Understanding challenges and enhancing the competency of healthcare providers for disability inclusive sexual and reproductive health services in rural Nepal

Pabitra Neupane; Suyasha Adhikari; Sushma Khanal; Sulochana Devkota; Manasi Sharma; Anisha Shrestha; Amit Timilsina

doi:10.1371/journal.pone.0311944

Peer Review History

Original SubmissionMay 6, 2024
7 Jun 2024 Decision Letter - Yitagesu Habtu Aweke, Editor PONE-D-24-16726Understanding challenges and enhancing the competency of healthcare providers for disability inclusive and gender sensitive Sexual and Reproductive Health Services in rural NepalPLOS ONE Dear Dr. Neupane, 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. Although the points they pointed out seems minor, reviewers raised important points to be addressed as a major concern to improve your manuscript and adhere the journal's standard. 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 22 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, Yitagesu Habtu Aweke, Ph.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. We note that your Data Availability Statement is currently as follows: All relevant data are within the manuscript and its Supporting Information files. Please confirm at this time whether or not your submission contains all raw data required to replicate the results of your study. Authors must share the “minimal data set” for their submission. PLOS defines the minimal data set to consist of the data required to replicate all study findings reported in the article, as well as related metadata and methods (https://journals.plos.org/plosone/s/data-availability#loc-minimal-data-set-definition). For example, authors should submit the following data: - The values behind the means, standard deviations and other measures reported; - The values used to build graphs; - The points extracted from images for analysis. Authors do not need to submit their entire data set if only a portion of the data was used in the reported study. If your submission does not contain these data, please either upload them as Supporting Information files or deposit them to a stable, public repository and provide us with the relevant URLs, DOIs, or accession numbers. For a list of recommended repositories, please see https://journals.plos.org/plosone/s/recommended-repositories. 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. If data are owned by a third party, please indicate how others may request data access. 3. Please include your full ethics statement in the ‘Methods’ section of your manuscript file. In your statement, please include the full name of the IRB or ethics committee who approved or waived your study, as well as whether or not you obtained informed written or verbal consent. If consent was waived for your study, please include this information in your statement as well. 4. We note you have included a table to which you do not refer in the text of your manuscript. Please ensure that you refer to Table 1 in your text; if accepted, production will need this reference to link the reader to the Table. 5. Please include captions for your Supporting Information files at the end of your manuscript, and update any in-text citations to match accordingly. Please see our Supporting Information guidelines for more information: http://journals.plos.org/plosone/s/supporting-information. 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: N/A Reviewer #2: N/A ****** 3. Have the authors made all data underlying the findings in their manuscript fully available? The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified. Reviewer #1: No Reviewer #2: Yes ****** 4. Is the manuscript presented in an intelligible fashion and written in standard English? PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here. Reviewer #1: Yes Reviewer #2: Yes ****** 5. Review Comments to the Author Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters) Reviewer #1: 1) It would be useful for the reader to understand what the national guideline for disability-unclusive services in Nepal says about providing SRH services to women with disabilities. It is unclear whether there are already provisions but the study is exploring the challenges to implementing these, or whether the guidelines are incomplete/insufficient and the challenges being explored in the study go beyond these. In the same vein, it would be important to clarify whether the authors have a specific understanding of what healthcare provider competency entails in this case, and whether they know what the services provided to women with disabilities ought to be. The sub-topic on gender sensitiveness should be developed further to ensure it is well argued and supported. As it stands now, it is unclear how the conclusion that there is a gender bias in care is arrived at. When describing the results on healthcare provider knowledge it would be important for the reader to know what they are expected to know. Overall, concluding that healthcare providers have limited knowledge and skills needs to be sustained by contrasting the findings with what they should know/the expected competencies they should hold. For instance, in the discussion the following claim is made: "Though there is inclusion of some clinical components of disability in the curriculum under the general practice subject, the contents are not adequate to understand and cater to the SRH needs of women or to provide disability inclusive SRH services to women". Although the authors may know what the adequate contents should be, the reader may not and it is important to make this explicit so that the reader can follow and draw their own conclusions. Many of these issues could be addressed by providing some context on healthcare for people living with disabilities drawn from documentary analysis (policy, guidelines). 4) The text is intelligible and overall clear, although minor grammar mistakes can be found throughout and should be addressed - for example, the use of the term 'adopted' when it is clear what is meant is 'adapted'. The formulation of sentences should be revised to improve clarity. The manuscript should be revised and edited accordingly. Reviewer #2: The authors should clarify the following points in the manuscript: 1. In Study design and setting: the authors should clarify how many municipalities and health institutions of the districts were covered by the study? 2. In Line no. 125: For which level of health professional did the authors intend to refer by the term "health in-charge"? 3. In Line no. 224: The authors mentioned the finding that there is lack of equipments including CT and MRI for the disability services. Authors need to clarify the need of these highly valued equipments for SRH in rural setting for disability. ****** 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: Yara Alonso Menendez Reviewer #2: Yes: Basant Adhikari ******** [NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.] While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step. https://doi.org/10.1371/journal.pone.0311944.r001
Revision 1
17 Jul 2024 Author Response 17th July 2024 Yitagesu Habtu Aweke, Ph.D Academic Editor, PLOS ONE RE: Revision of Manuscript PONE-D-24-16726 Dear Editor, We would like to thank you and the reviewers for your time and providing constructive comments on our manuscript entitled “Understanding challenges and enhancing the competency of healthcare providers for disability inclusive Sexual and Reproductive Health Services in rural Nepal.” A revised version (clean and track changes) reflecting the point-by-point response to the reviewers’ comments have been submitted for your consideration. We believe that we have addressed all the comments and that the manuscript has significantly improved. Should you require any additional information, please do not hesitate to let me know. Thank you very much for your time and kind considerations. Your sincerely, Pabitra Neupane RESPONSE TO THE REVIEWERS 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 RESPONSE: All necessary adjustments have been made. 2. We note that your Data Availability Statement is currently as follows: All relevant data are within the manuscript and its supporting informations. Please confirm at this time whether or not your submission contains all raw data required to replicate the results of your study. Authors must share the “minimal data set” for their submission. PLOS defines the minimal data set to consist of the data required to replicate all study findings reported in the article, as well as related metadata and methods (https://journals.plos.org/plosone/s/data-availability#loc-minimal-data-set-definition). For example, authors should submit the following data: - The values behind the means, standard deviations and other measures reported; - The values used to build graphs; - The points extracted from images for analysis. Authors do not need to submit their entire data set if only a portion of the data was used in the reported study. If your submission does not contain these data, please either upload them as Supporting Information files or deposit them to a stable, public repository and provide us with the relevant URLs, DOIs, or accession numbers. For a list of recommended repositories, please see https://journals.plos.org/plosone/s/recommended-repositories. 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. If data are owned by a third party, please indicate how others may request data access. RESPONSE: The codebook produced as the outcome of the data analysis, the interview guideline for the KII and FGDs and the informed consent forms have been available for this study. As participants have not consented for the available of full interview transcripts during this study, it has not been publicly available to respect participants anonymity and consent. 3. Please include your full ethics statement in the ‘Methods’ section of your manuscript file. In your statement, please include the full name of the IRB or ethics committee who approved or waived your study, as well as whether or not you obtained informed written or verbal consent. If consent was waived for your study, please include this information in your statement as well. RESPONSE: This section has been updated in Methodology and it reads as: the data was collected from 10th December 2023 to 15th January 2024. Written ethical approval was obtained from the Ethical Review Board of Nepal Health Research Council (Ref. Number 783) before conducting the data collection. The research follows standard ethical principles guided by the Helsinki Principles. The autonomy and confidentiality of participants has been maintained throughout the project period. All the participants were oriented about the study and its importance. Prior to data collection, written consent was taken from the participants after orientation, verbal consent was taken before starting the interviews and their right to withdraw from the research was reiterated. The participants were assured of anonymity and confidentiality before, during and after the study. 4. We note you have included a table to which you do not refer in the text of your manuscript. Please ensure that you refer to Table 1 in your text; if accepted, production will need this reference to link the reader to the Table. RESPONSE: This comment has been addressed in line number 167 5. Please include captions for your Supporting Information files at the end of your manuscript, and update any in-text citations to match accordingly. Please see our Supporting Information guidelines for more information: http://journals.plos.org/plosone/s/supporting-information. RESPONSE: All the supporting files has been made available in the manuscript so this is not applicable for this study. Reviewer’s Comment Reviewer #1: 1) It would be useful for the reader to understand what the national guideline for disability-inclusive services in Nepal says about providing SRH services to women with disabilities. It is unclear whether there are already provisions, but the study is exploring the challenges to implementing these, or whether the guidelines are incomplete/insufficient and the challenges being explored in the study go beyond these. Response: Thank you so much for your comment. The additional policy provision and mechanism has been adequately mentioned in the introduction section from line numbers 76-93. This comment has been addressed completely. 2) In the same vein, it would be important to clarify whether the authors have a specific understanding of what healthcare provider competency entails in this case, and whether they know what the services provided to women with disabilities ought to be. Response: Thank you so much for your feedback. The specific understanding of what healthcare providers competency is expected has been discussed in discussion section from line number 440-447. This comment has been addressed completely. 3) The sub-topic on gender sensitiveness should be developed further to ensure it is well argued and supported. As it stands now, it is unclear how the conclusion that there is a gender bias in care is arrived at. Response: We discussed on this as a team, and we agree that this study does not have enough evidences to establish lack of gender sensitiveness apart from one or two excerpts. Thus, we have removed 'gender sensitiveness' from the topic and sub-theme and removed 'gender bias' from conclusion to avoid any misleading information and discussion. It is discussed under discrimination but not as a separate sub-section. This comment has been addressed. 4) When describing the results on healthcare provider knowledge it would be important for the reader to know what they are expected to know. Overall, concluding that healthcare providers have limited knowledge and skills needs to be sustained by contrasting the findings with what they should know/the expected competencies they should hold. For instance, in the discussion the following claim is made: "Though there is inclusion of some clinical components of disability in the curriculum under the general practice subject, the contents are not adequate to understand and cater to the SRH needs of women or to provide disability inclusive SRH services to women". Although the authors may know what the adequate contents should be, the reader may not and it is important to make this explicit so that the reader can follow and draw their own conclusions. Many of these issues could be addressed by providing some context on healthcare for people living with disabilities drawn from documentary analysis (policy, guidelines). Response: Thank you so much for your comment. The additional policy provision and mechanism has been adequately mentioned in the introduction and discussion section. 4) The text is intelligible and overall clear, although minor grammar mistakes can be found throughout and should be addressed - for example, the use of the term 'adopted' when it is clear what is meant is 'adapted'. The formulation of sentences should be revised to improve clarity. The manuscript should be revised and edited accordingly. Response: The manuscript has been thoroughly revised and checked for any language and grammatical error. This comment has been addressed. Reviewer #2: The authors should clarify the following points in the manuscript: 1. In Study design and setting: the authors should clarify how many municipalities and health institutions of the districts were covered by the study? Response: The number of rural/municipalities and health facilities has been mentioned. However, the name of municipalities and health institutions has not been mentioned to ensure anonymity and confidentiality of health institutions and facilities. The socio-demographic information is in detail and naming the municipalities and health institutions could lead to participant identification. 2. In Line no. 125: For which level of health professional did the authors intend to refer by the term "health in-charge"? Response: The term "health in-charge" has been corrected to "health facility in-charge" for clarity. The health facility in-charge are usually medical doctors, H.A, or senior AHW. 3. In Line no. 224: The authors mentioned the finding that there is a lack of equipments including CT and MRI for the disability services. Authors need to clarify the need of these highly valued equipment for SRH in rural setting for disability. Response: The health facility under the study are health posts, Primary Health Care Centers and Hospitals at district/province level and the need for equipment, commodity and tool varies. The CT and MRI are required for abdominal or pelvic screening/assessment at district level while the need of health post include USG, fetal doppler, Pap-Smear test kit, Silicon Ring Pessary. This has been clarified in the discussion section. Attachments Attachment Submitted filename: Response to reviewer.docx https://doi.org/10.1371/journal.pone.0311944.r002
24 Sep 2024 Decision Letter - Yitagesu Habtu Aweke, Editor PONE-D-24-16726R1Understanding challenges and enhancing the competency of healthcare providers for disability inclusive Sexual and Reproductive Health Services in rural NepalPLOS ONE Dear Dr. Neupane, 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. Reviewer #4 has still concerns. 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 Nov 08 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, Yitagesu Habtu Aweke, Ph.D Academic Editor PLOS ONE Journal Requirements: Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice. [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 #3: All comments have been addressed Reviewer #4: (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 #3: Yes Reviewer #4: (No Response) ****** 3. Has the statistical analysis been performed appropriately and rigorously? Reviewer #3: Yes Reviewer #4: (No Response) ****** 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 #3: Yes Reviewer #4: (No Response) ****** 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 #3: Yes Reviewer #4: (No Response) ****** 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 #3: The authors have successfully addressed the feedback provided by the previous reviewers, demonstrating commendable engagement with critical suggestions. Upon reviewing this revised submission, I recommend it for publication. This study is particularly notable for its focus on a critically underexplored area—disability-inclusive sexual and reproductive health services in rural Nepal. The authors' examination of healthcare providers' competencies in delivering these services is highly relevant, especially given the persisting barriers faced by women with disabilities, including knowledge gaps in disability management, biased perceptions, and inadequate communication skills. The use of a qualitative, thematic research design, supported by key informant interviews and focus group discussions, has allowed for an in-depth exploration of these complex issues. The findings, which highlight significant gaps in procedural skills and the need for disability-inclusive training and infrastructure, provide valuable insights for improving health systems in underserved regions. Considering that the authors are university students, the depth and rigor of their work are commendable. They have contributed meaningfully to an area of research that has clear implications for both policy and practice in the context of rural health services in Nepal. Therefore, this manuscript contributes to the field and should be published. Reviewer #4: Abstract • Result (Line 38-45): This sentence is long and hard to follow. It's important to clarify this for the reader to easily grasp the meaning. • Conclusion (Line 46-50): Instead of writing one long sentence (which spans four lines), consider breaking it into simpler sentences to improve clarity. Introduction • Line 90: There are two periods (dots). Method (Lines 145-150): Participants and Sampling: • The criteria for inclusion/exclusion need more details. Do you include both males and females? What is the age range? What languages do participants speak (Nepali or English)? Results • Line 176: Double-check the spacing between words. • Lines 208-210: This sentence is somewhat unclear. Are healthcare providers aware of advocacy? Discussion: • “Professionalism and Behavior of Health Care Providers”: This section presents clear points and is easier to follow compared to the previous section, “Disability-Inclusive Health System,” which I have already commented on for revision. Line 428: There is an extra period (dot). ****** 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 #3: Yes: Dr. Shamim Ahmed Reviewer #4: No ******** [NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.] While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step. https://doi.org/10.1371/journal.pone.0311944.r003
Revision 2
27 Sep 2024 Author Response 27th September 2024 Yitagesu Habtu Aweke, Ph.D Academic Editor, PLOS ONE RE: Revision of Manuscript PONE-D-24-16726R2 Dear Editor, We would like to thank you and the reviewers for your time and providing constructive comments on our manuscript entitled “Understanding challenges and enhancing the competency of healthcare providers for disability inclusive Sexual and Reproductive Health Services in rural Nepal.” We are thankful to reviewers for their encouraging words and praises related to manuscript and also identifying areas of improvement. A revised version (clean and track changes) reflecting the point-by-point response to the reviewers’ comments have been submitted for your consideration. We believe that we have addressed all the comments and that the manuscript has significantly improved and ready to get published. Should you require any additional information, please do not hesitate to let me know. Thank you very much for your time and kind considerations. Your sincerely, Pabitra Neupane neupanepavitra@gmail.com RESPONSE TO THE REVIEWERS 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. Response: The reference list has been checked and the reference is updated accordingly. Answer: Reviewer’s Comment Reviewer #3: The authors have successfully addressed the feedback provided by the previous reviewers, demonstrating commendable engagement with critical suggestions. Upon reviewing this revised submission, I recommend it for publication. This study is particularly notable for its focus on a critically underexplored area disability-inclusive sexual and reproductive health services in rural Nepal. The authors' examination of healthcare providers' competencies in delivering these services is highly relevant, especially given the persisting barriers faced by women with disabilities, including knowledge gaps in disability management, biased perceptions, and inadequate communication skills. The use of a qualitative, thematic research design, supported by key informant interviews and focus group discussions, has allowed for an in-depth exploration of these complex issues. The findings, which highlight significant gaps in procedural skills and the need for disability-inclusive training and infrastructure, provide valuable insights for improving health systems in underserved regions. Considering that the authors are university students, the depth and rigor of their work are commendable. They have contributed meaningfully to an area of research that has clear implications for both policy and practice in the context of rural health services in Nepal. Therefore, this manuscript contributes to the field and should be published. Response: Thank you for your and encouraging feedback. We greatly appreciate your recognition of the importance of this research and are grateful for the opportunity to contribute to the underexplored area of disability-inclusive sexual and reproductive health services. We look forward to seeing our work published and hope it informs future policies and practices in rural health services. Reviewer #4: Abstract 1. Result (Line 38-45): This sentence is long and hard to follow. It's important to clarify this for the reader to easily grasp the meaning. Response: Thank you so much for your comment. The comment has been addressed in the manuscript in the line number 37-45. We have broken the single sentence into multiple for readability and clarity. 2. Conclusion (Line 46-50): Instead of writing one long sentence (which spans four lines), consider breaking it into simpler sentences to improve clarity. Response: Thank you so much for your feedback. The comment has been addressed in the manuscript from line number 48-54. We have broken the single sentence into multiple simpler sentences for readability. 3. Introduction • Line 90: There are two periods (dots). Response: The comment has been addressed in the manuscript line number: 92. We have removed the extra dot. 4. Method (Lines 145-150): Participants and Sampling: • The criteria for inclusion/exclusion need more details. Do you include both males and females? What is the age range? What languages do participants speak (Nepali or English)? Response: Thank you so much for your comment. The additional information about the participants and inclusion has been added in the manuscript, line number: 132-135, 148-151 5. Results • Line 176: Double-check the spacing between words. Response: Thank you for the comment, we have double checked the spacing between words and there is no any error. • Lines 208-210: This sentence is somewhat unclear. Are healthcare providers aware of advocacy? Response: Thank you so much for the comment. This comment has been addressed in manuscript, line number 212 6. Discussion: • “Professionalism and Behavior of Health Care Providers”: This section presents clear points and is easier to follow compared to the previous section, “Disability-Inclusive Health System,” which I have already commented on for revision. Response: Thank you for your positive remarks on this. We have tried to present the findings in the sections with clarity. 7. Line 428: There is an extra period (dot). Response: The comment has been addressed in the manuscript line number: 433. We have removed extra dot. We have thoroughly reviewed the manuscript for language edit. Attachments Attachment Submitted filename: Response to reviewers.docx https://doi.org/10.1371/journal.pone.0311944.r004
29 Sep 2024 Decision Letter - Yitagesu Habtu Aweke, Editor Understanding challenges and enhancing the competency of healthcare providers for disability inclusive Sexual and Reproductive Health Services in rural Nepal PONE-D-24-16726R2 Dear Dr. Pabitra Neupane, 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, Yitagesu Habtu Aweke, Ph.D Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0311944.r005
Formally Accepted
4 Oct 2024 Acceptance Letter - Yitagesu Habtu Aweke, Editor PONE-D-24-16726R2 PLOS ONE Dear Dr. Neupane, I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now being handed over to our production team. At this stage, our production department will prepare your paper for publication. This includes ensuring the following: * All references, tables, and figures are properly cited * All relevant supporting information is included in the manuscript submission, * There are no issues that prevent the paper from being properly typeset If revisions are needed, the production department will contact you directly to resolve them. If no revisions are needed, you will receive an email when the publication date has been set. At this time, we do not offer pre-publication proofs to authors during production of the accepted work. Please keep in mind that we are working through a large volume of accepted articles, so please give us a few weeks to review your paper and let you know the next and final steps. Lastly, 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 customercare@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 PhD Candidate Yitagesu Habtu Aweke Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0311944.r006

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