collective action and voice, like the CSC approach, work to improve private health behaviors for stigmatized health conditions like HIV/AIDS [16].

Other community-level interventions aimed at improving service uptake have likewise shown limited impact on clinical indicators. The CSC intervention conducted on maternal and child health in Malawi [17] found that while the CSC improved HCWs’ outreach and increased service satisfaction ratings among women, there was no improvement in women’s self-report of early ANC uptake or sufficient ANC attendance. Similarly, a community health worker intervention for people living with HIV in Tanzania showed improvements in adherence but not in retention in an analysis of clinical data before and after the intervention; they hypothesized that community outreach improved adherence for women who had already overcome economic and social barriers to HIV care but did not ably address retention barriers [31]. Social accountability approaches like the CSC have demonstrated that they are well-positioned to impact important patient-centered elements of service quality such as patient perception, satisfaction, and trust and communication between client and provider, that are often under-valued and neglected in quality-of-care frameworks. These elements are often within the direct control of individual HCWs, facilities, and, to some extent, community members, and so may be more amenable to change through a process like the CSC, particularly when implemented over just a short period of time. The valuable contributions of these approaches should not be dismissed, especially where efforts to improve patient-centered dynamics of care have fallen short. However, they may not be the ideal mechanisms to rapidly address systemic and interpersonal issues that are often critical to PMTCT retention and EID uptake, particularly in a context of stigma or other individual-level barriers.

Limitations

We collected data in only 11 selected facilities in two districts of Malawi, and thus may not be generalizable to other facilities or communities. During the intervention period, government, nonprofit, and community efforts were already being undertaken to address issues in HIV care and treatment, including PMTCT retention and EID uptake. As such, by the time this project was launched, these indicators were already steadily improving in the selected facilities, which may have diluted the effect of the CSC intervention.

Record availability and completeness was another limitation, particularly for the pre-intervention cohort; medical record completeness is a focus of ongoing clinical quality improvement interventions, which may have resulted in improved data availability at post-intervention, though this was not a focus of the CSC. Retention data were not available for eligible women either due to patient transfer to another facility or if the clinical card was not complete. There were challenges in finding records for eligible HEIs, and of those with records, some did not have an HIV testing date and were thus excluded from the HIV testing analysis.

Further, as noted in the Discussion, the modified CSC intervention included fewer rounds over a shorter period. This decision was made to accommodate the PMTCT timeframe; however, this timeframe may be too short to adequately affect and observe changes in clinical indicators, particularly as much of the clinical data reflected a period concurrent with the CSC intervention.

There was also variability in CSC implementation by site, which may have affected the outcomes. Variations in implementation and CSC actions by site were captured but were not included as a factor in the analysis as the study was not powered to analyze results by site.

A potential limitation is that the views from the respondents in the post-intervention FGDs may be more complementary of the CSC than those who did not participate. However, respondents who did not return may not have participated fully in the CSC intervention, and thus may not have been able to share more informed insights.

Conclusions

Overall, this study found that the CSC approach could be a productive way to foster mutual trust and respect between providers and beneficiaries, to strengthen HCW-client relationships, and to make meaningful improvements in service quality. More research is needed on how to best capture the results of these community-based interventions and the extent to which they are suited to address individual behaviors in the short-term, especially for often stigmatized behaviors such as HIV treatment and testing. Research is also needed on whether and how quickly changes in the relationships between service providers and users and in the quality of services can be expected to lead to improved clinical outcomes.

EID abstraction baseline.

(CSV)

Click here for additional data file.

EID abstraction endline.

(CSV)

Click here for additional data file.

HCW survey baseline.

(CSV)

Click here for additional data file.

HCW survey endline.

(CSV)

Click here for additional data file.

PMTCT and ART abstraction data endline.

(CSV)

Click here for additional data file.

PMTCT and ART abstraction baseline.

(CSV)

Click here for additional data file.

PMTCT client survey baseline.

(CSV)

Click here for additional data file.

PMTCT client survey endline.

(CSV)

Click here for additional data file.

17 Feb 2021

PONE-D-20-35790

Evaluating a Community Score Card for Pregnant and Breastfeeding Women Living with HIV in Malawi

PLOS ONE

Dear Dr. Kays,

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 submit your revised manuscript by Apr 03 2021 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 rebuttal 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: http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols

We look forward to receiving your revised manuscript.

Kind regards,

Hannah Tappis, DrPH, MPH

Academic Editor

PLOS ONE

Journal Requirements:

When submitting your revision, we need you to address these additional requirements.

1. 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. Please include a copy of the interview guide used in the study, in both the original language and English, as Supporting Information, or include a citation if it has been published previously.

3. We note that you have indicated that data from this study are available upon request. PLOS only allows data to be available upon request if there are legal or ethical restrictions on sharing data publicly. For information on unacceptable data access restrictions, please see http://journals.plos.org/plosone/s/data-availability#loc-unacceptable-data-access-restrictions.

In your revised cover letter, please address the following prompts:

a) If there are ethical or legal restrictions on sharing a de-identified data set, please explain them in detail (e.g., data contain potentially identifying or sensitive patient information) and who has imposed them (e.g., an ethics committee). Please also provide contact information for a data access committee, ethics committee, or other institutional body to which data requests may be sent.

b) If there are no restrictions, please upload the minimal anonymized data set necessary to replicate your study findings as either Supporting Information files or to a stable, public repository and provide us with the relevant URLs, DOIs, or accession numbers. Please see http://www.bmj.com/content/340/bmj.c181.long for guidelines on how to de-identify and prepare clinical data for publication. For a list of acceptable repositories, please see http://journals.plos.org/plosone/s/data-availability#loc-recommended-repositories.

We will update your Data Availability statement on your behalf to reflect the information you provide.

[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: Yes

Reviewer #3: No

**********

2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: No

**********

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

Reviewer #3: No

**********

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

Reviewer #3: No

**********

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: General summary comments from Reviewer.

The paper is generally well written and structured. This is an evaluation of Community Score Card in improving several PMTCT outcomes like retention and EID uptake. The study presents interesting results pertaining to patient and health worker collaboration to achieve a common goal and this makes the work novel.

However, I observe that the paper has some shortcomings and not clear why the study took place in only the specified targeted districts since the data used to express the gap had been national level data e.g national level prevalence, retention rate, and EID uptake. It would have been great if the author could also demonstrate the gaps at district level. The Methods section did not clearly state the significance level of the study error margin (e.g. 0.05 as significance level). The statistical analysis in this paper was appropriate and for all the significant associations, the author clearly specified the correponding p-values. On the other hand, the author may also wish to be more systematic : define both the primary and secondary outcomes ; then univariate analysis ; bivariate analysis and then multivariate. In terms of the study broader objective, the author ought to be consistent throughout the document: to use assess rather that describe or evaluate.– the author has used the term ‘describe ’ and ‘Evaluate’, but it seems the author means to say ‘assess’ (on p. 6, line 74 and line 104).

sOne of the limitatios of the evaluation is the data gaps, in the absense of proper data management sysytem for an intervention, results from the evaluation may not give a true reflection of change attributed to a particular intervention.

Major Comments:

- The author clearly specifies the study design

- The actual implementation of the intervention was summarized in such a way that it is difficult for the reviewer to understand what actually happened on the ground. Additional information on actual implementation of CSC is required.

- The variables tracked in the score card are not specified, this includes the indicators of issues that were identified and also the actual scores during the baseline and thereafter. Inclusion of score card indicators could have set a good background of the evaluation.

- The author to be consistent in the overall aim of the study: either to use assess or describe or evaluate throughout the document. (on p.6; par 2; line 74 and on p.7; par 4; line104)

- The discussion section has been well articulated

- The paper should clearly indicate the data management system that was introduced during the actual implementation of CSC and the evaluation could have also identified the gaps and recommend proper data management system for CSC rather than included that as an area of research.

Minor Comments:

- The authors should also consider specifying the significance margin error in the methodology section (e.g at 0.05 as significance level)

- One sentence in the Data section must be revised to be grammatically correct(P.11; Line 184)

- Include the prevalence, retention rate, and EID uptake for the study districts in the introduction section. These will help justify why the two districts were included in the priority districts for HIV/AIDS interventions.

- It is not clear how informed consent for the minors (15-17 years) was done

Reviewer #2: The article provides interesting and useful results on the efficacy and methods of a potential intervention to improve prevention of HIV mother-to-child transmission services. Despite the lack of evidence for an impact on some of the outcomes the manuscript shares very useful information on some of the perceived challenges with the PMTCT services. The authors have written the manuscript clearly and provided the relevant data to understand the results.

I do not have any big picture concerns. The statistical methods are appropriate. The methods for handling the qualitative data are thoroughly described.

I have a number of editorial and clarifying comments.

1. The data visuals are not overly appealing for an audience. Consider revising Table 2 into a graphic to show the pre and post results. Even a non-significant finding will still capture the audience’s eye faster in a graphic than a table. (not required, just for consideration)

2. Line 144-145. This sentence was unclear to me. "A subset of women who participated in the survey were randomly approached using a number, n, 2-6 for a FGD that took place at a different date and venue." Please explain what is meant that the women were approached with a number. Perhaps they were randomly assigned a number?

3. Line 154. Should "consenting" be "consent"

4. Line 249: the authors suggest that the reviews of the coded transcripts were done throughout the process but then mention three distinct time points. It seems like the sentence should either say “throughout the process” or at the three time points, but not both. Also you could consider providing a sentence on what was done to ensure inter-rater reliability or at a minimum how many different team members were doing the coding.

5. Line 291: it was interesting how different retention results were for women already on ART vs women starting ART in this study vs the previous research noted in the start of the document. Please comment on that in the discussion.

6. Line 444: The reflection on the lack of engagement with stigmatized populations is an important comment in the discussion. No action is necessary, I am just commending the authors for including this very important point.

7. Lines 459-464. Should this concluding statement come after the limitations – so explaining what was found despite the limitations mentioned before?

8. To meet the data transparency and availability requirements, I believe the statement that data are available from EGPAF should be included within the text of the manuscript.

Reviewer #3: Comments

Congratulations to the authors on the very important paper. Eliminating MTCT remains a critical challenge and such studies are essential to identify and stimulate stakeholder participation, patient cantered care and hopefully the desirable health outcomes.

I have the following suggestions for the authors to consider in improving their work.

1. The title of the paper could benefit from including what the outcome is so readers know from the onset what is being measured and it also sets the stage for what is follow in the paper – what is the intention of the score card and what are you expecting to change among your target population?

2. Still on the title, the study was done in a couple of districts and not the entire Malawi, the authors can be more precise by naming the districts or simply saying “in two districts in Malawi”.

3. The abstract and body of the paper could benefit from inclusion of participant selection or sampling method and criteria

4. Were the facilities compared all at the same level and what is the implication of lumping together different level of care in one analysis – any risk for of bias?

5. Better description on the distribution of sample by level care (if any) may also help understand any nuances that may be confounders to adjust for.

6. Did you have a same or separate sample pre and post intervention?

7. Still on the intervention I wasn’t sure if you used the same cohort for the different rounds of the CSC and if that has implication for the outcome of the study?

8. I do not think that CSC is appropriate for some of the outcomes given what CSC is intended for and what it can not do. In this regard, the background could benefit from a richer description of what the impediments to PMTCT service outcome are and which of them are amenable to CSC and make the study about such outcome. It is unsurprising that it had no impact on retention or EID given that their known determinants are more than relationship and power interactions and also includes psychosocial and structural factors beyond the competence and scope of the health care workers. The lower rate of retention of newly diagnosed HIV clients is one example to show that what affects retention is beyond service delivery and access.

9. With the above I am uncomfortable with the mismatch of problem and CSC solution. I feel the paper can be better structured from start to finish focusing on what CSC can achieve given the preponderance of evidence of what drives various PMTCT outcomes.

10. The six aims of improvement suggested by the Institute of Medicine may help to position element of improvement CSC can address and should be focus of the paper, otherwise will be an unfair or an insufficiently considered assessment – see link for application of IOM’s six aims of improvement https://doi.org/10.1097/01.pcc.0000160592.87113.c6.

11. In terms of the FGDs, will post intervention FGD of retained client not be biased to the views of those who were retained and may be exaggerate the intervention’s benefits?

12. Who conducted the data abstraction and interviews?

13. How was confidentiality maintained in both instances particularly the FGD of people living with HIV?

14. Why did you need ethics wavier for data abstraction if you had access to participants for your intervention why did they not consent to your using their data?

15. Who conducted the intervention?

16. What kind of actions were implemented to address issues emerging from the CSC?

17. How were the actions tracked to see if they changed before assessing impact? If nothing changed, can it be attributed to the CSC or other elements?

18. It may help to have a table of outcomes, data collection tools and reliability of the different scales. It is hard to follow from the narrative.

19. The description of qualitative analysis method could be improved to demonstrate process and stages of analysis, by who, quality assurance and trustworthiness elements etc.

20. The mixed methods used approach should be specified given its implication for data analysis and presentation, I may be wrong but it appears to me as a concurrent triangulation and would have preferred to see a greater mixing or integration of both quantitative and qualitative data rather than the observed clear separation

21. Back to my point on fair use of CSC, the discussion acknowledges its inability to address psychosocial issues which is an essential and established requirement for retention and mostly why newly tested were less likely to be retained due to adjustment issues that are amenable to psychosocial support.

22. Given what know about PMTCT today this paper may be more novel if it focuses on its elements of collective efficacy and with better description of the intervention, study design and methodology.

**********

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: Sam Phiri

Reviewer #2: No

Reviewer #3: 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.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

18 Apr 2021

Reviewer Comment Revision made

1 Not clear why the study took place in only the specified targeted districts since the data used to express the gap had been national level data e.g national level prevalence, retention rate, and EID uptake. It would have been great if the author could also demonstrate the gaps at district level. Include the prevalence, retention rate, and EID uptake for the study districts in the introduction section. These will help justify why the two districts were included in the priority districts for HIV/AIDS interventions. Thank you for this comment. We agree and have added some information in the Introduction on retention and EID uptake, as well as clarifying that these are intervention districts for EGPAF.

1 The Methods section did not clearly state the significance level of the study error margin (e.g. 0.05 as significance level). This is useful feedback. The p-value was (p<.05) was added to the Statistical Analysis section.

1 The author may also wish to be more systematic : define both the primary and secondary outcomes ; then univariate analysis ; bivariate analysis and then multivariate. Thank you for this suggestion. We feel the way the results are currently presented is the most straightforward, so we are maintaining this section as is.

1 In terms of the study broader objective, the author ought to be consistent throughout the document: to use assess rather that describe or evaluate.– the author has used the term ‘describe ’ and ‘Evaluate’, but it seems the author means to say ‘assess’ (on p. 6, line 74 and line 104). Thank you for this useful suggestion. We have changed the instances of “describe” and “evaluate” to “assess.”

1 The actual implementation of the intervention was summarized in such a way that it is difficult for the reviewer to understand what actually happened on the ground. Additional information on actual implementation of CSC is required. Thank you for this suggestion. We have added a few more clarifying details in the Intervention Description. We have also referenced the paper that was written on the adaptation that provides more details.

1 The variables tracked in the score card are not specified, this includes the indicators of issues that were identified and also the actual scores during the baseline and thereafter. Inclusion of score card indicators could have set a good background of the evaluation. Thank you, we agreed with this suggestion and added a few examples of issues identified to the Intervention Description.

1 The paper should clearly indicate the data management system that was introduced during the actual implementation of CSC and the evaluation could have also identified the gaps and recommend proper data management system for CSC rather than included that as an area of research. Thank you for flagging that this was not clear. We have added some information at the start of the study design description to clarify that we used existing clinical records.

1 One sentence in the Data section must be revised to be grammatically correct(P.11; Line 184) Thank you for the careful read. However, we did not find any grammatical inaccuracies in this section upon review.

1 It is not clear how informed consent for the minors (15-17 years) was done Thank you for noting this. We added this sentence in the Ethical Approval section: In Malawi, pregnant women aged 15-17 years are emancipated minors and thus can provide informed consent for themselves and their infants.

2 The data visuals are not overly appealing for an audience. Consider revising Table 2 into a graphic to show the pre and post results. Even a non-significant finding will still capture the audience’s eye faster in a graphic than a table. (not required, just for consideration) Thank you for your suggestion. However, we believe that the table efficiently sums up and presents the necessary information

2 Line 144-145. This sentence was unclear to me. "A subset of women who participated in the survey were randomly approached using a number, n, 2-6 for a FGD that took place at a different date and venue." Please explain what is meant that the women were approached with a number. Perhaps they were randomly assigned a number? Thank you for noting this. We have clarified this sentence to indicate that the women were randomly assigned a number.

2 Line 154. Should "consenting" be "consent" Thank you for this edit. We changed this to consent.

2 Line 249: the authors suggest that the reviews of the coded transcripts were done throughout the process but then mention three distinct time points. It seems like the sentence should either say “throughout the process” or at the three time points, but not both. Also you could consider providing a sentence on what was done to ensure inter-rater reliability or at a minimum how many different team members were doing the coding. Thank you for this suggestion. We have edited the Qualitative Analysis section to provide additional details on how the coding was conducted.

2 Line 291: it was interesting how different retention results were for women already on ART vs women starting ART in this study vs the previous research noted in the start of the document. Please comment on that in the discussion. Thank you for the interest. We have commented on this in the Discussion. The previous research compared retention of PMTCT women with non-pregnant women initiating ART. We did not make this comparison in our study.

2 Lines 459-464. Should this concluding statement come after the limitations – so explaining what was found despite the limitations mentioned before? Thank you for this suggestion. We have added a Conclusions section following the limitations and have added this text to the Conclusions.

2 To meet the data transparency and availability requirements, I believe the statement that data are available from EGPAF should be included within the text of the manuscript. Thank you for noting our omission. We have added a statement on data transparency.

3 The title of the paper could benefit from including what the outcome is so readers know from the onset what is being measured and it also sets the stage for what is follow in the paper – what is the intention of the score card and what are you expecting to change among your target population? Thank you for this suggestion. We felt that simplicity in the title was preferred.

3 Still on the title, the study was done in a couple of districts and not the entire Malawi, the authors can be more precise by naming the districts or simply saying “in two districts in Malawi”. Thank you for this suggestion. We did add “in two districts in Malawi” to clarify the scope of the intervention.

3 The abstract and body of the paper could benefit from inclusion of participant selection or sampling method and criteria Thank you for this suggestion. We have added more sampling and inclusion information to the abstract. We have more clearly indicated the sampling method for women participating in the surveys and FGDs in the Methods section.

3 Were the facilities compared all at the same level and what is the implication of lumping together different level of care in one analysis – any risk for of bias? Better description on the distribution of sample by level care (if any) may also help understand any nuances that may be confounders to adjust for. Thank you for this question. We adjusted for the different types of facilities, (hospital/health centers) in the analysis, through the logistic regression, and have specified that in the Statistical Analysis section.

3 Did you have a same or separate sample pre and post intervention? Thank you for this question. This was not a cohort study, so have tried to clarify that the pre and post were based on time period.

3 Still on the intervention I wasn’t sure if you used the same cohort for the different rounds of the CSC and if that has implication for the outcome of the study? Thank you for this question. We added language to Intervention Description to clarify that the participation in the CSC varied. We also added information to the Methods to further clarify that all women were eligible for abstraction, even if not participating in the CSC.

3 I do not think that CSC is appropriate for some of the outcomes given what CSC is intended for and what it can not do. In this regard, the background could benefit from a richer description of what the impediments to PMTCT service outcome are and which of them are amenable to CSC and make the study about such outcome. It is unsurprising that it had no impact on retention or EID given that their known determinants are more than relationship and power interactions and also includes psychosocial and structural factors beyond the competence and scope of the health care workers. The lower rate of retention of newly diagnosed HIV clients is one example to show that what affects retention is beyond service delivery and access. Thank you for this critique. We chose to test the CSC in a PMTCT setting as it has already been used for other health care issues and has been shown to be an effective approach for improving provider-client relationships, and thus perceived and actual quality of care. We do agree that this was not as clearly spelled out in this paper so we have added more information to the Introduction to clarify our use of the CSC, indicating that provider-client relationships can be a barrier to PMTCT and that CSC is a tool that can be used to improve these relationships, and thus clinical outcomes.

3 With the above I am uncomfortable with the mismatch of problem and CSC solution. I feel the paper can be better structured from start to finish focusing on what CSC can achieve given the preponderance of evidence of what drives various PMTCT outcomes. Again, thank you for flagging this. We have not changed the structure of the paper, as there is an accompanying paper that provides more information on the use of the CSC in this situation. However, we have added more information to the Introduction, as previously noted.

3 The six aims of improvement suggested by the Institute of Medicine may help to position element of improvement CSC can address and should be focus of the paper, otherwise will be an unfair or an insufficiently considered assessment – see link for application of IOM’s six aims of improvement https://doi.org/10.1097/01.pcc.0000160592.87113.c6.

Thank you for this resource. The accompanying CSC paper referenced uses the Kruk et al high quality health system framework, which is similar to IOM. We were testing whether this process could affect joint actions to address poor service quality. It is also well-suited to address patient-centeredness.

3 In terms of the FGDs, will post intervention FGD of retained client not be biased to the views of those who were retained and may be exaggerate the intervention’s benefits? Thank you for this question. We agree this is a potential limitation, and we have added the text to the Limitations section.

3 Who conducted the data abstraction and interviews? Thank you for this request for clarification. We have added more text to make it clearer that the data collection activities were conducted by research assistants.

3 How was confidentiality maintained in both instances particularly the FGD of people living with HIV? Thank you for this suggestion. We agree and have added some information in Methods on how confidentiality was protected.

3 Why did you need ethics wavier for data abstraction if you had access to participants for your intervention why did they not consent to your using their data? Thank you for this note. We added some language to clarify why consent was not sought in the Ethical Approval section.

3 Who conducted the intervention? Thank you for this question. We have clarified in the Intervention Description that the CSC was implemented by CARE-Malawi staff.

3 What kind of actions were implemented to address issues emerging from the CSC? Thank you for this suggestion. We agree and have added some examples to the Intervention Description.

3 How were the actions tracked to see if they changed before assessing impact? If nothing changed, can it be attributed to the CSC or other elements? Thank you for this suggestion. We have included some information in the intervention description, and the existing qualitative results note perceived improvements.

3 It may help to have a table of outcomes, data collection tools and reliability of the different scales. It is hard to follow from the narrative. Thank you for this idea. We have included the scales used and their reliability in a table, replacing the text.

3 The description of qualitative analysis method could be improved to demonstrate process and stages of analysis, by who, quality assurance and trustworthiness elements etc. Thank you for this suggestion. We have added more details about how the analysis was conducted in the Qualitative Analysis section.

3 The mixed methods used approach should be specified given its implication for data analysis and presentation, I may be wrong but it appears to me as a concurrent triangulation and would have preferred to see a greater mixing or integration of both quantitative and qualitative data rather than the observed clear separation Thank you for this critique, and we appreciate this idea. In the design, these were unique components that were then brought together at the analysis phase to provide context and clarity.

3 Given what know about PMTCT today this paper may be more novel if it focuses on its elements of collective efficacy and with better description of the intervention, study design and methodology. Thank you for this comment. Collective efficacy was one outcome of interest, but is not the only outcome associated with the CSC. We felt that the more novel aspect was a holistic evaluation of the intervention. Fewer studies in the literature have tried to link community action and clinical outcomes, which is one of the aspects we were assessing. As such, we have chosen to retain the focus of this paper as providing a broader view of the CSC’s performance.

Submitted filename: Response to reviewers 3.31.21.docx

Click here for additional data file.

14 Jun 2021

PONE-D-20-35790R1

Evaluating the effect of a Community Score Card among pregnant and breastfeeding women living with HIV in two districts in Malawi

PLOS ONE

Dear Dr. Kays,

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 submit your revised manuscript by Jul 29 2021 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 rebuttal 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.

We look forward to receiving your revised manuscript.

Kind regards,

Hannah Tappis

Academic Editor

PLOS ONE

Journal Requirements:

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. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #4: All comments have been addressed

Reviewer #5: (No Response)

**********

2. 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 #4: Partly

Reviewer #5: Partly

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #4: I Don't Know

Reviewer #5: I Don't Know

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #4: Yes

Reviewer #5: Yes

**********

5. 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 #4: Yes

Reviewer #5: Yes

**********

6. 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 #4: The original manuscript has undergone meticulous review by a previous reviewer on methodology, study design sampling etc and most of the issues and concerns raised have been addressed by the authors. Hence my observations are primarily on the CSC presentation, intervention, discussion, and interpretation of the results.

L2 The abstract could be improved by including the figure for low retention rate, and care continuum for PMTCT in Malawi. This may provide a stronger rationale for researching the complimentary CSC intervention.

Study design and selection of Health facilities and hospitals needs to be provided in the methods section of the abstract. How were the districts and facilities sampled? Stratified random sampling based on public/private facilities? Both district hospitals?

The key limitation of intervention duration may be mentioned in the conclusion.

L125 “Women did not have to participate in the CSC intervention to be included in the abstraction, as it was hypothesized that CSC-related clinical improvements may affect the quality of care, PMTCT retention, and EID uptake for all PMTCT clients” This sentence illustrating the selection of the sample, seems to be contrary to the principles of the CSC where engagement, ownership to the process leads to change, uptake of services or perceived quality due to visible improvements as illustrated by the scorecard

The authors may consider including a CSC model and describe the details of the process. References are provided but further explanation on the implementation of the generic model in the Malawian context is needed. How was the CSC introduced, were facilitated meetings scheduled for joint discussion and deliberation of results and the rationale for scoring poor, or high?

L169 Experience of HCW was as low as 1m? HCW has minimal time to engage with communities, due to the workload, shortages in staffing, and high priority services. It is unlikely that HCW who have 1m experience will be able to effectively address community needs, or challenges with the PMTCT demand side challenges without prior experience. This needs to be discussed as a limitation. Who were ‘other’ HCW cadre?

CARE has a well established CSC model that has been successfully adapted in other contexts. However, the period of intervention (1y?), maybe insufficient to establish the various community mechanisms and systems at the facility level to ensure optimal operations and internalization of the concept and procedures.

The CSC methodology needs more detailed description to improve the study rigor. The discussion or methodology does not include measures for implementation integrity and intensity of the CSC. Inclusive representation in the community CSC?

The facility aspects need to be optimized and integrated, as ART and maternity information was not available in one HF

L249. Level of engagement and contribution in meetings needs to be measured, rather than generic indicators for meeting participation.

Were the 606 women assessed in the post evaluation included in the 627 reported in the pre evaluation?

75% had data available in pre and 93-94% in post, was this improvement a result of the CSC?

How did the HCW participate in the CSC, what was their specific role and continuing responsibility, were HCW designated to facilitate follow up with the community? Were problem solving mechanisms or action plans instituted following the CSC mtgs? Was there an open community forum to discuss and deliberate results?

The authors have embarked on a critical people centered paradigm for enhancing health improvements using the CSC model. However, the mechanisms of implementation integrating an inclusive approach of patients and HCW need careful consideration and deliberation, for a meaningful interpretation of the effectiveness for health outcomes and health system improvements. Patient perception, satisfaction, perceived reduced discrimination must be weighted equally with the validated outputs/outcomes for the PMTCT utilization, continuum of care and quality, for a value based healthcare system. Harsh, disrespectful, unpleasant provider patient encounters need to be valued and integrated in quality of care framework.

Reviewer #5: Title: Evaluating the effect of a Community Score Card among pregnant and breastfeeding women living with HIV in two districts in Malawi.

Abstract: This is good

Introduction: This section is written well and summarized

Methods:

Intervention description

To be able to track improvement in service delivery

“Line 95-96- “Were the clients who were recruited utilizing services from the selected facilities? Where were these clinics and associations of people living with HIV selected from?

Line 97-99-Did the HCWs and PMTCT clients identify the issues and barriers most impacting their ability to successfully deliver and access quality of PMTCT services jointly or did HCWs do it alone and clients identified theirs alone? That part is not clear in the write-up

Line 104-105- What was the aim of revisiting previous issues?

Line 100-102-Was it only community leaders or community leaders and community members?

Line 165-167- I would think that for one facility, the quota should be 12 and not six as stated. Please clarify on this

Line 183 From what?

Line 184-6-Was ANC the point of identification of the clients who were included in the study?

Line 183-186- This sounds like a result which should be in the results section

Line 196-7-How do define social cohesion?

Line 201- How many research assistants facilitated the FGDs for PMTCT clients and how many research assistants facilitated FGDs for HCWs?

Line 275-What were the scores and How were the scores obtained. That is not explained

Results

Line 307- mean ages should be reported with corresponding standard deviations

Line 368-371- The table should include significant results

Line 381- was it a requirement for these participants not to share their socio demographic characteristics?

Line 382-3-It’s appropriate to report qualitative data in themes and sub themes and then you compare those themes pre- and post-intervention. This could be based on the different aspects that authors set out to evaluate e.g various aspects of PMTCT services

Line 384-386-It would be appropriate to first report the relationship that existed previously before the intervention was implemented and then the authors can report improved relationship after the project has been implemented

Line 393-4-Is it possible to have a quote for this?

Line 400- Who mentioned this; was it the HCW or the participant? Also note that at the end of each quote you should specify who said that quote

Line 401-Is it possible to get a quote indicating that the HCWs felts that the clients did not appreciate their work?

Line 404-405- Add whoever mentioned this quote at the end of the quote

Line 406-7-Where is the quote to sow that the HCWs reported a greater understanding of the clients’ feelings and their needs?

Line 410-13- Same comment as above

Line 415-18- Same comment as above

Line 419-23-Is it possible for the authors to back this statement up with a quote

Line 424-7-Could we get a quote from the HCWs to reflect this and also one from the PMTCT clients

Line 429- What does corrected information about HIV and ART mean?

Line 435-37-Include the participant who mentioned this quote at the end of the quote

General comment for the Results section: it’s usually appropriate to report results concurrently where mixed methods is used. Could the authors explore that possibility?

Discussion

Line 442-445- This is what the authors set out to find out before the intervention was implemented. So after the intervention what did the authors find out?

-Also the authors should be able to make the introductory section in the discussion section in line with the objectives of the study reporting significant findings in the first paragraph of the discussion section before going ahead to discuss each of the results in detail in the later paragraphs of this section

Line 449-451-This was the finding of the study but what does it imply? It would also be appropriate to give other studies with similar or dissimilar results when you are discussing your findings

Line 459-460-the authors should provide a reference for this statement

Line 463-465- What brought about this? Did it have any effect on the key findings of the study, if so then explain, giving other studies with the same or different findings

Line 492-Is 318 a reference or not? If it’s a reference, please correct it because reference 318 does not exist in the reference section

Line 492-497- Long sentence. Consider fragmenting it

-Also what makes the authors think that CSC is not an ideal mechanism to address systemic and interpersonal issues? Are there studies that suggest this? Please clarify and give a reference

**********

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.

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 #4: No

Reviewer #5: Yes: Christine Aanyu

[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.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

21 Jul 2021

Thank you for your additional comments on the manuscript. A revised manuscript and response to reviewers has been submitted.

Submitted filename: Malawi CSC response to reviewers 7.21.21.docx

Click here for additional data file.

26 Jul 2021

Evaluating the effect of a Community Score Card among pregnant and breastfeeding women living with HIV in two districts in Malawi

PONE-D-20-35790R2

Dear Dr. Kays,

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 for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org.

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,

Hannah Tappis, DrPH, MPH

Academic Editor

PLOS ONE

2 Aug 2021

PONE-D-20-35790R2

Evaluating the effect of a Community Score Card among pregnant and breastfeeding women living with HIV in two districts in Malawi.

Dear Dr. Kays:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

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.

If we can help with anything else, please email us at plosone@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. Hannah Tappis

Academic Editor

PLOS ONE