PONE-D-21-29483Health needs, behavioural characteristics and health care utilization among elderly residing on urban areas of eastern Nepal. A cross sectional studyPLOS ONE

Dear Dr. Poudel,

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.

Kindly address the comments and concerns put forward by reviewers one and two. Also consider strengthening the statistical analysis by including a regression model as suggested by the reviewers. 

Please submit your revised manuscript by Dec 26 2021 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,

Pranil Man Singh Pradhan, M.D.

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. Please include additional information regarding the survey or questionnaire used in the study and ensure that you have provided sufficient details that others could replicate the analyses. For instance, if you developed a questionnaire as part of this study and it is not under a copyright more restrictive than CC-BY, please include a copy, in both the original language and English, as Supporting Information.

3. In your Data Availability statement, you have not specified where the minimal data set underlying the results described in your manuscript can be found. PLOS defines a study's minimal data set as the underlying data used to reach the conclusions drawn in the manuscript and any additional data required to replicate the reported study findings in their entirety. All PLOS journals require that the minimal data set be made fully available. For more information about our data policy, please see http://journals.plos.org/plosone/s/data-availability.

Upon re-submitting your revised manuscript, please upload your study’s minimal underlying data set as either Supporting Information files or to a stable, public repository and include the relevant URLs, DOIs, or accession numbers within your revised cover letter. For a list of acceptable repositories, please see http://journals.plos.org/plosone/s/data-availability#loc-recommended-repositories. Any potentially identifying patient information must be fully anonymized.

Important: If there are ethical or legal restrictions to sharing your data publicly, please explain these restrictions in detail. Please see our guidelines for more information on what we consider unacceptable restrictions to publicly sharing data: http://journals.plos.org/plosone/s/data-availability#loc-unacceptable-data-access-restrictions. Note that it is not acceptable for the authors to be the sole named individuals responsible for ensuring data access.

We will update your Data Availability statement to reflect the information you provide in your cover letter.

4. We noted in your submission details that a portion of your manuscript may have been presented or published elsewhere. [DETAILS AS NEEDED] Please clarify whether this [conference proceeding or publication] was peer-reviewed and formally published. If this work was previously peer-reviewed and published, in the cover letter please provide the reason that this work does not constitute dual publication and should be included in the current manuscript.

[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: Partly

Reviewer #2: Yes

**********

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

Reviewer #1: No

Reviewer #2: Yes

**********

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

**********

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: No

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: Dear authors,

Thank you for addressing an important issue concerning the older population in Nepal. Although the topic is important, it is not novel. It is not clear what is new in comparison to similar studies conducted in Nepal in the past. You may also consider conducting multivariate logistic/linear regression or other higher analysis (as appropriate) as this study only has descriptive data. Higher analyses will also make your study stronger. Please find my detailed comments below.

Line 57: What are the challenges and additional demands?

Lines 60-63: It is not clear what the unmet needs were and the purpose/objective of follow-up.

Line 96: Numbers less than ten should be spelled out in academic writing

Line 122: Check the spelling of “than” or “then”. “the complaints and findings were then….”

Line 166: Check spellings

Lines 165-169: Logistic regression is missing in the result section.

Proteinuria as a variable is not mentioned in the methods section.

Line 236: The term “developing country” may not be appropriate. The authors may consider using another term and also instead of using “like ours”, it is preferable to use “like/such as Nepal”.

Lines 235-239: The first paragraph of the discussion should mention the major findings of the study.

Discussion: Do not repeat sentences from the result section in discussion.

Discussion of major findings is lacking in general.

The conclusion section is weak and can be improved.

Academic writing:

1. Avoid use of unnecessary capitalizations

2. Use past tense to report methods and results

3. Use hyphenation where necessary (e.g.: face-to-face)

4. Inconsistent use of percentage (example: 53%, 27. 2%, 56.9% etc.)

5. Inconsistent use of the Oxford comma before “and”.

6. Commas missing in many sentences.

7. Check spellings

8. Inconsistent use of the words “aging” and “ageing”; “elderly” and “older people”. Use the same term throughout the text.

9. Recheck the text. The flow of paragraphs can be improved.

Hope the suggestions are useful. Best wishes.

Reviewer #2: � The topic is interesting and explores an important area of public health research. The article is good. However, there are some changes that need to made to make the article even better.

Overall Suggestions:

o There are minor errors in grammar/language. Please kindly proofread the article.

o Also some rearranging and adding of text may be necessary.

o Please make sure that the numbers in tables are correct. Details are in my comments below.

� Title page:

o Line 10: Please use the correct spelling of ‘Hetauda’

� Abstract:

o Line 50: Keywords not in alphabetical order

� Materials and Methods:

o Line 86: What do you mean by structured interview? You have mentioned that the questionnaire itself is semi-structured. Do you mean face to face interview?

o Line 102: Please explain how this was a stratified proportionate random sampling? Did you have a sampling frame? If yes, please mention it.

o Line 134: The term elderly is defined here. As this study is about elderly people, it should be moved it up in the text so that reader can understand the context

o Line 165: Please specify which version of SPSS was used

o 167-169: Where are the results of multivariate analysis? Where is the Chi-square test used?

� Results

o Line 182: In Table 1: for Age distribution, the percentage does not sum up to 100.0%. Please correct it.

o Line 184-186: Not clear what the author wants to say and may be confusing for the readers. Please re-write to bring clarity.

o Line 200-203: How did you assess the blood pressure at the time of visit? Did you measure the blood pressure yourselves? It is not mentioned in the methodology or tools used.

o Line 209: Measurement of proteinuria by the researcher and the tools used for this process is not mentioned in the methodology.

� What you are trying to present as health needs is not clearly depicted in the results and discussion section.

� References:

o Some of the references are not according to the journal guidelines. Please make required changes.

**********

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.

PONE-D-21-29483R1Morbidities, health problems, health care seeking and utilization behaviour among elderly residing on urban areas of eastern Nepal: a cross-sectional studyPLOS ONE

Dear Dr. Poudel,

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.

Please submit your revised manuscript by Jul 28 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'.

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,

Pranil Man Singh Pradhan, M.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):

Please address the minor comments provided by the reviewers.

[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: Partly

**********

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

Reviewer #2: Yes

Reviewer #3: I Don't Know

**********

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: The authors have done a good job in addressing all the comments. After the revision, the quality of the article has been enhanced.

Reviewer #3: Dear Authors,

The article is very well written and the enormous effort undertaken during the study design, data analysis and writing of the manuscript is greatly appreciated. Indeed, the issues of elderly is an important issue and in developing countries like Nepal, more such research and articles are appreciated.

There are few comments which might help in making the manuscript better.

General Writing: The article is well written but at some places, reorganization of the writing for a better flow can be considered (details in ‘review comment’ section). Minor grammar/punctuation/scientific writing errors are there like:

Line 26 (abstract) inconsistent use of hyphenation in ‘health care seeking’

Line 216 ‘6’ to be written as six

Line 276 comma missing.

Yes, the manuscript is well written. However, the data shared is coded and codes for limited variables are given so reviewer is unable to decide with full confidence. Eg GD column in data sheet reads as ‘multimorbidity’ which has 271 rows coded as 1 (51.13%). Reviewer cannot be sure what this implies. Most of the conclusions seem possible when the questionnaire is reviewed.

Line 99 Sampling method has been explained and eight wards have been selected as per the manuscript but data sheet shows missing data in 45 participants and there are 9 wards in one of the cities i.e. Dharan (if the number allotted after Dharan is the ward no in the data sheet). More clarity would be there if authors showed the number in sampling frame and ward wise population as reviewer believes this is a great strength of this article.

Line 112-116 Calculation of sample size: The formula used one proportion sample size seems fine, but in the stated formula, I am not sure where the power (85%) is used. The rationale for choosing prevalence of unmet health care needs in people suffering with ‘hypertension’ along with the full calculation would clarify readers.

Line 118 onwards in “variables studied’’ there is inconsistent writing style with some of the variables being described in paragraph and some with heading.

Line 119 The questionnaire is ‘pre-tested’. Elaborating the pre-testing technique would strengthen the article as the questionnaire shared is in great detail with translation to local language. This work is not reflected in the manuscript.

Line 134-136 BDI II scale used for depression but the result of this has not been expressed in ‘Results’ section. If authors are not publishing this, maybe they can omit from methods section too. It also raises a question why only ‘depression’ was assessed and not other mental health issues.

Line 140-141 ICPC is used for health problems which is a standard in itself so the sentence following it with Ref 30 seems only to add to the authors long list of references (study among inmates vs study of elderly)

Line 149 Reference for this variable (if provided) would be good.

Table 3

Mentions “Pention camp’’, the terminology might not be clear to many people so elaboration below table on what kind of ‘health facility’ would add to clarity.

In ‘Last visit to any health facility’, one of the options reads as ‘Never’ with 47 responders choosing it. Does it mean in their 60 years, they never visited a health facility?

Discussion Section:

Overall slightly weak. Authors have compared their findings with other researches but they have not explained why the variations are there. Eg for HTN, eye (66.2 vs 19.1), dental issues etc

Line 257 The article including the title of the article refers the study setting as urban eastern Nepal, while in this line the article claims to represent whole Nepal in terms of culture, ethnicity, religion, education, socioeconomic status, lifestyle which seems contradictory in itself.

Flow of article in chronic morbidities section needs to be worked out. Eg

Line 271-275 Manuscript is describing articles

Line 276-277 Manuscript gives a broad comment

Line 277 onwards manuscript starts to describe individual articles

When discussing, it is better to discuss one variable and then start others, broad statements are better at beginning of discussion to start a variable discussion or the end.

Line 277 The prevalence of HTN is 34% in this study. The manuscript reports a ‘similar’ range of 27-57% in other studies. Maybe the authors should reconsider the term ‘similar’ considering the expressed range.

References in discussion section is missing. Eg Line 280, Line 291, Line 303. It gives more clarity to readers if reference is given immediately after a particular article is discussed and not at the end of the paragraph. Author is advised to check this throughout the discussion section.

References:

One Ref 37 is of the year 2022 while most others are relatively not recent so maybe the author can add more recent articles in discussion section while revising the manuscript. Author has 56 references; some references might need reconsideration for citation as stated above.

**********

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.

Morbidities, health problems, health care seeking and utilization behaviour among elderly residing on urban areas of eastern Nepal: a cross-sectional study

PONE-D-21-29483R2

Dear Dr. Poudel,

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,

Pranil Man Singh Pradhan, M.D.

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments: