Burden and resources in caregivers of people with multiple sclerosis: A qualitative study

Stefano Benini; Erika Pellegrini; Carlo Descovich; Alessandra Lugaresi

doi:10.1371/journal.pone.0265297

Peer Review History

Original SubmissionFebruary 27, 2022
26 May 2022 Decision Letter - Sander L. Hitzig, Editor PONE-D-22-05892BURDEN AND RESOURCES IN CAREGIVERS OF PEOPLE WITH MULTIPLE SCLEROSIS: A QUALITATIVE STUDYPLOS ONE Dear Dr. Lugaresi, 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. Both reviewers viewed the merits of your manuscript but they indicated a need for some more details regarding your methodological approach. As well, Reviewer #2 felt there was a need for some more critical reflection regarding your themes. Please also review the manuscript submission guidelines if you decide to re-submit your paper (e.g., please ensure your submission is double-spaced). Please submit your revised manuscript by Jul 10 2022 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'. 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Hitzig Academic Editor PLOS ONE Journal Requirements: When submitting your revision, we need you to address these additional requirements. 1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf 2. We note that you have stated that you will provide repository information for your data at acceptance. Should your manuscript be accepted for publication, we will hold it until you provide the relevant accession numbers or DOIs necessary to access your data. If you wish to make changes to your Data Availability statement, please describe these changes in your cover letter and we will update your Data Availability statement to reflect the information you provide [Note: HTML markup is below. Please do not edit.] 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: Partly ******** 2. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: N/A Reviewer #2: N/A ****** 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: No Reviewer #2: Yes ****** 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 ****** 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 paper is readable and clear. Thanks for the opportunity of reading about this topic!I want to thank the authors for this exciting work. However, some points should be considered to revise the manuscript. Methods: We invite the authors to justify their decision of methodology in further detail. Numerous other methodologies have been used in caregiver research and thus your justification is not suitable. The implications of this approach are warranted. What does 'All protocol requirements have been formulated with respect for data confidentiality and 34 confidentiality required by the applicable regulatory regulations." mean? The analysis section needs more detail. Results Why are these presented as bullet points? A more throughout thematic analysis of the burden of assistance and the effect of the effort is needed. Overall: I think a review for colloquial language should be conducted Reviewer #2: This is an interesting topic focusing on the burden of caregiving and exploring further what that burden might look like. There is also a brief evaluation of the MS clinical pathway and the local support group. At the moment, the rationale for the study could be stronger in relation to the gap in the literature and also the positioning of the study in relation to the evaluation context – is this really an evaluation of the MS clinical pathway? If it is then there needs to be a much closer tie between the facets of burden identified and the ways in which the MS clinical pathway does/does not meet those needs currently (maybe a table would help here?) Introduction • The rational needs to be clearer. Old studies are cited but what has significantly changed in the past 20 years that suggests that an update is necessary – I agree it might be the context needs to be made explicit. • If this is going to include an evaluation of the MS clinical pathway then we need to hear more about it – we need some context about what it is/its aims etc • What is meant in this context by ‘resources’ - groups, family and fiends, online information etc? This should be described further with relevant literature on what we already know about these resources included. Method • Justify excluding early stage caregivers • What does AUSL stand for? • What is the survey – do you mean the interview schedule? • It would be useful to have more information around the interview schedule and some example questions? Did these vary for the focus groups? • How many focus groups were there? • Describe the characteristics of the caregivers (the participants) first before describing the pwMS and refer to table 1 in the text. • What does EDSS stand for? • More information on the analysis is required -how was this conducted, which authors were involved? Results and discussion • The themes mentioned in the opening paragraph of the results section do not match the themes presented beneath. Different number (4 then 6) in a different order and with different names. This needs to be reviewed. • The first theme is interesting and speaks to the complexity of ‘burden’ but it feels a little rushed and under explored here. Can you use longer, richer quotes? • Quotes need to be attributed to P1, P2 etc. • Some themes are very descriptive in nature and are list like in places and some contain very few or no quotes to support the interpretation. • Overall, this section feels unbalanced. The first theme feels like a theme with a lot of potential for really exploring the different facets of burden, the other themes feel either very light weight with few supporting quotes or more like a straightforward evaluation of the service. I think the paper needs to emphasise either the themes of burden further or at least find a way to tie together the burden and the current resources/support of the service to bring the findings together and identify key gaps for service provision and for future research. This could be achieved in the results and also carried through into the discussion. ****** 6. 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 #2: No [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. https://doi.org/10.1371/journal.pone.0265297.r001
Revision 1
5 Jan 2023 Author Response RESPONSE TO REVIEWERS Reviewers' comments: Reviewer's Responses to Questions Comments to the Author Reviewer #1: The paper is readable and clear. Thanks for the opportunity of reading about this topic! I want to thank the authors for this exciting work. However, some points should be considered to revise the manuscript. Methods: We invite the authors to justify their decision of methodology in further detail. Numerous other methodologies have been used in caregiver research and thus your justification is not suitable. The implications of this approach are warranted. We thank the reviewer for the request. We have better explaind our chice in the methods section What does 'All protocol requirements have been formulated with respect for data confidentiality and 34 confidentiality required by the applicable regulatory regulations." mean? We thank the reviewer for highlighting the need to clarify this point. We have rewritten the sentence more concisely and clearly. We intended to certify that all regulations on data protection had been thoroughly applied. The analysis section needs more detail. The study is a qualitative work. We have now added more details about the analytical method, adding a sentence at the end of this section: “…The research team used several strategies to ensure the accuracy of the findings. The analytic team met regularly throughout the iterative process of data analysis to reflect on ways individual values, experiences, or preconceptions might influence or create bias in interpretations of the data may have informed perceptions of participant statements and emerging themes. In addition, the analytic team wrote memos throughout the data analysis, noting observations and reactions to the interview responses. Finally, the last author (AL), who had not previously participated in data analysis, conducted an independent review of the findings and coding documents to assess the trustworthiness of the analysis.” Results Why are these presented as bullet points? A more throughout thematic analysis of the burden of assistance and the effect of the effort is needed. Rather than bullet points it was a sequence of the 6 identified relevant themes analyzed from the transcripts of the interviews and focus group. We have maintained, therefore, the division into the main themes emerged from interviews and for each we have tried to extract and cite verbatim meaningful parts of the interviews. We have also tried to deepen the considerations about the meaning of the different issues raised by caregivers as requested. Overall: I think a review for colloquial language should be conducted We thank reviewer #1 for highlighting this point. We have revised language accordingly, and we hope this will satisfy reviewers and editor. However colloquial expressions have been maintained in excerpts from interviews. Reviewer #2: This is an interesting topic focusing on the burden of caregiving and exploring further what that burden might look like. There is also a brief evaluation of the MS clinical pathway and the local support group. At the moment, the rationale for the study could be stronger in relation to the gap in the literature and also the positioning of the study in relation to the evaluation context – is this really an evaluation of the MS clinical pathway? If it is then there needs to be a much closer tie between the facets of burden identified and the ways in which the MS clinical pathway does/does not meet those needs currently (maybe a table would help here?) We thank the reviewer for raising the issue of the evaluation of the clinical pathway. After thorough consideration we have opted for not evaluating the CPW, only mentioning some issues raised by caregivers. We have amended the manuscript eliminating point b from the last paragraph of the introduction. • The rational needs to be clearer. Old studies are cited but what has significantly changed in the past 20 years that suggests that an update is necessary – I agree it might be the context needs to be made explicit. We thank the reviewer for this comment. We have updated the literature and hope to have better clarified the rationale. • If this is going to include an evaluation of the MS clinical pathway then we need to hear more about it – we need some context about what it is/its aims etc As stated above we have decided to limit the study to cargivers observations. A further study, in the future, might be dedicated to a formal evaluation of changes needed to improve the efficacy of the CPW and improve caregivers satisfaction. A yearly monitoring and revision of the CPW is performed in this respect • What is meant in this context by ‘resources’ - groups, family and friends, online information etc? This should be described further with relevant literature on what we already know about these resources included. We have added a sentence in the methods section: b) assess which resources the carers rely on to manage the burden of care. These include: psychological help, emotional resources; relationship (family, friends or groups); support system resources, financial resources etc. Method • Justify excluding early stage caregivers We thank the reviewer for raising this point. In MS caregivers are not needed in the early stages of Multiple Sclerosis, where the patient may have subtle impairment of some functions, but usually does not need a caregiver. Thus we did not exclude caregivers of people in the early stages of the disease, who were very few, if any. We have concentrated our attention on PwMS at stages where impairment and disability are more pronounced and require a caregiver • What does AUSL stand for? We thank the reviewer for asking. This is the acronym for Azienda Unica Sanitaria Locale, which identifies the Local Health Authority of Bologna, responsible for Healthcare provision in the area of Bologna, in the Emilia Romagna Region, in Italy. • What is the survey – do you mean the interview schedule? We thank the reviewer for suggesting a more precise wording. • It would be useful to have more information around the interview schedule and some example questions? Did these vary for the focus groups? We thank the reviewer for asking for more information. We have added the required information in the manuscript. In particular the same questions were asked both in interviews and in the single focus group • How many focus groups were there? We thank the reviewer for asking. We held a single focus group, due to the small number of subjects included in the study and willing to participate to a focus group. People unable or unwilling to attend the focus group were individually interviewed • Describe the characteristics of the caregivers (the participants) first before describing the pwMS and refer to table 1 in the text. We thank the reviewer for noticing that table 1 was unlinked. We have now amended this imprecision and modified the order of presentation of caregiver and patient characteristics according to the reviewer suggestions. • What does EDSS stand for? We apologize for the use of a technical acronym without explaining first its meaning The EDSS is the Expanded Disability Status Score, a scale used to assess impairment (below 4) or disability (4 or higher). The score derives from the scores in 7 different “functional systems”: pyramidal, sensory, brainstem, cerebellar, visual, mental, bowel and bladder. It’s not arithmetical, 0 stands for normal neurological examination, 10 for death due to MS. In between relevant scores for this study: 6 stands for needing a stick, 7 needing a wheelchair (Kurtzke, 1983: Kurtzke JF. Rating neurologic impairment in multiple sclerosis: an expanded disability status scale (EDSS). Neurology. 1983 Nov;33(11):1444-52. doi: 10.1212/wnl.33.11.1444. PMID: 6685237). • More information on the analysis is required -how was this conducted, which authors were involved? Authors involved in interviews and the focus group were SB and EP. CD provided critical methodological supervision and AL discussed the results with the other co-authors and revised the draft. Details have now been reported in the last paragraph of the analysis section. Results and discussion • The themes mentioned in the opening paragraph of the results section do not match the themes presented beneath. Different number (4 then 6) in a different order and with different names. This needs to be reviewed. We thank the reviewer for noticing the discrepancies between the methods section and the results section. We have revised the text accordingly • The first theme is interesting and speaks to the complexity of ‘burden’ but it feels a little rushed and under explored here. Can you use longer, richer quotes? Thank you for asking longer quotes, we had omitted for brevity. We have now widened the quotations • Quotes need to be attributed to P1, P2 etc. We have now attributed quotes to individual caregivers, in the table called PARTICIPANTS, therefore in brief P (P01 to P17) • Some themes are very descriptive in nature and are list like in places and some contain very few or no quotes to support the interpretation. We have increased quotations in order to provide a better support for themes identified • Overall, this section feels unbalanced. The first theme feels like a theme with a lot of potential for really exploring the different facets of burden, the other themes feel either very light weight with few supporting quotes or more like a straightforward evaluation of the service. I think the paper needs to emphasise either the themes of burden further or at least find a way to tie together the burden and the current resources/support of the service to bring the findings together and identify key gaps for service provision and for future research. This could be achieved in the results and also carried through into the discussion. This is a very relevant observation. We hope the revised version of the results and discussion sections will be found satisfactory 6. 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 #2: No [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. Attachments Attachment Submitted filename: 221229 PONE-D-22-05892 RESPONSE TO REVIEWERS (3).docx https://doi.org/10.1371/journal.pone.0265297.r002
6 Mar 2023 Decision Letter - Habil Otanga, Editor PONE-D-22-05892R1BURDEN AND RESOURCES IN CAREGIVERS OF PEOPLE WITH MULTIPLE SCLEROSIS: A QUALITATIVE STUDYPLOS ONE Dear Dr. Alessandra Lugaresi, 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. ============================== 1. Clearly provide details of the Ethical Review Board the protocol was submitted to 2. Check journal requirements for labelling tables 3. Remove bullet points in discussing 'Theme a' 4. Change the word to 'Limitations' on p13 5. Define the appropriate referencing style in line with journal requirements and ensure consistency. Each reference is presented differently from the next.============================== Please submit your revised manuscript by Apr 20 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. 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, Habil Otanga, Ph.D Academic Editor PLOS ONE Journal Requirements: 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. Additional Editor Comments (if provided): 1. Clearly provide details of the Ethical Review Board the protocol was submitted to 2. Check journal requirements for labelling tables 3. Remove bullet points in discussing 'Theme a' 4. Change the word to 'Limitations' on p13 5. Define the appropriate referencing style in line with journal requirements and ensure consistency. Each reference is presented differently from the next. [Note: HTML markup is below. Please do not edit.] 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 #2: All comments have been addressed Reviewer #3: (No Response) ******** 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 #2: Yes Reviewer #3: Yes ****** 3. Has the statistical analysis been performed appropriately and rigorously? Reviewer #2: N/A Reviewer #3: Yes ****** 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 #2: Yes Reviewer #3: Yes ****** 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 #2: 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 #2: (No Response) Reviewer #3: 1. Ethical considerations: Clearly provide details of where the protocol was submitted for review (and found that no authorization was necessary) 2. Check journal rules concerning labelling tables 3. Results: Present findings of 'Theme a' without bullet points. 4. Change the word to 'Limitations' on p13 5. References: Define the referencing style and ensure consistency. Each reference is presented differently from the next. ****** 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 #2: No Reviewer #3: No ******** [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. https://doi.org/10.1371/journal.pone.0265297.r003
Revision 2
26 Mar 2023 Author Response PONE-D-22-05892R1 BURDEN AND RESOURCES IN CAREGIVERS OF PEOPLE WITH MULTIPLE SCLEROSIS: A QUALITATIVE STUDY PLOS ONE Point-by-point response 1. Clearly provide details of the Ethical Review Board the protocol was submitted to We have added in the text what was already attached to the submission: the local ethics committee is the Comitato Etico di Area Vasta Emilia Centro della Regione Emilia-Romagna (CE-AVEC), and was active since 10/1/2018. As stated in Italian, there is no need to submit to the ethics committee, as no personal details have been provided 2. Check journal requirements for labelling tables We have adhered to journal requirements (Caption above the table). We apologize for not noticing earlier. 3. Remove bullet points in discussing 'Theme a' We have removed the bullet points, numbering in the text the 6 issues 4. Change the word to 'Limitations' on p13 We have changed limits to LIMITATIONS, as required 5. Define the appropriate referencing style in line with journal requirements and ensure consistency. Each reference is presented differently from the next. We apologize for the imprecisions. References have been revised to be in line with journal requirements In addition we have corrected some typos we picked in re-reading the manuscript. ============================== Journal Requirements: 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. We have not cited papers which have been retracted. A few are not on PubMed, but have a DOI, which we have used to enable readers to easily find the right article or chapter in a book (they are open access). Additional Editor Comments (if provided): 1. Clearly provide details of the Ethical Review Board the protocol was submitted to 2. Check journal requirements for labelling tables 3. Remove bullet points in discussing 'Theme a' 4. Change the word to 'Limitations' on p13 5. Define the appropriate referencing style in line with journal requirements and ensure consistency. Each reference is presented differently from the next. See above Attachments Attachment Submitted filename: PONE-D-22-05892R2 RESPONSE TO REVIEWERS.docx https://doi.org/10.1371/journal.pone.0265297.r004
27 Mar 2023 Decision Letter - Habil Otanga, Editor BURDEN AND RESOURCES IN CAREGIVERS OF PEOPLE WITH MULTIPLE SCLEROSIS: A QUALITATIVE STUDY PONE-D-22-05892R2 Dear Dr. Alessandra Lugaresi, 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. An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org. If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org. Kind regards, Habil Otanga, Ph.D Academic Editor PLOS ONE Additional Editor Comments (optional): Reviewers' comments: https://doi.org/10.1371/journal.pone.0265297.r005
Formally Accepted
6 Apr 2023 Acceptance Letter - Habil Otanga, Editor PONE-D-22-05892R2 Burden and resources in caregivers of people with multiple sclerosis: a qualitative study Dear Dr. Lugaresi: I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department. If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org. If we can help with anything else, please email us at plosone@plos.org. Thank you for submitting your work to PLOS ONE and supporting open access. Kind regards, PLOS ONE Editorial Office Staff on behalf of Dr. Habil Otanga Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0265297.r006

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