Dear Dr. Liyanage,

Thank you very much for submitting your manuscript "Utilisation of Government Healthcare Services by Adult Leprosy Patients in the Western 

Province, Sri Lanka" for consideration at PLOS Neglected Tropical Diseases. As with all papers reviewed by the journal, your manuscript was reviewed by members of the editorial board and by several independent reviewers. The reviewers appreciated the attention to an important topic. Based on the reviews, we are likely to accept this manuscript for publication, providing that you modify the manuscript according to the review recommendations.

Please prepare and submit your revised manuscript within 30 days. If you anticipate any delay, please let us know the expected resubmission date by replying to this email.  

When you are ready to resubmit, please upload the following:

[1] A letter containing a detailed list of your responses to all review comments, and a description of the changes you have made in the manuscript. 

Please note while forming your response, if your article is accepted, you may have the opportunity to make the peer review history publicly available. The record will include editor decision letters (with reviews) and your responses to reviewer comments. If eligible, we will contact you to opt in or out

[2] Two versions of the revised manuscript: one with either highlights or tracked changes denoting where the text has been changed; the other a clean version (uploaded as the manuscript file).

Important additional instructions are given below your reviewer comments.

Thank you again for your submission to our journal. We hope that our editorial process has been constructive so far, and we welcome your feedback at any time. Please don't hesitate to contact us if you have any questions or comments.

Sincerely,

Linda B Adams

Associate Editor

PLOS Neglected Tropical Diseases

Gerson Penna

Deputy Editor

PLOS Neglected Tropical Diseases

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Reviewer's Responses to Questions

Key Review Criteria Required for Acceptance?

As you describe the new analyses required for acceptance, please consider the following:

Methods

-Are the objectives of the study clearly articulated with a clear testable hypothesis stated?

-Is the study design appropriate to address the stated objectives?

-Is the population clearly described and appropriate for the hypothesis being tested?

-Is the sample size sufficient to ensure adequate power to address the hypothesis being tested?

-Were correct statistical analysis used to support conclusions?

-Are there concerns about ethical or regulatory requirements being met?

Reviewer #1: This study covers an important area in diagnosis of leprosy, namely the delay in diagnosis of leprosy. since delay in diagnosis can directly affect subsequent disability in leprosy the study is of importance and relevance to NTD s.

Reviewer #2: The authors clearly state their primary objective to determine the utilization of leprosy health services by patients. However, they do not discuss their secondary objective of testing patient's leprosy knowledge until the methods section. The authors should discuss both objectives in the abstract and introduction sections and especially discuss the role that general knowledge or lack of knowledge about leprosy may play in impacting the accessibility of health services. The authors describe the study population adequately although it is slightly unclear about the role of the clinic's leprosy register in patient recruitment. Otherwise, the study design, sample size, and analyses were well done and properly addressed the objectives.

Reviewer #3: Yes

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Results

-Does the analysis presented match the analysis plan?

-Are the results clearly and completely presented?

-Are the figures (Tables, Images) of sufficient quality for clarity?

Reviewer #1: results are in keeping with he analysis plan. The results are clearly mentioned. I have requested one clarification of a statement.

Reviewer #2: Analyses and the results were explained thoroughly. All of the tables were well designed and easy to understand and interpret. Only correction in the Results was that at several points the authors refer to a "Type 11" reaction, which is confusing. I would recommend correcting that to be "Type 2" to improve clarity.

Reviewer #3: Yes

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Conclusions

-Are the conclusions supported by the data presented?

-Are the limitations of analysis clearly described?

-Do the authors discuss how these data can be helpful to advance our understanding of the topic under study?

-Is public health relevance addressed?

Reviewer #1: the conclusions are clearly mentioned and supported by the data presented.

Reviewer #2: The conclusions presented are supported by the data presented, however the authors need to further expand on the significance of these conclusions both for Sri Lanka and for the global leprosy field. Additionally, while the authors offer informative comparisons of their results to the results of studies conducted in other countries, they do not discuss any limitations of their own study.

Reviewer #3: Yes

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Editorial and Data Presentation Modifications?

Use this section for editorial suggestions as well as relatively minor modifications of existing data that would enhance clarity. If the only modifications needed are minor and/or editorial, you may wish to recommend “Minor Revision” or “Accept”.

Reviewer #1: the Author summary was not clearly presented. I have taken the liberty to make some modifications. The modified version is attached.

Reviewer #2: There are a few minor grammatical errors throughout the manuscript. Additionally, the second half of the author summary is a little awkward. I understand what the authors are trying to say, but I think a few sentences could be reworded to improve clarity.

Reviewer #3: (No Response)

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Summary and General Comments

Use this section to provide overall comments, discuss strengths/weaknesses of the study, novelty, significance, general execution and scholarship. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. If requesting major revision, please articulate the new experiments that are needed.

Reviewer #1: The study is of relevance since delay in diagnosis of leprosy is of importance to all endemic countries.

Reviewer #2: Overall, this is a well-written manuscript of an interesting cross-sectional study of healthcare utilization by leprosy patients in the Western Province of Sri Lanka. The results are interesting, and the study was thoroughly conducted. However, I felt that the authors needed to expand on their discussion of how these results affect both Sri Lanka and the field of leprosy research. The authors started to do this with an interesting comparison of their results to other similar studies conducted in other countries. However, they did not discuss why their results were better or worse than those seen elsewhere. For instance, what programs or healthcare factors affect these outcomes? More discussion on these factors could really help to show why their results are relevant both in Sri Lanka and also globally.

Reviewer #3: (No Response)

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Reviewer #1: No

Reviewer #2: No

Reviewer #3: Yes: Srinivas G

Figure 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. 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 us at figures@plos.org.

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Reproducibility:

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Attachments

Attachment

Submitted filename: PLOS review.docx

Attachment

Submitted filename: Review of Liyanage, N. 2020 manuscript.pdf

Dear Dr. Liyanage,

We are pleased to inform you that your manuscript 'Utilization of Government Healthcare Services by Adult Leprosy Patients in the Western Province, Sri Lanka' has been provisionally accepted for publication in PLOS Neglected Tropical Diseases.

Before your manuscript can be formally accepted you will need to complete some formatting changes, which you will receive in a follow up email. A member of our team will be in touch with a set of requests.

Please note that your manuscript will not be scheduled for publication until you have made the required changes, so a swift response is appreciated.

IMPORTANT: The editorial review process is now complete. PLOS will only permit corrections to spelling, formatting or significant scientific errors from this point onwards. Requests for major changes, or any which affect the scientific understanding of your work, will cause delays to the publication date of your manuscript.

Should you, your institution's press office or the journal office choose to press release your paper, you will automatically be opted out of early publication. We ask that you notify us now if you or your institution is planning to press release the article. All press must be co-ordinated with PLOS.

Thank you again for supporting Open Access publishing; we are looking forward to publishing your work in PLOS Neglected Tropical Diseases.

Best regards,

Linda B Adams

Associate Editor

PLOS Neglected Tropical Diseases

Gerson Penna

Deputy Editor

PLOS Neglected Tropical Diseases

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