A Community Engagement Approach to Snakebite Prevention in Rural Uganda: Exploring Knowledge, Attitudes, and Practices

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

The authors present an interesting topic with respect to snakebite in a country where few data regarding snakebite and cultural beliefs have been documented.

"Participatory workshops" were provided to people in the local community to determine if information regarding snake behavior and biology could be beneficial in mitigating the risk of suffering a snakebite. In addition to the authors' reporting study results there is a considerable amount of historical and cultural information included with some of it documenting unique aspects of snakebite culture in a local Uganda community.

The following comments should be considered:

The number of individuals in the workshop and non-workshop categories presented in some tables by those who provided responses is quite limited. For example, Tables 3, 4,1 9,10, 11 and Table S1 and S2 report quite small numbers despite that it was stated that there were seven workshops that were delivered to 157 community members? This is a significant mismatch unfortunately as it would be expected that there would have been more responders and limits meaningful interpretation. There also appear to be some inconsistencies with the data and information provided in some Tables in the manuscript versus the Supplementary Tables (see comments).

Scientific designation of all snake species should be provided since common names and local names are vague, such as Naja melanoleuca is "black spitting cobra - Enchwera".  These should be provided in Tables 1, 2, and S1.

Inconsistencies are apparent. For example, data presented in Table 1 and Table S1- identification of species: Table 1 does not show Black Spitting Cobra yet the data in S1 show data for this species. Why is there no data for this species in Table 1 if there were responders for this species in S1? Consistency of data presented should be carefully reviewed throughout the manuscript.

The Interview questions in the Supplementary, under Snakes and Snakebite-Interview Questions, are difficult to easily link with the main manuscript in an orderly process. 

The terms, "snakebite" versus "snake bite": one or the other should be consistently used throughout the manuscript. Use only one.

There are numerous grammatical and wording errors throughout the manuscript. The authors should carefully review the manuscript for these errors. For example:

- line 74 - Improve wording for clarity since, "26 clinically venomous snakes", is really intended to reflect that it is 26 different venomous snake species that are of clinical importance.

- lines 87-88 - grammar correction needed for, "particularly strongly on prevention".  

- line 111- Sentence wording correction needed with respect to, “yet neither those authors ..." should be, "yet none of those authors....."

Discussion - There are no references to the Tables or Figures in any part of the discussion, which reiterates much of the results. It is important to link these with comments made in the discussion even though they may have been referenced in the results.

Overall, the manuscript needs to be reduced in length. The introduction and Discussion could be narrowed down. 

Author Response

Please see the attachment.

Author Response File: Author Response.pdf

Reviewer 2 Report

Comments and Suggestions for Authors

This study assesses a community-based snakebite prevention workshop in rural Uganda, examining its association with knowledge, risk perception, and intended behaviours related to snakes and snakebite. Workshop attendance was linked to improved snake identification and reduced endorsement of snake killing, but also to some underestimation of risk for certain snakes, highlighting challenges in risk communication. Despite low recalled mortality, perceived snakebite fatality remained high, indicating fear-driven perceptions. Overall, the findings suggest educational workshops can positively influence attitudes, but must be carefully framed and aligned with local health-system realities to avoid unintended safety risks. Below, I have added my comments: 

Major issues

1. Lines 906–913: The authors acknowledge reliance on self-reported changes and potential desirability bias. As written, the comparison of attendees vs non-attendees is highly vulnerable to self-selection (people more motivated/concerned may attend). Without baseline measures on the same individuals (or randomisation/stepped-wedge), attributing effects to the workshop remains uncertain. In this sense, in my opinion,  consider reframing causal language throughout results/discussion: “associated with” rather than “caused by. If feasible, add a short “future evaluation” paragraph proposing a stepped-wedge rollout or pre–post design with the same participants.
2. Lines 379–386: respondents report low observed fatality (3.4% of 178 “recalled” bites) but very high perceived fatality from untreated bites (mean 89% in one subgroup). This mismatch is central to snakebite prevention (fear drives snake-killing, delays in care, stigma, and reliance on traditional measures), yet the paper treats it mainly descriptively. There are some papers on the literature focusing on fear, which can help to improve this discussion. 
3. Lines 268–277: attendees were more likely to incorrectly consider a snake harmless; non-attendees were more likely to incorrectly consider a snake dangerous. This is a major safety issue. A snakebite prevention intervention must avoid creating false reassurance, even if it reduces indiscriminate killing.
4. The manuscript would be stronger if it distinguished: (i) stated intentions vs (ii) observed behaviours vs (iii) health outcomes. 
5. Lines 931–937: the manuscript notes that many Ugandan facilities may be ill-equipped (antivenom/adrenaline/training). If the intervention message is “seek formal care,” the manscript  should more clearly reconcile that with service gaps; otherwise, communities may learn a message they cannot realistically act on (undermining trust). I suggest considering important to add a short mapping of nearest facilities/typical travel time/cost (even descriptive) and whether antivenom is reliably available. 
6. You claim retained messages “at least 10 months.” Please state how “10 months” was determined (time since workshop for those interviewees?).

Minor comments

1. The manuscript have excessive number of tables. Many of them can be combined or added as supplementary material. The authors must focused on the main findings.
2. In addition to the figures titles, the authors can add a brief description.
3. Statistical analysis must be performed and included, where it is applicable for better understanding and analysis. 
4. Lines 110-113. please avoid one sentence paragraph. 
5. In my view, the title is too long. 

Author Response

Please see the attachment.

Author Response File: Author Response.pdf

Reviewer 3 Report

Comments and Suggestions for Authors

Method Section
(Comment 1) This study employed a mixed-methods approach combining a survey and interviews. Therefore, please complete the following reporting checklists and provide them as supplementary files:
 - STROBE (Strengthening the Reporting of Observational Studies in Epidemiology)
 - SRQR (Standards for Reporting Qualitative Research)

(Comment 2) Please revise the Method section according to the outline below. Avoid describing the workshop content in detail in the Methods section. The Methods section should be written in sufficient detail to allow the study to be reproducible.
 - Study sample
 - Study design
 - Development of the survey and interview instruments (to be provided as a supplementary file)
 - Survey and interview procedures
 - Statistical and qualitative analysis

Results Section
(Comment 3) Lines 127–176 are not appropriate for inclusion in the Results section. Please report only the results under the three headings below. Do not describe methodological details in the Results section; report survey and interview findings only.
 - Baseline characteristics of survey and interview participants
 - Survey results
 - Interview results

(Comment 4) Please revise the Results section to include only the main findings, and remove the remaining content. The Results section should present only the key outcomes at a level appropriate for a graphical abstract, focusing on the main results. The current manuscript appears to take the form of a workshop outcome report rather than a research article.
 
Discussion Section
(Comment 5) The Discussion section requires re-evaluation after the Methods and Results sections have been revised.

Conclusion Section
(Comment 6) It is difficult to conclude, based on the current data, that the workshops themselves constitute an effective intervention for preventing or mitigating snakebite incidence. Such a conclusion would require evidence derived from comparisons of snakebite incidence before and after the workshops, or between intervention and non-intervention areas. Please revise the Conclusions section so that it is appropriately aligned with the current results.

Author Response

Please see the attachment.

Author Response File: Author Response.pdf

Round 2

Reviewer 1 Report

Comments and Suggestions for Authors

The authors appear to have carefully considered reviewer comments and have made significant effort to address these appropriately. The manuscript is a unique and interesting study in country with limited snakebite information previously reported, and also incorporates original and unique cultural perspectives regarding snakes and snakebite. There are still some minor grammatical errors with respect to missing words or incomplete sentences. For example, 2.4.2 line 512, "going to hospital" should be, "going to the hospital", or line 743-44 ," Interestingly, in our survey, photograph of a forest cobra......", the word, "the" needs inserted before the word photograph to read "..the photograph..".. This reviewer understands there may be language differences; however, these are small changes that will make the manuscript more correct and polished. So, it will be beneficial for the authors to carefully review for these minor corrections.   

Author Response

Thank you for your positive comments regarding our efforts to revise the manuscript according to your comments. We are also grateful for your time and effort in providing suggestions in the earlier round and do believe that the revised manuscript has been much improved as a result. We hope that our final changes in response to your new comments (detailed below) now make the manuscript acceptable for publication. In terms of your specific comments on this version of the manuscript:-

"For example, 2.4.2 line 512, "going to hospital" should be, "going to the hospital""

We have not changed this because we feel our original version is closer to what we mean. We note that both 'go to hospital' and 'go to the hospital' are used and can be interchangeable, however there are differences between British English and American English usage: https://www.oxfordlearnersdictionaries.com/us/definition/english/hospital. Specifically, although these are seemingly used as synonyms in American English, in British English 'go to the hospital' implies visiting the building (most commonly to visit patients or otherwise visit the building itself) whereas 'go to hospital' is most commonly used to imply that the person is seeking healthcare/treatment at the hospital as a patient. The latter meaning is what we intend by this phrase, and as both the authorship team and Uganda (the location of the study) use British English rather than American English we believe that our meaning is most likely to be preserved as intended with minimal confusion based on our original phrasing.

 

"line 743-44 ," Interestingly, in our survey, photograph of a forest cobra......", the word, "the" needs inserted before the word photograph to read "..the photograph..""

We have made this change and thank you kindly for pointing this error out and avoiding an embarrassing mistake on our part.

 

Thank you once again for your time and efforts. They are appreciated.

Reviewer 2 Report

Comments and Suggestions for Authors

The manuscript shows improvement. The authors have addressed the comments raised, and have provide explanations for some points where revisions were not adopted or partially considered. 

Author Response

Thank you for your time and efforts in improving the manuscript, we genuinely appreciate the constructive comments you provided us and firmly believe that they have made our manuscript better. We are glad that you agree that the manuscript is improved as a result and that our responses (either changes or explanations) were appropriate to address the suggestions.