ALL Metrics
-
Views
-
Downloads
Get PDF
Get XML
Cite
Export
Track
Research Article
Revised

Association between no referral versus health centres referrals preceding hospital admission and in-hospital child mortality in rural Malawi

[version 2; peer review: 1 approved with reservations, 2 not approved]
Previously titled: Association between care-seeking at health centres preceding hospital admission and in-hospital child mortality in rural Malawi
PUBLISHED 07 Jan 2025
Author details Author details
OPEN PEER REVIEW
REVIEWER STATUS

This article is included in the Global Public Health gateway.

This article is included in the University College London collection.

Abstract

Background

The under-five mortality rate counted 71 deaths per 1000 live births for children under five in Sub Saharan Africa in 2022, far above the SDG under five-mortality goal of 25 deaths per live 1000 birth. Referral issues are major challenges to child health and a hypothesis is that care at lower-level facilities delays quality emergency care. This study investigates the extent of no-referral versus health centres-referrals prior to hospital admission for sick children, and with inpatient mortality associations in Malawi.

Methods

We conducted a cohort study of children aged 0-12 years admitted to hospitals in Mchinji district. Data-collection was done from September 2019 to April 2020 at one district-hospital and three community-hospitals. Information was collected from caregivers, patient files and ward admission registers. The primary analysis assesses the association between referral from a health centre and in-hospital outcomes using logistic regression. Inpatient mortality was the primary outcome.

Result

The 4926 included children demonstrated that 86.6% had gone straight to hospital without referral. The majority (67.9%) were admitted due to malaria, sepsis (21.3%) and pneumonia (13.3%). Referred children had a case fatality rate of 5.3%, while the non-referred had a case fatality rate of 2.5%. Referred children had higher odds of dying (AOR: 2.0, CI 95%: 1.3-3.0), compared to not referred children. Children with anaemia (AOR: 4.1, CI 95%: 2.7-6.3) and malnutrition (AOR: 6.3, CI 95%: 2.7-14.6) had significantly higher odds of dying, than those without these conditions.

Conclusion

Most children admitted to hospital were taken without a referral, and these children had better survival than those who were referred. While being referred could be a proxy for being more severely sick the mortality difference emphasises a need to better understand care-seeking pathways, including referral challenges, to direct interventions to improve timely provision of care for sick children.

Keywords

In-hospital child mortality; Care-seeking, Referral; Paediatric; Malawi; low-income country

Revised Amendments from Version 1

Adjustments have been made according to reviewers. Among these the title has been changed to better address what this article is presenting. Strengths and limitations have been elaborated. We also found a comma mistake on our result om AOR. This has been corrected in the new version.

See the authors' detailed response to the review by Sumathi Swaminathan
See the authors' detailed response to the review by Faisal Ahmed
See the authors' detailed response to the review by Bryan Vonasek

Introduction

Many countries, mostly in Sub-Saharan Africa (SSA), continue to suffer from a high child mortality rate.1 In 2022 the under-5 mortality was 71 deaths per 1,000 live births in SSA, and 40 per 1,000 for Malawi.2 This is far from the Sustainable Development Goal (SDG) 3,2 to decrease the under-five mortality to less than 25 deaths per 1,000 live births by 2030.3 The Lancet Global Health Commission on Quality Healthcare argued in 2018 that poor quality of healthcare is a now a bigger barrier than access to care in reducing child mortality and accounts for as much as 60% of avoidable deaths in low and middle-income countries (LMIC).4 The Integrated Management of Childhood Illness (IMCI) and integrated Community Case Management (iCCM) programs, were developed to improve the quality of care for sick children in low-income settings. Children with signs of severe illness in the community or in the health centre should be referred to higher level facilities for further management.5 IMCI does not include any components of emergency case management, and primary healthcare facilities in low-income countries commonly lack the resources to treat severely ill children.6 Furthermore, challenges in the identification of severely ill children have been reported under IMCI, potentially leading to missed referrals.7

Delays in care seeking for young children in LMIC have been reported due to guardians’ inability to recognise illness, household challenges in mobilising resources and/or deciding to seek care, especially in poor and less educated households.810 This, along with referral challenges within the health system including waiting times, poor triage, and lack of referral transport, could lead to increased risks for children who are brought to primary care with an acute illness, as adequate care at a higher-level facility may be further delayed.

This study was performed to assess the care-seeking patterns, and more specifically on referrals, prior to being admitted to hospital, to establish the association between pre-admission referrals and inpatient mortality for children in Mchinji District, Malawi. We also investigated which characteristics who was associated with higher mortality.

Methods

Study setting

Malawi was one of ten countries in SSA that achieved the Millennium Development Goal 4 to reduce child mortality.11 Despite the improvements in child mortality in Malawi, the mortality rate still falls short of the SDGs. The Malawian healthcare system, who heavily depends on external financing,11,12 is organized in public (free of charge), private for profit and private not for profit sector.12 The Ministry of Health supports services in the private not for profit sector in essential care, such as maternal and child health. This sector is dominated by non-governmental organisations and religious institutions, such as The Christian Health Association of Malawi (CHAM).13 Malawi adopted and implemented IMCI in 1999 and iCCM was introduced in Malawi in 2007. The World Health Organisations (WHO) Emergency Triage Assessment and Treatment (ETAT)14 has been implemented in Malawian tertiary and secondary hospitals.

Mchinji is a district in the Central Region of Malawi with a mainly rural population and with an under-five population of approximately 90,000 in 2018. In 2018 574.000 of the population in Mchinji lived in rural areas while only 28.000 lived in urban.15 The country economy heavily relies on agriculture, with 80% of the population working in this field.16 Data was collected at the paediatric department of the main district hospital, Mchinji District Hospital (MDH) and the three CHAM community hospitals within the district. The primary care health centres do not offer any inpatient care, and children in need of admission are referred to hospital for further care.

The recruitment and data collection were planned for one year from the 9th of September 2019 but was stopped in April 2020 due to the Covid-19 pandemic.

Study design

This was an observational cohort study involving all children admitted to hospitals within Mchinji district during the study period.

Participants

Children aged 0-12 years old who were admitted to a paediatric ward at any of the four hospitals within Mchinji District during the study period were eligible for enrolment to the study. The only exclusion criteria were neonates (age <28 days) who were born within the included hospitals, as they were unable to present with a referral history.

Data sources

Data collection involved interviews with guardians and patient file review which was performed by study data collectors. Two of these were based at MDH and one each in the three community hospitals. The data collectors had a minimum education of completed secondary school and could read and write in English and Chichewa. All data collectors attended one week of training on the study protocol and ethics in research. They were supervised on a weekly basis by field supervisors and a clinical officer. Data collectors approached caretakers of admitted children in the hospitals and asked for their consent to participate in the study. Following consent, data was collected on whether the caretaker had brought the child straight to the hospital, or whether another health facility had been visited before coming to the hospital. Patient demographics, including patient age, sex, admission diagnosis, the time and day of the hospital admission and outcomes were recorded from patient files and ward admission books. Data collectors follow up on patient outcomes. Data was entered into password protected tablets using Open Data Kit (ODK) for electronic data collection. A data collection supervisor and a data manager checked the data for completeness on a weekly basis. In our case the data was then exported to Stata for analysis. Data can also be analysed in other software such as R. As data was collected at the hospital during admission, and records were kept over all patients, the risk of loss to follow up bias was minimal. All admitted children in the relevant age groups were invited to participate, eliminating the risk of selection bias.

Sample size

The initial plan was to include all admitted children for one year using routine hospital admission data from the Mchinji district. The assumption was that data from Mchinji would sufficiently be representative to comfortable make generalisations of the whole population of interest. While data collection was stopped due to the Covid-19 pandemic the inclusion of close to 5000 children was still deemed enough to yield statistically significant results.

Data analysis

The primary outcome variable for the analysis was inpatient mortality, and primary exposure was if the child had been referred from elsewhere prior to hospital admission. Age and sex of the child, day and time of admission and admission diagnosis were considered potential confounders. Sex was determined from medical records and any difference was explored as there are differences in mortality patterns between sexes in children under-five. All variables were converted into categorical variables. Admission days were categorized as weekdays (Monday to Friday) or weekends (Saturday and Sunday), and time as “day” (8 am to 8 pm) or “night” (8 pm to 8 am). This gave an indication if hospital admissions outside of daytime working hours, when there are less staff on the wards, were associated with higher mortality. Children could be assigned multiple admission diagnoses, we created binary variables for diagnosis category, meaning a total of more than 100% is presented in the diagnosis variable.

Proportions were stratified by facility type (district hospital versus community hospitals) and compared using chi2 ( Table 1). Logistic regression analysis was done to determine the associations between the main exposure and outcome ( Table 2). All statistical analysis was preformed using Stata/IC 16.1. Stata was chosen as the researchers had license and experience using this software. Alternatively, the free statistical software R could have been used.

Ethical considerations

Guardians were informed about the study and provided verbal consent for their minors to participate in the study prior to any data collection. Due to literacy levels, study information was given verbally in Chichewa, and consent given verbally –the informed consent was subsequently recorded in the electronic data collection form. Refusal to participate had no impact on the care provided to the patients and study procedure including consenting was approved by the Malawi College of Medicine Research and Ethics Committee (reference: P11/18/25389).

Results

A total of 4926 children, 2322 (47.1%) female and 2604 (52.9) males, were admitted to hospitals in Mchinji district during the study period. Of these, 172/4926 (3.5%) where less than one month old, 852 (17.3%) where 1 month to 12 months old, 2758 (56.0%) were between 1 and 5 years, and 1138 (23.1%) were aged 5 to 12 years. 4265 (86.6%) of the total admitted children had been brought straight to hospital, and 661 (13.4%) children had been referred from another health care provider ( Table 1). The proportion of admitted children that had been referred was higher at the district hospital compared to the community hospitals (29.0%, vs 3.9%, p<0.001). Out of the 4926 children who were admitted, 141 died with an overall in-hospital mortality of 2.9%. The in-hospital mortality was 5.3% for referred children compared to 2.5% for the non-referred cases (p<0.001). The in-hospital mortality was 3.3% at the district hospital compared to 2.1% at community hospitals for non-referrals (p=0.021). For referred cases, the in-hospital mortality was 5.3% at the district hospital and 5.2% at the community hospitals (p=0.998). The overall in-hospital mortality was higher at the district hospital at 3.9%, compared to 2.2% at the community hospitals (p=0.01). Of the 545 children referred to the district hospitals, 33 had been referred from any of the included community hospitals and 5 of these died (CFR 15.1%).

Table 1. Distribution of patient characteristics and mortality between hospitals.

TotalMchinji district hospitalCommunity hospitals
Deaths (n/N)Case fatality rate (%)Deaths (n/N)Case fatality rate (%)Deaths (n/N) Case fatality rate (%)
Referral
Referred35/6615.329/5455.36/1165.2
Non-referred 106/42652.544/13323.362/29332.1
Age
<29 days6/1723.62/414.94/1313.1
1–12 months33/8523.918/2836.415/5692.6
>1–5 years79/27582.937/10423.642/17162.5
>5–12 years23/11382.016/5053.27/6331.1
Sex
Female71/23223.138/8704.433/14522.3
Male70/26042.735/10073.535/15872.2
Admission diagnosis
Pneumonia17/6562.612/3543.45/3021.3
Malaria97/33452.944/10254.353/23202.3
Diarrhoea8/3432.32/742.76/2692.2
Sepsis22/10472.16/2482.416/7992.0
Anaemia37/4418.421/18011.716/2616.1
Malnutrition8/5813.83/348.85/2420.8
Trauma3/1981.52/1211.71/771.3
Other10/4392.34/1522.66/2872.1
Admission time
Weekday113/36033.159/14244.154/21792.5
Weekend28/13232.114/4533.114/8701.6
Day120/39783.065/16833.955/22952.4
Night*21/9482.28/1944.113/7541.7

* Admission any time from 8 pm to 8 am the following day.

Referral history and in-hospital mortality risk

The adjusted odds ratio of in-hospital mortality was 1.9 (95% CI:1.3-2.9) for children who were admitted to hospital who had been referred compared to those who was not referred. Table 2 presents the unadjusted (UOR) and adjusted Odds Ratios (AOR) for the variables included in the logistic regression analysis.

Table 2. Association of patient characteristics and presence of referral with in-hospital mortality.

VariableUnadjusted odds ratio p-value 95% CIAdjusted odds ratio p-value 95% CI
Referral
Not referred1.0
Referred2.2<0.0011.5-3.21.90.0011.3-2.9
Age
<29 days1.0
1–12 months1.10.8100.5-2.70.70.5450.3-2.0
>1–5 years0.80.6370.4-1.90.50.1060.2-1.2
>5–12 years0.60.2390.2-1.40.30.0280.1-0.9
Sex
Male1.0
Female1.20.4380.8-1.61.10.4880.8-1.6
Admission diagnosis *
Pneumonia0.90.6550.5-1.51.00.9040.6-1.9
Malaria1.00.8180.7-1.51.40.1950.6-2.2
Sepsis0.70.0980.4– 1.10.90.5200.5-1.4
Diarrhoea0.80.5420.4-1.61.00.9500.5-2.2
Anaemia3.9<0.0012.6-5.74.1<0.0012.6-6.3
Malnutrition5.7<0.0012.6-12.36.2<0.0012.7-14.4
Trauma0.50.2550.2-1.61.00.9710.3-3.4
Other0.70.4430.4-1.50.90.7190.4-1.8
Admission time
Weekday1.00.0590.4-1.00.80.2010.5-1.2
Weekend0.7
Night1.0
Day1.40.1850.9-2.21.20.4830.7-1.9

* More than one diagnosis per child possible.

For the different age-groups, neonates (age <29 days) represented 3.5% of all admissions (172/4926), with a CFR of 3.6%. Infants, aged 1 to 12 months, represented 17.3% (852/4926) of the admitted children and had the highest CFR at 3.9%. The biggest group of admitted children (56.0%) were between 1 and 5 years of age (2758/4926) while 1138 children (23.1%) were between 5 to 12 years of age. The children aged 1-5 year olds had a CFR of 2.9% and the CFR for children aged 5-12 years old was 2.0%. Only a small difference was seen depending on sex, with 52.9% of the admitted children being males and 47.1% females, and with a CFRs of 2.7% and 3.1%, respectively (p-value: 0.437).

Most of the other included factors did not show any statistical significance. The exceptions were children in the age-group from 5 to 12 years, whose AOR for in-hospital mortality was 0.3 compared to neonates (95% CI: 0.1-0.9).

The diagnosis with the highest CFR was malnutrition at 13.8%, followed by anaemia at 8.5% with an AOR of 6.2 (95% CI 2.7-14.4) and AOR 4.1 (95% CI: 2.6-6.3) respectively. A bigger proportion of children died from malnutrition at the community hospitals than at the district hospital, however the result was not significant (20.8%, vs 8.8%, p<0.191). The proportion that died of anaemia was higher in the district hospital (11.7%) than at the community hospitals (6.2%, p=0.039).

Discussion

We observed a higher in-hospital mortality among children who had been referred from a lower-level facilities compared to children who were brought straight to hospital in a rural Malawian setting. Most children who are admitted to hospital had been brought there without seeking any previous care at lower-level facilities. In terms of diagnosis, the evidence suggests children with malnutrition and anaemia carry an increased mortality risk.

The in-hospital mortality was twice as high for children who had been referred to hospital from a lower-level facility compared to children who were brought straight to the hospital. The CFR was highest for children who had been referred from any of the community hospitals to the district hospital. While the study did not establish the actual causes of the mortality, and can be assumed that referred children were likely to be sicker than the non-referred children, and thus at higher risk of dying. However additional explanations to the mortality difference could be that adequate care was delayed during the time it took to seek and receive care elsewhere, followed by the time it took to complete referrals. Lower-level facilities have limited abilities to offer stabilisation of severely ill children with transport issues for referrals reported as a main constraint.17,18 Delays may also occur within facilities including the decision to refer a child.19 While IMCI was rolled out in 1999 and include guidelines on when to refer a sick child, challenges in the sustainability have been reported including limitations in equipment, training, and adherence to guidelines.18,20 To ensure that all in need are referred early, current IMCI guidelines may need more objective definitions for timely stabilisation.21,22

The majority of children admitted to the included hospitals had come straight to the hospital. This may suggest a good awareness among guardians on when a child’s illness requires hospital care. Alternatively, there is a general preference for hospital care which could be due to lack of trust in lower level facilities.23 A study conducted in Southern Malawi showed that patient satisfaction with the primary healthcare system demonstrated considerable variation24 and better facility quality is associated with a higher utilisation of sick child healthcare services.25

The highest mortality was seen among children diagnosed with malnutrition and anaemia. This confirms findings from previous studies2628 and children with these diagnoses also suffer an increased risk of post-discharge mortality.29,30 It is possible the ETAT guidelines need to pay more attention to malnourished children with multiple diagnoses for priority and stabilisation at admission, and IMCI and iCCM should focus on earlier referral for children with malnutrition and anaemia. For age differences, young children had the highest mortality. While neonates generally suffer the highest mortality rates, in this study the mortality was highest among infants. Part of this may be explained by the study exclusion of babies born within the facilities, a study on place of death and care-seeking prior to death that poor illness recognition is a major driver in neonatal deaths, whereas death despite care-seeking among older children indicates inadequate quality care and referral.31

The strengths of this study include a district wide approach with a big sample of children included. However, there are some major limitations that preclude any conclusion on the overall mortality-risks in the study population. Firstly, it is possible that referred children as a group were suffering from more severe conditions than the ones who were not-referred. The study did not collect any information on the symptoms at the time the decision to seek care was made or whether a progression occurred during the time spent on care seeking prior to reaching the hospital. Indeed, the high CFR among children referred from community hospitals to the district hospital may reflect on illness severity and a higher need for more advanced care among these children, rather than failures within the referral system. Secondly, we did not collect any data on reasons for referrals and whether the selection of children to be referred adhered to guidelines. Thirdly, there is also the possibility that caretakers who were recommended referral to hospital could not make their way there, causing an under-estimation of post-referral mortality. Similarly, we did not assess post-discharge mortality which is reportedly high in many SSA settings.29

To conclude, the higher in-hospital mortality demonstrated between children who were referred from a health centre compared to not-referred cases may be caused by more severe illness and greater need for more advanced care. However, given the overall high CFRs among referred cases it is also plausible that it is linked to poor quality care at primary healthcare facilities, inadequate guidelines for when to refer a sick child and/or or difficulties to completing referrals. Future studies to better understand the demonstrated mortality pattern should include data on illness severity and caretaker’s reasons for care-seeking choices. The vulnerability of children with malnutrition and/or anaemia should be especially considered when assessing sick children at all levels of the health care system.

Comments on this article Comments (0)

Version 2
VERSION 2 PUBLISHED 29 Aug 2023
Comment
Author details Author details
Competing interests
Grant information
Copyright
Download
 
Export To
metrics
Views Downloads
F1000Research - -
PubMed Central
Data from PMC are received and updated monthly.
- -
Citations
CITE
how to cite this article
Selstø A, King C, Hildenwall H et al. Association between no referral versus health centres referrals preceding hospital admission and in-hospital child mortality in rural Malawi [version 2; peer review: 1 approved with reservations, 2 not approved]. F1000Research 2025, 12:1053 (https://doi.org/10.12688/f1000research.133981.2)
NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article.
track
receive updates on this article
Track an article to receive email alerts on any updates to this article.

Open Peer Review

Current Reviewer Status: ?
Key to Reviewer Statuses VIEW
ApprovedThe paper is scientifically sound in its current form and only minor, if any, improvements are suggested
Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit.
Not approvedFundamental flaws in the paper seriously undermine the findings and conclusions
Version 1
VERSION 1
PUBLISHED 29 Aug 2023
Views
33
Cite
Reviewer Report 21 Oct 2024
Sumathi Swaminathan, St John’s National Academy of Health Sciences, St John's Research Institute, Bengaluru, Karnataka, India 
Not Approved
VIEWS 33
Your Report

Please provide a full report, expanding on your answers to the questions above. In particular, if you answered “no” or “partly” to any of the questions, please give constructive and specific details as to how ... Continue reading
CITE
CITE
HOW TO CITE THIS REPORT
Swaminathan S. Reviewer Report For: Association between no referral versus health centres referrals preceding hospital admission and in-hospital child mortality in rural Malawi [version 2; peer review: 1 approved with reservations, 2 not approved]. F1000Research 2025, 12:1053 (https://doi.org/10.5256/f1000research.147003.r319092)
NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article.
  • Author Response 07 Jan 2025
    Annlaug Selstø, Division of Mental and Physical Health, Norwegian Institute of Public Health, Oslo, Postboks 222 Skøyen, 0213, Norway
    07 Jan 2025
    Author Response
    Dear Sumathi Swaminathan

    We appreciate the comments and have revised the manuscript accordingly. Please see our responses  listed under, and our new version of our article.
    • Thank you
    ... Continue reading
COMMENTS ON THIS REPORT
  • Author Response 07 Jan 2025
    Annlaug Selstø, Division of Mental and Physical Health, Norwegian Institute of Public Health, Oslo, Postboks 222 Skøyen, 0213, Norway
    07 Jan 2025
    Author Response
    Dear Sumathi Swaminathan

    We appreciate the comments and have revised the manuscript accordingly. Please see our responses  listed under, and our new version of our article.
    • Thank you
    ... Continue reading
Views
16
Cite
Reviewer Report 18 Sep 2024
Bryan Vonasek, Michigan State University College of Osteopathic Medicine, East Lansing, Michigan, USA 
Not Approved
VIEWS 16
This manuscript focuses on a very important topic and includes a large dataset to explore associations with in-hospital mortality. However, there are several major limitations in the study design and interpretation of results that need to be addressed. 

... Continue reading
CITE
CITE
HOW TO CITE THIS REPORT
Vonasek B. Reviewer Report For: Association between no referral versus health centres referrals preceding hospital admission and in-hospital child mortality in rural Malawi [version 2; peer review: 1 approved with reservations, 2 not approved]. F1000Research 2025, 12:1053 (https://doi.org/10.5256/f1000research.147003.r319089)
NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article.
  • Author Response 07 Jan 2025
    Annlaug Selstø, Division of Mental and Physical Health, Norwegian Institute of Public Health, Oslo, Postboks 222 Skøyen, 0213, Norway
    07 Jan 2025
    Author Response
    Dear Bryan Vonasek

    Thank you for your thorough reading and review of our article. We appreciate your comments and have revised the manuscript accordingly. Please see our responses listed below. ... Continue reading
COMMENTS ON THIS REPORT
  • Author Response 07 Jan 2025
    Annlaug Selstø, Division of Mental and Physical Health, Norwegian Institute of Public Health, Oslo, Postboks 222 Skøyen, 0213, Norway
    07 Jan 2025
    Author Response
    Dear Bryan Vonasek

    Thank you for your thorough reading and review of our article. We appreciate your comments and have revised the manuscript accordingly. Please see our responses listed below. ... Continue reading
Views
19
Cite
Reviewer Report 21 Mar 2024
Faisal Ahmed, Urology Research Center, Al-Thora General Hospital, Department of Urology, School of Medicine, Ibb University of Medical Sciences, Ibb, Yemen 
Approved with Reservations
VIEWS 19
The authors present a useful study of the Association between care-seeking at health centers preceding hospital admission and in-hospital child mortality. Instead of an interesting study, it still needs extensive revision.
My comments/queries:

Abstract:
    ... Continue reading
    CITE
    CITE
    HOW TO CITE THIS REPORT
    Ahmed F. Reviewer Report For: Association between no referral versus health centres referrals preceding hospital admission and in-hospital child mortality in rural Malawi [version 2; peer review: 1 approved with reservations, 2 not approved]. F1000Research 2025, 12:1053 (https://doi.org/10.5256/f1000research.147003.r248631)
    NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article.
    • Author Response 07 Jan 2025
      Annlaug Selstø, Division of Mental and Physical Health, Norwegian Institute of Public Health, Oslo, Postboks 222 Skøyen, 0213, Norway
      07 Jan 2025
      Author Response
      Dear Editors

      Thank you for the opportunity to review our manuscript. We appreciate the comments form the reviewers and have revised the manuscript accordingly. Please see our responses to ... Continue reading
    COMMENTS ON THIS REPORT
    • Author Response 07 Jan 2025
      Annlaug Selstø, Division of Mental and Physical Health, Norwegian Institute of Public Health, Oslo, Postboks 222 Skøyen, 0213, Norway
      07 Jan 2025
      Author Response
      Dear Editors

      Thank you for the opportunity to review our manuscript. We appreciate the comments form the reviewers and have revised the manuscript accordingly. Please see our responses to ... Continue reading

    Comments on this article Comments (0)

    Version 2
    VERSION 2 PUBLISHED 29 Aug 2023
    Comment
    Alongside their report, reviewers assign a status to the article:
    Approved - the paper is scientifically sound in its current form and only minor, if any, improvements are suggested
    Approved with reservations - A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit.
    Not approved - fundamental flaws in the paper seriously undermine the findings and conclusions
    Sign In
    If you've forgotten your password, please enter your email address below and we'll send you instructions on how to reset your password.

    The email address should be the one you originally registered with F1000.

    Email address not valid, please try again

    You registered with F1000 via Google, so we cannot reset your password.

    To sign in, please click here.

    If you still need help with your Google account password, please click here.

    You registered with F1000 via Facebook, so we cannot reset your password.

    To sign in, please click here.

    If you still need help with your Facebook account password, please click here.

    Code not correct, please try again
    Email us for further assistance.
    Server error, please try again.