Barriers and facilitators for adopting a healthy lifestyle in a multi-ethnic population: A qualitative study

Mythily Subramaniam; Fiona Devi; P. V. AshaRani; Yunjue Zhang; Peizhi Wang; Anitha Jeyagurunathan; Kumarasan Roystonn; Janhavi Ajit Vaingankar; Siow Ann Chong

doi:10.1371/journal.pone.0277106

Peer Review History

Original SubmissionMay 5, 2022
1 Aug 2022 Decision Letter - Eliana Carraça, Editor PONE-D-22-13181Barriers and Facilitators for adopting a healthy lifestyle in a multi-ethnic population: A qualitative studyPLOS ONE Dear Dr. Mythily Subramaniam, 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. ============================== ACADEMIC EDITOR: The topic of this paper is of interest to the Plos One scientific community. Adherence to healthy lifestyle behaviours remains a challenge, thus exploring which factors might facilitate or hinder the adoption of these behaviours is critical to improve intervention’s design and efficacy. Still, the current paper does not show the novelty of this study. This should be made totally clear in all sections of the paper, but most importantly in the introduction and discussion sections. Authors are also advised to be more specific and support all affirmations in the literature. The methodology should be clearer, especially regarding the process of development of the instrument and how the framework analysis was conducted. The impact of COVID on recruitment and on this study should be discussed, as these results could be different in a normal, non-COVID, situation. Being the first study on the Singapore population, this should be interpreted with caution and unlikely generalisable. Therefore, avoid using terms that imply that your findings are comprehensive and generalisable to all Singapore population within the same age range. Grammatical errors should be carefully revised. The authors should pay close attention to the reviewers’ comments, carefully addressing all of them. ============================== Please submit your revised manuscript by Sep 15 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'. 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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. [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: Yes ******** 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: Yes Reviewer #2: No ****** 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: This paper provides interesting insight into the barriers and facilitators to adopting healthy lifestyles among adults in Singapore. The paper is clear and well written and I appreciate the inclusion of the interview guide. I would suggest the following revisions to improve the manuscript: 1) As the authors note, many studies have been published describing barriers and facilitators to healthy lifestyle practices. While this study is novel in its focus on Singapore, the results do not seem to differ much at all from the large body of work on this topic. It would be useful in the discussion to frame how the findings of this study compare to other similar studies. Are there barriers and facilitators specific to adults in Singapore that could be targeting in a healthy lifestyle intervention? 2) Authors make the claim that this study provides a "comprehensive" understanding of barriers and facilitators (pg 5). I am not sure this claim can be made with a fairly small sample (n=30). The paper can still bring forward important findings without being comprehensive. 3) Pg 8: spell out "SSI" on first use 4) Pg 8, table 1: Given the important of education level and adoption of healthy lifestyle habits (as the authors mention in the introduction), it's surprising that education is not included in the demographics. It would also be interesting to see how barriers and facilitators differed among those with varying levels of education. 5) Similarly to the comment above, it would have been nice to see a segmentation of the data by demographics. For example, are barriers and facilitators different for men and women? Older and younger people? By ethnicity and/or language? 6) pg 14: What is meant by "hawker center" in the quote? Provide definition or use a different quote. 7) pg 16: What is meant by "community exercises"? Is this physical activity opportunities in the community? 8) Informed consent was collected from all participants. Was the study protocol reviewed and approved by an institutional review board? 9) In the introduction, the authors state that this paper will contribute to developing interventions to promote healthy lifestyles among people in Singapore, where diabetes and other chronic conditions are on the rise. I would therefore expect to see explicit recommendations in the discussion or conclusion for interventions tailored to this context. Most of the recommendations mentioned (PA/healthy eating in schools, built environment to promote PA) have been well studied and documented in other contexts and are not novel or innovative. In the revision, I suggest the authors consider what this data adds to the literature and how it can be used to inform intervention development. 10) Various grammatical errors were noted throughout the manuscript (see comments in attached PDF). Suggest careful re-reading and editing for clarity. Reviewer #2: Please see the review comments in the PDF document. I have highlighted the comments. Overall, the paper does not show the novelty of this study, even though (as argued but not substantiated) that Singapore has yet to be the focus of such a study. If authors proceed with a revision, care and clarification is necessary with the manuscript revision to demonstrate study rigor and allow for replication. Further, authors should revisit the discussion and conclusion to 1) enhance the limitations section, and 2) truly demonstrate why this study is novel and important in PLOS One ****** 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: PONE-D-22-13181_reviewer_JRH.pdf Attachment Submitted filename: PONE-D-22-13181_reviewer.pdf https://doi.org/10.1371/journal.pone.0277106.r001
Revision 1
26 Aug 2022 Author Response 27 August 2022 Eliana Carraça Academic Editor PLOS ONE Ref: PONE-D-22-13181 Barriers and Facilitators for adopting a healthy lifestyle in a multi-ethnic population: A qualitative study Dear Dr. Carraca We would like to thank you and the reviewers for your constructive review. We have addressed the points raised by the reviewers in the revised manuscript in as tracked changes. Our replies to their comments are attached and highlighted in bold for easy reference. The major comments on the pdf have been addressed separately as we are not sure which reviewer has commented on them. The minor comments have been addressed directly in the text as tracked changes. Academic Editor The topic of this paper is of interest to the Plos One scientific community. Adherence to healthy lifestyle behaviours remains a challenge, thus exploring which factors might facilitate or hinder the adoption of these behaviours is critical to improve intervention’s design and efficacy. Still, the current paper does not show the novelty of this study. This should be made totally clear in all sections of the paper, but most importantly in the introduction and discussion sections. Authors are also advised to be more specific and support all affirmations in the literature. We have added relevant references and clarified the novel aspects of this study. The methodology should be clearer, especially regarding the process of development of the instrument and how the framework analysis was conducted. The methodology has been substantially revised as suggested by the reviewers. The impact of COVID on recruitment and on this study should be discussed, as these results could be different in a normal, non-COVID, situation. Being the first study on the Singapore population, this should be interpreted with caution and unlikely generalisable. Therefore, avoid using terms that imply that your findings are comprehensive and generalisable to all Singapore population within the same age range. We have avoided the use of terms that suggest that the findings are comprehensive and generalizable. Grammatical errors should be carefully revised. Grammatical errors have been revised. 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 2. Thank you for stating the following in the Acknowledgments Section of your manuscript: “This study is supported by the Singapore Ministry of Health’s National Medical Research Council under its Health Services Research Grant (NMRC/HSRG/0085/2018).” We note that you have provided additional information within the Acknowledgements Section that is not currently declared in your Funding Statement. Please note that funding information should not appear in the Acknowledgments section or other areas of your manuscript. We will only publish funding information present in the Funding Statement section of the online submission form. Please remove any funding-related text from the manuscript and let us know how you would like to update your Funding Statement. Currently, your Funding Statement reads as follows: “SAC received the funding NMRC/HSRG/0085/2018 This study is supported by the Singapore Ministry of Health’s National Medical Research Council under its Health Services Research Grant The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.” Please include your amended statements within your cover letter; we will change the online submission form on your behalf. We would like to retain the statement as it is in the online submission form. We have removed the statement in the revised manuscript. 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. 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. 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: https://imsva91-ctp.trendmicro.com:443/wis/clicktime/v1/query?url=http%3a%2f%2fjournals.plos.org%2fplosone%2fs%2fdata%2davailability%23loc%2dunacceptable%2ddata%2daccess%2drestrictions&umid=C1935020-E531-7305-AE14-9D67384FA132&auth=6e3fe59570831a389716849e93b5d483c90c3fe4-a54b28680ec209732c5562257d5ed9d73bc73984. 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. Revised data availability statement: The data underlying the results presented in the study are available from the first author Dr Mythily Subramaniam (Mythily@imh.com.sg) Reviewer: 1 1) As the authors note, many studies have been published describing barriers and facilitators to healthy lifestyle practices. While this study is novel in its focus on Singapore, the results do not seem to differ much at all from the large body of work on this topic. It would be useful in the discussion to frame how the findings of this study compare to other similar studies. Are there barriers and facilitators specific to adults in Singapore that could be targeting in a healthy lifestyle intervention? We would like to thank the reviewer for this suggestion. We have revised our introduction to address how the study is different from others that have been carried out in other countries. 2) Authors make the claim that this study provides a "comprehensive" understanding of barriers and facilitators (pg 5). I am not sure this claim can be made with a fairly small sample (n=30). The paper can still bring forward important findings without being comprehensive. We have removed the word ‘comprehensive’. 3) Pg 8: spell out "SSI" on first use We apologise for the error and have added the full form as suggested by the reviewer. 4) Pg 8, table 1: Given the important of education level and adoption of healthy lifestyle habits (as the authors mention in the introduction), it's surprising that education is not included in the demographics. It would also be interesting to see how barriers and facilitators differed among those with varying levels of education. We have included the educational backgrounds of the participants in the revised table. 5) Similarly to the comment above, it would have been nice to see a segmentation of the data by demographics. For example, are barriers and facilitators different for men and women? Older and younger people? By ethnicity and/or language? We are unable to do such an analysis as the study design was set up to get a good representation across the groups but did not set out to examine differences across the groups. The sample size does not lend to such a nuanced segmentation and we apologise for that. 6) pg 14: What is meant by "hawker center" in the quote? Provide definition or use a different quote. We have explained what is meant by a ‘hawker center’. We think it is important to retain this quote as it highlights the availability of affordable food which is often not healthy. 7) pg 16: What is meant by "community exercises"? Is this physical activity opportunities in the community? We have clarified the term by changing it to community-based group exercise programs for clarity. 8) Informed consent was collected from all participants. Was the study protocol reviewed and approved by an institutional review board? Yes, we have clearly stated just below the statement on consent that - ethical approval for the study was obtained from the relevant institutional review board (National Healthcare Group Domain Specific Review Board; protocol ref:2019/00926). 9) In the introduction, the authors state that this paper will contribute to developing interventions to promote healthy lifestyles among people in Singapore, where diabetes and other chronic conditions are on the rise. I would therefore expect to see explicit recommendations in the discussion or conclusion for interventions tailored to this context. Most of the recommendations mentioned (PA/healthy eating in schools, built environment to promote PA) have been well studied and documented in other contexts and are not novel or innovative. In the revision, I suggest the authors consider what this data adds to the literature and how it can be used to inform intervention development. We have revised our discussion and conclusion as suggested by the reviewer. 10) Various grammatical errors were noted throughout the manuscript (see comments in attached PDF). Suggest careful re-reading and editing for clarity. We have revised the manuscript as suggested by the reviewer. Reviewer #2: Please see the review comments in the PDF document. I have highlighted the comments. Main comments in the pdf Introduction 1. Authors should take a paragraph or two to summarize the studies in Asia populations. This would help to demonstrate why a specifically cultural focus/regional focus is important. We have added a paragraph focusing on Asian studies in the revised manuscript. 2. At some point, authors need to explain why the study reported here is focused on general health behaviors vs. Diabetes related health behaviors, as the parent study is a diabetes study. Otherwise, authors are encouraged to situate these findings within health behaviors around Diabetes. As we have stated in the revised manuscript the intent of the study was to examine barriers and faciltators to healthy lifestyle in the broader context of general health behaviors which have been promoted at the policy level in Singapore. While the larger study was towards knowledge, attitudes and practices towards diabetes, the questions on lifestyle were general and not towards diabetes related health behaviors (Koh YS, Asharani PV, Devi F, Roystonn K, Wang P, Vaingankar JA, Abdin E, Sum CF, Lee ES, Müller-Riemenschneider F, Chong SA, Subramaniam M. A cross-sectional study on the perceived barriers to physical activity and their associations with domain-specific physical activity and sedentary behaviour. BMC Public Health. 2022 May 26;22(1):1051. doi: 10.1186/s12889-022-13431-2). This was also in consultation with diabetologists who opined that diabetes was often associated with other comorbid conditions and risk factors for several NCIDs were common. Thus, it was decided to understand general health behaviors. We have clarified this in the methodology. Methodology 3. Please clarify: was this sampling method used for the parent study AND the interview component or both or just the interview component? If a specific sampling method was conducted (were there only 30 people who agreed to be recontacted from the survey? Probably not). So how did authors select FOR RECRUITMENT those who said they’d be willing to be contacted. We have clarified the sampling method for the parent study. For the current study the participants were sampled randomly from those who gave consent for recontact. We have clarified the process in the methodology. 4. Are authors claiming that there were no a priori coding structures? If so, why use framework analysis? We would like to respectfully state that a framework analysis can be used without apriori coding structures. We have further expanded the steps to explain what we did. While our initial coding was guided by our research questions and hence the topic guide, we did not use apriori coding. Framework analysis in applied research have varied from highly deductive analysis (Pope et al., 2000) to inductively-oriented approaches in healthcare research (e.g., Goldsmith et al., 2017; Swallow et al., 2011). Results 5. Specify cis, trans, nonbinary gender participants. None of the participants identified themselves as cis/ trans or non-binary. 6. Authors should describe more about the participants in this sample: rurality, occupation (or employment), wealth or income, some measure of health (healthy weight? Health behavior such as smoking?). Readers need to understand more about the sample for this interview cohort. We have described the sample in Table 1. Singapore is a highly urbanised city-state, there is no rural area in Singapore. We did not link health data to the qualitative interviews, and we have acknowledged it as a limitation of the study. We have added education and employment data. Overall, the paper does not show the novelty of this study, even though (as argued but not substantiated) that Singapore has yet to be the focus of such a study. We have revised our introduction to substantiate the novelty of the study. If authors proceed with a revision, care and clarification is necessary with the manuscript revision to demonstrate study rigor and allow for replication. Further, authors should revisit the discussion and conclusion to 1) enhance the limitations section, and 2) truly demonstrate why this study is novel and important in PLOS One We have made the changes suggested by the reviewers. We hope that we have addressed the reviewers’ comments adequately and we look forward to a favourable reply. Regards Authors Attachments Attachment Submitted filename: Response to Reviewers.doc https://doi.org/10.1371/journal.pone.0277106.r002
2 Oct 2022 Decision Letter - Eliana Carraça, Editor PONE-D-22-13181R1Barriers and Facilitators for adopting a healthy lifestyle in a multi-ethnic population: A qualitative studyPLOS ONE Dear Dr. Subramaniam, 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. ============================== ACADEMIC EDITOR:The manuscript was improved, but there are still some issues that need to be properly addressed. Please see the comments in the attached file. Make sure you reply to all comments, including those left in the previous response letter to reviewers. ============================== Please submit your revised manuscript by October 20. 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, Eliana Carraça Academic Editor PLOS ONE 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: PONE-D-22-13181_R1_Ed.pdf https://doi.org/10.1371/journal.pone.0277106.r003
Revision 2
18 Oct 2022 Author Response 15 October 2022 Eliana Carraça Academic Editor PLOS ONE Ref: PONE-D-22-13181R1 Barriers and Facilitators for adopting a healthy lifestyle in a multi-ethnic population: A qualitative study Dear Dr. Carraca We would like to thank you and the reviewers for the second review. We have addressed the points raised by the reviewers in the revised manuscript as tracked changes. Our replies to their comments are attached and highlighted in bold for easy reference in our reply. Academic Editor The manuscript was improved, but there are still some issues that need to be properly addressed. Please see the comments in the attached file. Make sure you reply to all comments, including those left in the previous response letter to reviewers. We have addressed all the comments in the attached file. Reviewer: 1 (Comments in pdf file and response to our Reply to the reviewers) We want to thank the reviewer for once again going through our article carefully and providing us with invaluable insights. The changes suggested in the language have been incorporated directly as tracked changes in the manuscript. We have analysed the themes by socio-demographic groups and presented the data. We hope we have addressed the reviewers’ comments adequately and look forward to a favourable reply. Regards Authors Attachments Attachment Submitted filename: Response to Reviewers October.doc https://doi.org/10.1371/journal.pone.0277106.r004
20 Oct 2022 Decision Letter - Eliana Carraça, Editor Barriers and Facilitators for adopting a healthy lifestyle in a multi-ethnic population: A qualitative study PONE-D-22-13181R2 Dear Dr. Subramaniam, 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, Eliana Carraça Academic Editor PLOS ONE Additional Editor Comments (optional): Reviewers' comments: https://doi.org/10.1371/journal.pone.0277106.r005
Formally Accepted
24 Oct 2022 Acceptance Letter - Eliana Carraça, Editor PONE-D-22-13181R2 Barriers and Facilitators for adopting a healthy lifestyle in a multi-ethnic population: A qualitative study Dear Dr. Subramaniam: 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. Eliana Carraça Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0277106.r006

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