Raising Stroke Prevention Champions: Evaluation of a Nurse-Led Primary Health Care Nurse Training Intervention
Round 1
Reviewer 1 Report
Comments and Suggestions for Authors#INTRODUCTION AND METHODOLOGY
The introduction presents good points that effectively contextualize the topic; however, it could be reorganized to improve the connection and flow of ideas.
The study reports the selection of 34 nurses from 18 health units; however, it also describes that two nurses were selected from each unit. Therefore, the total should be 36 nurses instead of 34. Were there any sample losses? If so, this should be made explicit, and an explanation should be provided regarding how these losses were managed.
There is a gap concerning the Ethics Committee, as the name of the institution and the approval number of the study’s ethical review are not provided. These are essential details for studies involving human participants.
Regarding the data collection instrument, it is unclear whether it was developed by the authors or adapted from existing sources. If it was created by the authors, was there a prior content validation process? For methodological rigor, it is important to clarify this aspect. Additionally, regarding the collected information, how many items per domain were included in the instrument? Was it divided into knowledge, attitude, and practice? Was any response scale, such as Likert, used?
With respect to the intervention period, the authors mention that a post-test was conducted, but was it administered immediately after the intervention or after a certain interval? Clarifying this point is important because it may affect the assessment of knowledge retention.
Similarly, regarding the data collection setting, was it carried out within a single institution — in a classroom with all 34 nurses — or separately with the nurses from each unit within their respective health institutions? It is important to specify this to ensure control over external inferences.
Concerning the statistical analysis, it is recommended to complement the results by including and reporting the effect size in order to understand the magnitude of the change, not only its statistical significance.
#REFERENCES
After analyzing the manuscript, it was observed that several references are not formatted according to the journal’s guidelines, showing inconsistencies in the order of elements. It is recommended that all citations be carefully reviewed and adjusted to strictly comply with the normalization standards required in the Instructions for Authors .
It was also noted that a significant portion of the sources used predates the COVID-19 pandemic. Considering that there have been substantial changes in the practices of training and capacity-building of healthcare teams since that period, it is suggested to include more recent studies that reflect the current state of knowledge on the topic.
Author Response
Comment 1: The introduction presents good points that effectively contextualize the topic; however, it could be reorganized to improve the connection and flow of ideas.
Response 1: The introduction was revised and beefed-up to improve logical flow of ideas.
Comment 2: The study reports the selection of 34 nurses from 18 health units; however, it also describes that two nurses were selected from each unit. Therefore, the total should be 36 nurses instead of 34. Were there any sample losses? If so, this should be made explicit, and an explanation should be provided regarding how these losses were managed.
Response 2: It is clarified that to facilities sent one representative/delegate instead of two.
Comment 3: There is a gap concerning the Ethics Committee, as the name of the institution and the approval number of the study’s ethical review are not provided. These are essential details for studies involving human participants.
Response 3: The Ethics Committee which approved the study/project has been reflected together with the approval ID number.
Comment 4: Regarding the data collection instrument, it is unclear whether it was developed by the authors or adapted from existing sources. If it was created by the authors, was there a prior content validation process? For methodological rigor, it is important to clarify this aspect. Additionally, regarding the collected information, how many items per domain were included in the instrument? Was it divided into knowledge, attitude, and practice? Was any response scale, such as Likert, used?
Response 4: The tool development and validation process has been clarified. A description of the structure of the questionnaire is provided.
Comment 5: With respect to the intervention period, the authors mention that a post-test was conducted, but was it administered immediately after the intervention or after a certain interval? Clarifying this point is important because it may affect the assessment of knowledge retention.
Response 5: I have indicated that the post-test was administered immediately.
Comment 6: Similarly, regarding the data collection setting, was it carried out within a single institution — in a classroom with all 34 nurses — or separately with the nurses from each unit within their respective health institutions? It is important to specify this to ensure control over external inferences.
Response 6: It was carried out at a designated venue.
Comment 7: Concerning the statistical analysis, it is recommended to complement the results by including and reporting the effect size in order to understand the magnitude of the change, not only its statistical significance.
Response 7: It has been included.
Comment 8: After analyzing the manuscript, it was observed that several references are not formatted according to the journal’s guidelines, showing inconsistencies in the order of elements. It is recommended that all citations be carefully reviewed and adjusted to strictly comply with the normalization standards required in the Instructions for Authors.
Response 8: References revised.
Comment 9: It was also noted that a significant portion of the sources used predates the COVID-19 pandemic. Considering that there have been substantial changes in the practices of training and capacity-building of healthcare teams since that period, it is suggested to include more recent studies that reflect the current state of knowledge on the topic.
Response 9: Where applicable, recent studies were used.
Reviewer 2 Report
Comments and Suggestions for AuthorsThis paper highlights the vital role of nurses in managing stroke care within primary healthcare (PHC) settings. It offers valuable insights into the advantages of nurse-led educational interventions, particularly in low-resource environments such as Lesotho. However, several recommendations are available to enhance the paper further.
The title
The title effectively captures the reader's attention and clearly defines the subject matter. To enhance the overall impact, the author should add details about the setting in the title, specifically highlighting that it takes place within a primary health care context. Additionally, specifying that the intervention is nurse-led, rather than just referring to it as training, could provide greater clarity for the reader.
The abstract
The abstract is well-organized, but the methods section would benefit from a clearer description of the research design and the nurse-led intervention method. Additionally, adding a statement on the implications for policy or health practice in the conclusion would enhance the impact.
Introduction Section
To effectively convey the urgency of addressing stroke as a significant health issue, it would be beneficial for the author to incorporate the most recent data on stroke prevalence at the global, regional, and national levels. Utilizing the latest information from sources such as the WHO NCD, GDP 2023, and the most up-to-date health survey from Lesotho could enhance the impact of the message and underscore the importance of timely action.
What is the importance of nurses in primary health care settings for stroke care? How do they contribute to the stroke care team compared to hospital nurses? Are there any gaps in knowledge, attitudes, or skills that hinder their ability to provide effective stroke care? The author should address these questions using previous research findings. Additionally, it's important to include information about the healthcare system in Lesotho to illustrate why nurse-led interventions are the most effective and practical way to enhance nurses' capabilities in stroke management.
Materials and Methods Section
It's important to specify that this study uses a Pre-experimental one-group pretest–posttest design. This clarification ensures that the methodology is clear and prevents confusion with the term "pre–post interventional study," which could imply a connection to true or quasi-experimental designs.
Add a reference at Line 130 for the source used to develop the educational guide so readers can verify or replicate the intervention content.
Please provide detailed information about the questionnaire assessing respondents' knowledge, attitudes, and clinical practices regarding stroke management in the PHC setting. Was it developed by the author or adapted from a previous study? Also, include the parameters for each variable, along with the scoring system.
The author used a questionnaire to assess clinical practice, but it's unclear why skill observations were not performed. This should be noted as a limitation of the study.
The description of the five-day educational intervention is informative but could be clearer. It should include an outline of the training sessions, detailing the topics, their sequence, and whether the days were consecutive or spread out. Additionally, clarify when and how the post-test was administered. Was it right after the final session or given later?
Discussion section
The author should include the strengths and limitations of this study.
Reference
It would be beneficial for the author to consider updating the references, as 8 out of 25 were published before 2015, indicating they are over a decade old. Given that research related to strokes is rapidly evolving, incorporating more recent studies could enhance the relevance and impact of the work.
There are no self-citations present.
Author Response
Comment 1: The title effectively captures the reader's attention and clearly defines the subject matter. To enhance the overall impact, the author should add details about the setting in the title, specifically highlighting that it takes place within a primary health care context. Additionally, specifying that the intervention is nurse-led, rather than just referring to it as training, could provide greater clarity for the reader.
Response 1: The title was edited to include the setting.
Comment 2: The abstract is well-organized, but the methods section would benefit from a clearer description of the research design and the nurse-led intervention method. Additionally, adding a statement on the implications for policy or health practice in the conclusion would enhance the impact.
Response 2: The abstract is revised to clarify research design and added implication for policy and health policy.
Comment 3: To effectively convey the urgency of addressing stroke as a significant health issue, it would be beneficial for the author to incorporate the most recent data on stroke prevalence at the global, regional, and national levels. Utilizing the latest information from sources such as the WHO NCD, GDP 2023, and the most up-to-date health survey from Lesotho could enhance the impact of the message and underscore the importance of timely action.
Response 3: Data included to convey the urgency.
Comment 4: What is the importance of nurses in primary health care settings for stroke care? How do they contribute to the stroke care team compared to hospital nurses? Are there any gaps in knowledge, attitudes, or skills that hinder their ability to provide effective stroke care? The author should address these questions using previous research findings. Additionally, it's important to include information about the healthcare system in Lesotho to illustrate why nurse-led interventions are the most effective and practical way to enhance nurses' capabilities in stroke management.
Response 4: The introduction is revised to include role of primary care nurses, gaps and Lesotho's healthcare system information highlighted.
Comment 5: It's important to specify that this study uses a Pre-experimental one-group pretest–posttest design. This clarification ensures that the methodology is clear and prevents confusion with the term "pre–post interventional study," which could imply a connection to true or quasi-experimental designs.
Response: 6: It has been specified.
Comment 7: Add a reference at Line 130 for the source used to develop the educational guide so readers can verify or replicate the intervention content.
Response 7: The reference included.
Comment 8: Please provide detailed information about the questionnaire assessing respondents' knowledge, attitudes, and clinical practices regarding stroke management in the PHC setting. Was it developed by the author or adapted from a previous study? Also, include the parameters for each variable, along with the scoring system.
Response 8: Tool development clarified.
Comment 9: The author used a questionnaire to assess clinical practice, but it's unclear why skill observations were not performed. This should be noted as a limitation of the study.
Response 9: Reflected as a limitation.
Comment 10: The description of the five-day educational intervention is informative but could be clearer. It should include an outline of the training sessions, detailing the topics, their sequence, and whether the days were consecutive or spread out. Additionally, clarify when and how the post-test was administered. Was it right after the final session or given later?
Response 10: Training outline included and clarified that the test was taken immediately.
Comment 11: The author should include the strengths and limitations of this study.
Response 11: Strengths and limitations included.
Comment 12: It would be beneficial for the author to consider updating the references, as 8 out of 25 were published before 2015, indicating they are over a decade old. Given that research related to strokes is rapidly evolving, incorporating more recent studies could enhance the relevance and impact of the work.
Response 12: Where possible, recent references were included.
Round 2
Reviewer 2 Report
Comments and Suggestions for AuthorsThe manuscript shows clear improvement and provides added nuance to the evidence base on similar interventions, especially in LMIC settings.
Author Response
Comment 1: The manuscript shows clear improvement and provides added nuance to the evidence base on similar interventions, especially in LMIC settings.
Response 1: Thanks.
