Wright Map Analysis to Determine Nurses and Midwives’ Knowledge of Treatment of Primary Postpartum Haemorrhage in Nigeria

Response to Reviewer 1 Comments

1. Summary

Thank you very much for taking the time to review this manuscript. Please find the detailed responses below and the corresponding revisions/corrections highlighted/in track changes in the re-submitted files

2. Point-by-point response to Comments and Suggestions for Authors

Comments 1: Line 62-63: Indicate the studies that report a prevalence rate of 16.8%.

Line 88-89 Line92: In these lines you refer to cities or regions in your country that are not known to readers in the rest of the world, indicating that they are areas or cities in your country. Example: Sagamu (Nigeria)

Line 138: You refer to a methodological framework by Rasch but cite a study in your field (a reference that is also misquoted).

Response 1: Thank you for pointing this out. We agree with this comment. Therefore, we have amendments, see in line 74, line 107&112 and line 143.

Comments 2: In your case you do not present the difficulty values, the discrimination indices, the separation and reliability indices, etc. Nor do you present what kind of model has been used for the Rasch. I am passing you a recent useful article so that you can present a Rasch analysis and include Wright's graph which, I insist, only makes sense if you provide the complete data from the analysis that support the model.

Response 2: We agree. We have, accordingly, modified lines 226 to 236 to emphasize this point in the revised manuscript.

Comments 3: Indicate the sampling system and how the sample was recruited. You should also indicate data on the sample estimate made, which has not been reached.

-Clearly state the inclusion and exclusion criteria for the study population.

Response 3: We agree. We have, accordingly, modified lines 188 to 204 to emphasize this point in the revised manuscript.

Comments 4: Indicate in more detail how all the variables under study were measured (not all the variables that later appear in the results are reflected).

Response 4: It seemed the reviewer has referred to items as “variables” because knowledge is the only variable measured in the study. The sociodemographic table (see lines 298 to 300) should also account for this information.

Comments 5: Must include a table with all the socio-demographic characteristics of the participants under study.

-Include the results of the Rasch analysis mentioned above, including the infit and outfit for each item. Remember to include data that ensure the independence of the items (e.g. Yen's Q3 matrix).

Response 5: We agree, please see lines 298, lines 226 to 236

Additional clarifications

Foremost, we once again commend your rigorous analysis, useful suggestions and meaningful comments which mirrors your belief in high-quality manuscript to meet the standards of this journal and beneficial to all readers. Nonetheless, we noticed you “insisted” on extensive reports of Rasch analysis which we presume may distract nurses and midwives or other readers who are concerned about simple useful information other than complex statistics. Correspondingly, the emphasis of this study is on displaying test takers knowledge of PPH treatment on a Wright map based the theoretical relevance of the items. The test items forming the test were being a direct paraphrasing of best practice guidelines recommended by the WHO. We believe the benefits of focusing on Wright map in simplifying respondents’ outcome in providing clearer and practical implications for clinicians and researchers outweighs complex statistical analysis. Therefore, we have supplied additional information such as item fit, item separation, person reliability, local independence and scale reliability while we omitted other extensive technical analysis such as category functioning and eigen value. 

Response to Reviewer 2 Comments

1. Summary

Thank you very much for taking the time to review this manuscript. Please find the detailed responses below and the corresponding revisions/corrections highlighted/in track changes in the re-submitted files

2. Comment: Point by point response to comments, response and suggestions

Comments 1: The abstract is too dense; simplifying key findings will improve readability.

Response 1: Thank you for pointing this out. However, in this case we have presented the findings of the study in the simplest terms prescribed by the journal. To aid better understanding of Wright map and its interpretation, familiarizing oneself with Rasch techniques in objective measurement theory may be useful.

Comments 2: Ethical approval is mentioned, but bias control and informed consent should be explicitly stated.

Response 2: Agree. We have, accordingly, revised our manuscript to emphasize this point. Please see lines 199 to 237 under section called sample recruitment line.

Comments 3: Results refer to Wright maps and ANCOVA, but clearer in-text links are needed.

Response 3: Agree. We have, accordingly, modified lines 399 to 403 to emphasize this point.

1. Summary

Thank you very much for taking the time to review this manuscript. Please find the detailed responses below and the corresponding revisions/corrections highlighted/in track changes in the re-submitted files

2. Point-by-point response to Comments and Suggestions for Authors

Comments 1: The research objective is not clearly stated in the Background, making it difficult for readers to grasp the focus of the study.

Response 1: Thank you for pointing this out. We agree with this comment. Therefore, we have amendments, see in line 167 to 172.

Comments 2: The Background lacks specific information about the target population (nurses and midwives).

Response 2: We agree. We have, accordingly, modified lines 85 to 87 to emphasize this point in the revised manuscript.

Comments 3: Lack of methodological transparency regarding sample size justification and consideration of confounding factors

Response 3: We agree. We have, accordingly, modified lines 188 to 204 to emphasize this point in the revised manuscript.

Comments 4: Insufficient details on the test development process

Response 4: We agree. We have, accordingly, modified lines 206 to 237 to emphasize on this point in the revised manuscript.

Comments 5: Statistical analysis; the interpretation of the Wright map analysis could be enriched by providing a more detailed explanation of why certain items were positioned as more or less difficult. This would enhance the depth and clarity of the analysis.

Response 5: We agree, please see the extensive changes made from lines 469 to 542.

Comment 6: Insufficient distinction between results and discussion, leading to a conflation of data presentation and interpretation In the current manuscript, the Discussion section includes detailed descriptions of objective data such as the distribution of knowledge levels, trends among respondents around the average score, and the identification of knowledge gaps. I recommend moving these objective findings to the Results section to allow readers to clearly distinguish between data presentation and its interpretation. Subsequently, the Discussion should delve deeper into questions like "Why were these results obtained?", "What do these results mean?", and "What are the implications for future research and practice?" At present, the Discussion mainly reiterates the data without sufficient analysis or interpretation. Emphasizing the knowledge gaps revealed through Wright map analysis and highlighting their educational significance would better clarify the methodological benefits of this approach.

Response 6: We agree, please see the extensive changes made from lines 354 to 386 & lines 469 to 542.

Comment 7: The interpretation of the Wright map analysis is somewhat superficial, with insufficient detailed explanations for individual items While Wright map analysis is an interesting methodological choice, its interpretation in the manuscript appears to lack depth. Specifically, the reasons why certain items were positioned as more difficult and why some questions had high or low correct response rates are not thoroughly discussed. Providing more detailed explanations for these points would enhance the analytical rigor of the paper.

Response 7: We agree however this comment seems to be a repetition of comments 5 & 6. Hence we believe, the problem no longer exists after attending to comments 5 & 6.

1. Summary

Thank you very much for taking the time to review this manuscript. Please find the detailed responses below and the corresponding revisions/corrections highlighted/in track changes in the re-submitted files

2. Point-by-point response to Comments and Suggestions for Authors

Comments 1: Facial validity is made on the basis of the evaluations of the target population of a given instrument, and it is normally carried out on the basis of a pretest on the target population. It really seems that what you have done is to evaluate the content validity on the basis of the judgement of experts. It so happens that this instrument was designed for nurses (target population), so it could be assumed, but I call your attention to it for possible studies. Perhaps this aspect should be clarified. 

Response 1: Thank you for pointing this out and we have noted this comment for future studies.

Comments 2: Can you confirm that the correlations between the items that were measured (line 230-232) were based on the residuals? I understand that this is the Yen's Q3 test that you conducted.

1. Summary

Thank you very much for taking the time to review this manuscript. Please find the detailed responses below and the corresponding revisions/corrections highlighted/in track changes in the re-submitted files

2. Point-by-point response to Comments and Suggestions for Authors

Comments 1: Facial validity is made on the basis of the evaluations of the target population of a given instrument, and it is normally carried out on the basis of a pretest on the target population. It really seems that what you have done is to evaluate the content validity on the basis of the judgement of experts. It so happens that this instrument was designed for nurses (target population), so it could be assumed, but I call your attention to it for possible studies. Perhaps this aspect should be clarified. 

Response 1: Thank you for pointing this out and we have noted this comment for future studies.

Comments 2: Can you confirm that the correlations between the items that were measured (line 230-232) were based on the residuals? I understand that this is the Yen's Q3 test that you conducted.