PONE-D-23-28365Exploring the psycho-social burden of infertility: Perspectives of infertile couples in Cape Coast, GhanaPLOS ONE

Dear Dr. Abdoul Azize,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process. The reviewers have recommended that major revisions be made to your paper in order to meet the publication criteria. As indicated by both reviewers, the methods and data analysis sections require significant revision to be clearer and more critical to show how the findings were reached. There must also be a critical discussion on the implications of the findings for couples facing infertility and a reflection on the wider utility of suggested interventions for other couples. Please ensure that this important distinction is made throughout the paper. A thorough proofreading of the manuscript is also necessary. Please submit your revised manuscript by Nov 25 2023 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

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Lily Kpobi, Ph.D.

Academic Editor

PLOS ONE

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Yes

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2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: N/A

Reviewer #2: N/A

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3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

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4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

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5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: The authors presented the psycho-social impact of infertility in affected couples in a qualitative study, using a phenomenology approach. Data was collected from 10 couples attending fertility clinic in Feb 23 in Cape Coast, Ghana.

The paper is generally well written, the structure is good and clear and the topic is relevant to health care providers in fertility treatment as psycho-social burden on the affected couples should be addressed concurrently with the actual treatment. Therefore, results from this study can inform health care professionals to provide better care.

The population is small, and the results are not applicable to the general infertile population due to various reasons (some of which addressed in the discussions), including the fact these couples were specifically seeking fertility treatment. However, this study population is certainly an important subset more likely to benefit from possible interventions, compared to couples not reaching out for help and support, due to the complexity and sensitivity of the problem.

Further comments:

1- In the abstract where it says, “we explored the impact of infertility on the psychological and social health of infertile couples” I would add “receiving fertility treatment”. Similarly, in other relevant places of the manuscript, it should be highlighted that the targeted population was not general infertility couples but the ones attending fertility clinics.

2 -The Social Ecological Model (SEM) - can the author explain better the difference between interpersonal, organizational and community please? as at the moment they seem to overlap.

3 - Can the authors add whether fertility treatment in Ghana is supported by the National health system or whether the affected couples need to pay for treatment as this would clarify better the socio-economic status of the interviewed couples.

4 - Can the author expand on further bias in the selected population, in the discussion section. For example, that these people were proactively addressing the infertile issue and were willing (and able) to seek help. Would this attitude come from a more or less ‘desperate’ population? And how easy/difficult would it be to recruit a more general infertile population? And what are the implications on the results of this study, by using this restricted population?

5 - Page 15 - “This strategy works better when the husbands of the various couples are very supportive of their wives”. This statement seems to highlight that women need support from men but not the other way around when the cause of infertility is with the man. Can the authors expand a bit on this in the discussion section? is it a preconception that women need a husbands’ support as they are considered the main cause of infertility but not the other way around?

6 - Previous literature has reported the difference in perception and attitude towards infertility between developing and developed countries. Can the authors discuss this and if the study confirmed any of these differences?

7 - In the conclusion, I think one important message, other than educating interpersonal-level actors, is also for the health care professionals to provide more comprehensive care (including psychological) to the affected couples.

8 - Table 2 - can the authors add the Frequency of sub-theme in an added column please?

9 - page 11- “self-distractive” did the authors mean “self-destructive”?

10 - Page 20 - “although the source of stigma and coping strategies” I suggest deleting the text “and coping strategies” to make sense of the phrase.

Reviewer #2: Manuscript Number PONE-D-23-28365

"Exploring the psycho-social burden of infertility: Perspectives of infertile couples in Cape Coast, Ghana"

- Aim of the study not clearly identified; this needs to be specified in the study background.

- Methods – it is not specified which phenomenological approach was used for the study – descriptive or interpretive with clear descriptions of its respective philosophical underpinnings and how that was used as guide for the data collection and analysis. The research design fits an exploratory-descriptive study

- Minor phrase correction Table 2: Themes and subthemes from the infertile couples; Subthemes – need to be numbered.

-In the data analysis, how were the themes and subthemes generated noting that a model was used for the research? How was the Social Ecological Model (SEM) used as the organizing framework for the research noting that study themes are largely predetermined when models/frameworks are used in research; it is unclear how the constructs of the existing model guided the development of the current themes/subthemes which are different from the constructs of the model.

- Explanatory/analytic statement have been provided for some quotes but not all; these transition statements need to be provided between participant quotes before moving on to other themes and subthemes and subsequent headings.

-Study limitations - Explain measures to address language translation implications on the findings of the study, its inherent dynamics, how it influences participants' narratives and the meanings of the text. It is important to note potentially lost meanings of the translated text since the interviews were conducted in the local language and translated into the English language. Within the Ghanaian local language, there are words or phrases or expressions that do not have its direct translations into English.

- Minor sentence correction - The authors express appreciation to the management of the study health facilities and the study participants shared who their perspectives with us.

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Reviewer #1: No

Reviewer #2: No

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Attachments

Attachment

Submitted filename: Reviewer Comments - Manuscript Number PONE-D-23-28365.pdf

PONE-D-23-28365R1Exploring the psycho-social burden of infertility: Perspectives of infertile couples in Cape Coast, GhanaPLOS ONE

Dear Dr. Abdoul Azize,

Thank you for submitting your manuscript to PLOS ONE. After the second round of reviews, Reviewer 1 has recommended important minor revisions before this manuscript can be taken forward. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

The reviewer raises an important point about the differences in adverse psychological reactions based on ability to afford treatment or otherwise. This is important to reflect on and discuss.

Please submit your revised manuscript by Jan 26 2024 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

• A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
• A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
• An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols. Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols.

We look forward to receiving your revised manuscript.

Kind regards,

Lily Kpobi, Ph.D.

Academic Editor

PLOS ONE

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Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: (No Response)

Reviewer #3: All comments have been addressed

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2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #3: Yes

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3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: N/A

Reviewer #3: Yes

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4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #3: Yes

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5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #3: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: My only comment is on the edited text on page 19, paragraph 2, about participants being infertile couples who were actively seeking treatment. I think that couples who have resigned to fate might have less adverse psychological impact than the ones seeking treatment, however the blocker to treatment access could also be financial. Couples that cannot afford to pay for the treatment could have a more severe psychological impact than the ones able to pay for it. I suggest the authors add this potential option too.

There is typo on page 20, 2nd paragraph, edited text - “cooing strategy” should be “coping strategy”.

The authors addressed all my other comments in a satisfactory manner.

Reviewer #3: Thank you for the opportunity to review this paper on the important subject of infertility in Ghana.

Thank you for your responses to the comments made by the reviewers.

Congratulations!

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7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

Reviewer #3: Yes: Timothy Tienbia Laari

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[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

Exploring the psycho-social burden of infertility: Perspectives of infertile couples in Cape Coast, Ghana

PONE-D-23-28365R2

Dear Dr. Abdoul Azize,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

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Kind regards,

Lily Kpobi, Ph.D.

Academic Editor

PLOS ONE