PONE-D-23-29716Evaluating the long-term effectiveness of school cancer education programs on behavior change: a first trial studyPLOS ONE

Dear Dr. minamitani,

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 Feb 01 2024 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

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

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

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

We look forward to receiving your revised manuscript.

Kind regards,

Boyen Huang, DDS, MHA, PhD

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. Note from Emily Chenette, Editor in Chief of PLOS ONE, and Iain Hrynaszkiewicz, Director of Open Research Solutions at PLOS: Did you know that depositing data in a repository is associated with up to a 25% citation advantage (https://doi.org/10.1371/journal.pone.0230416)? If you’ve not already done so, consider depositing your raw data in a repository to ensure your work is read, appreciated and cited by the largest possible audience. You’ll also earn an Accessible Data icon on your published paper if you deposit your data in any participating repository (https://plos.org/open-science/open-data/#accessible-data).

3. We note that you have indicated that data from this study are available upon request. PLOS only allows data to be available upon request if there are legal or ethical restrictions on sharing data publicly. For more information on unacceptable data access restrictions, please see http://journals.plos.org/plosone/s/data-availability#loc-unacceptable-data-access-restrictions.

In your revised cover letter, please address the following prompts:

a) If there are ethical or legal restrictions on sharing a de-identified data set, please explain them in detail (e.g., data contain potentially sensitive information, data are owned by a third-party organization, etc.) and who has imposed them (e.g., an ethics committee). Please also provide contact information for a data access committee, ethics committee, or other institutional body to which data requests may be sent.

b) If there are no restrictions, please upload the minimal anonymized data set necessary to replicate your study findings as either Supporting Information files or to a stable, public repository and provide us with the relevant URLs, DOIs, or accession numbers. For a list of acceptable repositories, please see http://journals.plos.org/plosone/s/data-availability#loc-recommended-repositories.

We will update your Data Availability statement on your behalf 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: Partly

Reviewer #2: Partly

**********

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

Reviewer #1: Yes

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: 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 is important to consider for overall impact of cancer, education, screening and health in general, however, I think there are some limitations to study that may limit the applicability of these results in the real world.

Considering that largely young males were included in the survey portion of the study, there may be significant impact on the results given that this group rarely has needs for screening in general, and I'm unaware of any immediate needs for cancer screening outside of Circle cancer, screening and women. This may influence the results, although it is unclear to me what it is more less likely to respond that they are willing to consider screening in the future.

Relatively high willingness to have any sort of cancer screening in the future, and concerned that this overall willingness to undergo cancer screening also results. it is unclear to me whether this is a Japanese cultural connection, or that overall willingness tend to cancer has risen from what be historical controls.

It is also unclear to me what the specific intervention was regarding cancer education. The level of detail is sparse, and, as an educationalist, it is unclear to me, whether the lack of impact is due to limitations in the teaching or evaluation methods at the time of teaching. While this is not specifically part of the study, this contextual background is important to understand what Impacts the actual education program itself potentially have on the outcomes of this survey.

Reviewer #2: Summary of research and overall impression

This is an interesting article to investigate if school-based cancer education programs supported behavioral change (defined as likelihood to participate in cancer screening) in those participating. While many school-based programs only look at the impact immediately after the program or at most a few months afterwards, the authors of this study sought to understand a long term effect by surveying participants 9+ years post-program. Of the thirteen schools contacted, only one school agreed to participate and contact their students; this resulted in the participants being all male (all male school) and in an urban setting. The authors established study and control groups using students from the school which agreed to participate. Of the six hundred who received invitations to participate, thirty-eight fitting the study group and fifty-five fitting the control group responded and completed the survey. The authors detailed the results of the study and performed statistical analysis to investigate which factors were significant.

The authors should be commended for seeking to understand the long-term impact of program such as these. Only through evaluation and continuous improvement do programs improve so that their outcomes show more impact and better connect with their learning objectives. However, the paper would be strengthened if the authors provided additional information needed for the reader to better understand the education program, the content delivered and how it connects with the behavioral change being investigated, and the delivery of the material (was it a one day, one module, year long program; was it delivered using age-appropriate language; was a learning objective of the program to create understanding of preventative cancer behaviors; etc. ). Knowing this would provide the reader a good foundation on which to understand the rest of the paper/study, as well as potential consider how to perform a similar study on their own programs. It would also be beneficial to acknowledge that data requirements for t-test and logistic regression were reviewed and met.

Major issues

1. The paper would be strengthened if the authors provided details on the cancer education programs.

a. What age level (JH-2 is mentioned in the table, but knowing the age level of the students would be beneficial.

b. Was the program a one day, one module, one year event?

c. The authors state the program was delivered by a radiation oncologist. Is it known if the physician communicated in an age-appropriate language to increase the understanding/learning of the students.

2. In the abstract (line 31), it is mentioned that the Japan Cancer Society has conducted these education programs since 2011; however in the introduction (lines 51-53), it is mentioned that the education programs became part of the curriculum in 2016. Before 2016 (which is when the study/control participants were in school), it would be helpful to know if the delivery of information was standardized or more invited guest lecture and variable. For instance, was focus on preventive measure compliance a learning objective/goal of the program; this is not mentioned in the objectives mentioned (lines 54-55).

3. It would be helpful if the authors were able to comment on if the questionnaire used was mapped to the curricular objectives of the program in which the students participated or if it was based only on general health and cancer related questions (lines 87-88). For instance, were the items included on lines 91-95 included in the curricular program for the students, or are they general health questions.

4. The authors describe the control group as students from one year before and one year after the study group. It would be helpful to explain this in more detail. As written, the reader understands that education programs began in 2011 and more formally in 2016; so, if the education program was ongoing at the time of the study participants, how are students one year afterwards a control group. One year before could be students who did not have the program, but if the program was given in 2013 (table 1), would one year before and one year after students both have been exposed to the education program.

5. It would be beneficial to acknowledge that data requirements for t-test and logistic regression were reviewed and met.

6. On lines 129-130, it would be helpful to further explain. Were all surveys completed by May 1, or was the letter an invitation to participate and survey sent later. This will help the reader better understand the timeline set in line 125.

7. It would be helpful if the authors provide more detail on what “medical and welfare” educational background is, as the reader is not familiar with these terms.

8. On table 2, what is “past medical history” with options of “zero” or “any”?

9. Lines 216-217, as written, the reader understands this to mean that the validity of the participants in the study/control groups could be compromised. Therefore, it would be extremely helpful to reword and further explain the meaning.

10. Lines 226-227, as written the sentence is very lofty as it refers to “cancer education programs” in general, and this study is limited to one school, one program (which may not be similar to current programs?). It would be helpful to reword and focus on the implications of this studying while also understanding the limitations.

Minor issues

1. The authors may want to revisit the phrasing of the sentence on lines 56-57. The incidence of cancer could be due to genetic factors or factors outside the influence of the education programs. However, the mortality rate could be influenced by preventive screening.

2. On line 66, the authors should consider replacing “survey” with “intervention” or “program”

3. On line 84, is it correct to interpret exclusion criteria #2 as “only a subset of students….”

4. On line 85, it would help if the authors provided a short explanation as to why exclusion criteria #4 is important.

5. The acronym OECD on line 91 needs to be spelled out as many readers may not know what that is.

6. For the survey (lines 100-101), were all questions Likert, were any open-ended questions used to better understand the impact of the program. For instance, “when did you first become aware of the importance of cancer screening”?

7. On line 108, were these questions written with the term “recommended” before them which could potentially influence responses. Or, were they written as (a) never smoked and (b) have smoked.

8. On lines 113-114, it may be helpful to provide additional information in the sentence on if the thresholds were set to reduce cancer risk or just for general healthy living.

9. On lines 119 and 121, it would be helpful to add in “logistic” to describe the regression

10. On line 120, it would be helpful to describe the “half-split” further or provide a reference for when/how it is used. That will be helpful for any reader attempting to replicate these methods.

11. On line 122, it would be beneficial to write, even parenthetically, the “variables that were not significant”. That will help the reader understand all parameters investigated.

12. For table 1, it would be helpful to describe what the column “time” is. The reader is assuming this is the time of the educational program, but it would be better to not leave that to interpretation.

13. Also, on table 1, there appears to be a typo “survery” instead of “survey”

14. For table 2, would the authors be open to writing the age of the control as 21-24 instead of 21-22 & 23-24, or is there significance in writing the age as written?

15. On lines 153-162, were multiple t-tests run, an ANOVA/MANOVA, or were the correlations part of the SPSS outcome from the logistic regression protocol?

16. Could the authors explain line 165. Is it a reference to the total number of participants, and if so, what is the correlation between?

17. On lines 173-174, the authors may want to comment on if the cancer education program could have influenced the health literacy score.

18. On lines 178-180, were any of the studies cited focused on behavioral change, as is the focus of this paper. If so, the authors could further discuss how their work fits into the literature.

19. Lines 194-195, the paper could benefit from the authors commenting or addressing limitations on if the intention to undergo screening could be influenced by the participant’s health care provider/main physician for regular checkups.

20. For lines 196-197, did the 68% of students in that study complete the cancer education program?

21. Lines 204-206, it could be helpful to briefly explain why one-on-one education provided additional benefit.

22. Lines 212-213, how many of the eligible participants did the school contact?

23. Lines 221-222, it would be helpful to address the change in curriculum briefly, key learning objectives that were different, etc.

Other comments

1. Before finalizing, the paper would benefit from a thorough review for minor typos and to improve flow of the document.

**********

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: Yes: Myles Nickolich

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-23-29716R1Evaluating the long-term effectiveness of school cancer education programs on behavioral change: a first trial studyPLOS ONE

Dear Dr. minamitani,

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 address the comments and suggestions made by Reviewer 1, as shown below.

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

Please include the following items when submitting your revised manuscript:

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

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

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

We look forward to receiving your revised manuscript.

Kind regards,

Boyen Huang, DDS, MHA, PhD

Academic Editor

PLOS ONE

[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 #1: (No Response)

Reviewer #2: All comments have been addressed

**********

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

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

Reviewer #1: Partly

Reviewer #2: Yes

**********

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

Reviewer #1: Yes

Reviewer #2: 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 #1: Yes

Reviewer #2: 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 #1: Yes

Reviewer #2: Yes

**********

6. Review Comments to the Author

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

Reviewer #1: Thank you for your revisions and further consideration of the focus of the manuscript.

Major Issues:

1. Outcome applicability: I still have significant concerns about the overall question being asked with this and, in its current form, I would not feel comfortable applying the data from this study in a manner that would influence an educational curricular or assessment design nor would I utilize this to inform public health interventions with a population (either from an educational intervention standpoint or in policy/procedure development). I am not certain of what we are truly measuring as, with the further definition of the educational intervention, it sounds that the educational intervention was highly heterogeneous from site to site with multiple instructors each providing different forms of cancer-education/prevention information and without a standardized framework of learning objectives or curricular interventions. With the level of heterogeneity here, I fear that we are essentially measuring more about characteristics related to the limited student population at one individual school that participated more than the impacts of any remote and heterogeneous educational intervention on cancer education or prevention. I also fear that, with the current design of the manuscript focusing on the impact of the cancer education intervention, that, with the currently identified research question in mind, the study design is inherently flawed and unable to provide a usable result unless the research question is adjusted. Please identify if I have misinterpreted the details of the delivery and content of the educational intervention. Your description in the reviewer response is more detailed than what is identified in line 202, if there is indeed the level of heterogeneity in delivery that you describe in the reviewer response, I would recommend updating the description in the manuscript around line 202. This seems to go into more detail describing the heterogeneity around line 280.

2. Patient population: Related to major issue 1, I have significant concerns about the applicability of the data with the study population being so limited and being 1. a single gender, and 2, in such limited numbers, the applicability and validity of the data comes into question. Unless the study population can be expanded both in number and in demographics, this will be a significant limitation. I'm wondering if there may be an opportunity to reconnect with the school that had staffing issues (school 13) or if additional connections or resources could be provided to institutions that responded, this would assist in establishing a more diverse respondent population and thus more theoretically valid and applicable results. Given the limitations if this is the only response feasible, I would recommend refocusing the research question in some way to make the results more applicable.

3. Immediate survey results vs longer term results: Details of results from a pre and post course survey identified in line 211 would be important to expand upon and may contribute to the study results. Was it clear that the educational intervention met targets at the time of the intervention based upon the initial pre and post survey results?

Minor issues:

1. Japanese cultural influence of results: Please expand upon the item listed in line 231 and 232 that Japanese individuals are less likely to seek cancer screening than other populations. I worry about over generalization here. If this is the case, how could this help to adjust the research question here to make this study outcomes more meaningful and applicable?

2. Learning objectives for educational intervention: Could you provide further detail as to learning objectives or goals for the educational sessions offered in the initial intervention?

Reviewer #2: Thank you for the additions to the manuscript; they provide clarity for the reader. The additional information (and table) on the statistical methods/results is helpful in understanding factors considered. The reader also appreciated the track changes version as that helped identify the new components.

**********

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

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

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

Reviewer #1: No

Reviewer #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-23-29716R2Comparing Health Literacy and Behavioral Changes in Adulthood: A Pilot Study on Alumni of a Single School Cancer Education ProgramPLOS ONE

Dear Dr. minamitani,

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.

In addition to Reviewer 1's comments on the revisions in text (as below), I would strongly suggest the authors further address the limitations reported in the manuscript. For example, what can you and future researchers do differently in study design, data collection and/or data analysis to minimize the impact from those limitations on the validity of this study? What caution should readers take when they interprete your data and conclusion? 

Please submit your revised manuscript by Jun 10 2024 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

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

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

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

We look forward to receiving your revised manuscript.

Kind regards,

Boyen Huang, DDS, MHA, PhD

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.

[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 #1: All comments have been addressed

**********

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

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

Reviewer #1: Yes

**********

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

Reviewer #1: 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 #1: 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 #1: Yes

**********

6. Review Comments to the Author

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

Reviewer #1: Overall, I believe the authors have adapted the overall focus of the manuscript and the direction of the text in a way that more accurately identifies the study's scope, focus, and limitations. The limitations are significant, and I would leave it up to the editorial board to identify whether these limitations are enough to exclude the study from publication. This is a negative study and, from an education-focused research perspective, it could be helpful to highlight the point that it is incredibly important to consider educational outcome evaluations as a part of designing an educational intervention (if there is a desire to observe outcomes). It is not entirely clear to me if this was a retrospective effort driven opportunistically by the authors or whether the authors did have a role in the initial intervention (I apologize if I missed this, either way, this should be identified in the manuscript).

Revisions in text:

Line 43: would recommend changing "no significant effects" to highlight that no significant impact on measured outcomes.

Line 56: this seems like too profound of a statement, this seems like it was a regional educational intervention, may walk back the degree of this statement's grandeur.

Line 59: this seems too narrow of a statement about the purpose of cancer education programs. Would eliminate or soften language.

Line 310: I would argue that "effectiveness" is not the true measurement of this, it sounds more consistent with understanding if there was a subject's behavior that would be consistent with recommendations of the educational intervention. This is a surrogate the for efficacy element.

Line 311: would change to nine years prior rather than nine years ago.

**********

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

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

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

Reviewer #1: No

**********

[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.

Comparing Health Literacy and Behavioral Changes in Adulthood: A Pilot Study on Alumni of a Single School Cancer Education Program

PONE-D-23-29716R3

Dear Dr. minamitani,

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 will be generated when your article is formally accepted. Please note, if your institution has a publishing partnership with PLOS and your article meets the relevant criteria, all or part of your publication costs will be covered. Please make sure your user information is up-to-date by logging into Editorial Manager at Editorial Manager® and clicking the ‘Update My Information' link at the top of the page. If you have any questions relating to publication charges, 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,

Boyen Huang, DDS, MHA, PhD

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments: