Using Prospective Methods to Identify Fieldwork Locations Favourable to Understanding Divergences in Health Care Accessibility

Round 1

Reviewer 1 Report

The topic of this paper is interesting. I have some suggestions and comments that need to be addressed before this manuscript is qualified to be published in this prestigious journal.

1. Line 62: Use the full name not abbreviation when you use a word for the first time in the manuscript: geographic information system instead of GIS.
2. Authors discuss previous studies on. I suggest authors have a look at the below study in which a comparative analysis was conducted in Florida to measure the accessibility to mental health services given different age groups and expand this discussion a little bit:

• Ghorbanzadeh, M., Kim, K., Ozguven, E. E., & Horner, M. W. (2020). A comparative analysis of transportation-based accessibility to mental health services. Transportation Research Part D: Transport and Environment, 81. https://0-doi-org.brum.beds.ac.uk/10.1016/j.trd.2020.102278

3. Section 1.5: There are several methods in the literature in order to assess the spatial accessibility to critical facilities and more specifically healthcare facilities including gravity models, regional availability models, and kernel density models. The two-step floating catchment area (2SFCA), the enhanced two-step floating catchment (E2SFCA) area, and three-step floating catchment area (3SFCA) methods also can measure spatial accessibility. Please refer to the following articles for more information:

• Luo, W., & Qi, Y. (2009). An enhanced two-step floating catchment area (E2SFCA) method for measuring spatial accessibility to primary care physicians. Health and Place, 15(4), 1100–1107. https://0-doi-org.brum.beds.ac.uk/10.1016/j.healthplace.2009.06.002
• Luo, W., & Wang, F. (2003). Measures of spatial accessibility to health care in a GIS environment: Synthesis and a case study in the Chicago region. Environment and Planning B: Planning and Design, 30(6), 865–884. https://0-doi-org.brum.beds.ac.uk/10.1068/b29120
• Wan, N., Zou, B., & Sternberg, T. (2012). A three-step floating catchment area method for analyzing spatial access to health services. International Journal of Geographical Information Science, 26(6), 1073–1089. https://0-doi-org.brum.beds.ac.uk/10.1080/13658816.2011.624987

4. The authors mention that GPS during the survey in 2011 and 2012 to collect the data. This approach of providing datasets is not an accurate method so you can rely on it and conduct the study based on that. In general, the dataset that has been used in this study has some limitations that might affect the accuracy of the obtained results. The authors may need to clarify this.
5. Avoid self-citations to the most extent possible.
6. In this paper, the authors focused on the travel distance and accessibility of residents to these types of services. How about the capacity of these facilities? The closest facility may not be the best option for a patient. Please explain this and provide more information to justify your approach.
7. Although the authors point out a little bit the difference between their work and others, I suggest them mention the key contribution of this study clearly and how this paper can add to the body of knowledge.
8. I feel you came up short in your conclusions and recommendations - the true value of this study is the applicability of its methodology to other events and transferability to other sites.

Author Response

Please find our response in the attached document.

Author Response File: Author Response.docx

Reviewer 2 Report

While this article has value to investigate the barriers of healthcare access in Malawi and provide some insights, this paper might need more clarification. After major revision, the editorial office can consider accepting this work for publication.

Comments

Lines 59-132: this part should be a portion of the second chapter (2. Materials and Methods). It seems the authors mixed up previous studies with methodology. I suggest splitting previous studies and your methods. In the introduction, it would be beneficial to have a summary of previous approaches i.e., methodologies to measure health care access and (if any) the studies related to the similar regional context (e.g., are there any studies to measure health care access in Africa? Or more specifically southern Africa?). This is because, as the authors noted, the condition is not the same compared to other developed countries (e.g., some studies in North America, measure driving time instead of walking time).

Lines 226-241: regarding “functional limitations (LimFunc- see Table 2)”, are all 8 variables relevant to define difficulty to “walk to healthcare”? I read some explanation in lines 242-255, but this part should provide a more clear statement of why these 8 questions are used. Particularly, question 8 is overlapped with “Age” in the equation.  

Line 368-401: this part summarizes the limitation of this study. The parts need, what the other studies say? For example, the first limitation is “data noise”. Is this issue a unique observation from your study? Or Do the other studies that used the household survey method have the same issues? If so, how did they handle this? It would be good to synthesize your findings with other literature for the reader.

About the fifth limitation, what is “realistic walking time”? this part should be more elaborated since there is not much information in this sentence.

While the authors acknowledge a lot of data-related limitations, the discussion should be addressed and highlighted.

Author Response

Please find our responses in the attached document.

Author Response File: Author Response.docx

Reviewer 3 Report

A good manuscript addressing a somewhat timely problem. It provides a practical approach and a working solution to the research question under scrutiny.

Author Response

Thank you for your positive comment.

Round 2

Reviewer 1 Report

The authors have addressed all my concerns, and the manuscript can be published.

Reviewer 2 Report

Thanks for addressing my comments and suggestions.