PONE-D-24-17598Predictors of internalised stigma among people with mental illness attending a psychiatry outpatient clinicPLOS ONE

Dear Dr. Getinet,

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.

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ACADEMIC EDITOR: The manuscript contains important finding regarding the internalized stigma. However, please revise some comments raised by the reviewers giving more focus to the ethical issues, validity of the tools and editorial components. Please submit your revised manuscript by Dec 19 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.

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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.

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We look forward to receiving your revised manuscript.

Kind regards,

Yadeta Alemayehu

Academic Editor

PLOS ONE

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2. Please describe in your methods section how capacity to provide consent was determined for the participants in this study. Please also state whether your ethics committee or IRB approved this consent procedure. If you did not assess capacity to consent please briefly outline why this was not necessary in this case.

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4. 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 If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references.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 If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

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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

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

Reviewer #1: Yes

Reviewer #2: Yes

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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

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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

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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: Predictors of internalised stigma among people with mental illness attending a psychiatry outpatient clinic

Overall, the manuscript provides valuable insights into the relationship between metacognitive beliefs, mood symptoms, and fatigue in stroke survivors. It is generally well-written and organized, with a clear introduction providing context for the study. However, addressing the recommendations would enhance the clarity, robustness, and applicability of the findings.

General recommendation:

1. The study's cross-sectional design limits its ability to establish causal relationships. The manuscript acknowledges this limitation, but it would be beneficial to explicitly discuss the implications of this design choice on the interpretation of results and suggest avenues for future longitudinal research.

More specific recommendation:

Introduction

The introduction provides a thorough overview of the stigma associated with mental illness, distinguishing between internalized and perceived stigma. It effectively highlights the public health significance of stigma and the need for research in low and middle-income countries, especially Ethiopia. The literature review is comprehensive, addressing various factors contributing to stigma and noting the global relevance. However, it could benefit from a more in-depth discussion of cultural differences in stigma experiences and the rationale for choosing Ethiopia as the study site.

Methods

The methods section is well-detailed, covering the study design, sampling, and data collection procedures. The use of standardized tools, such as the ISMI-9 for measuring stigma, adds rigor to the study. However, the inclusion of more information about the training provided to data collectors and steps to minimize bias would strengthen the methodological transparency. Additionally, while the sample size calculation is justified, a discussion of potential limitations related to excluding severely impaired individuals could provide a more balanced view.

• The title of “Tools used for data collection” should be renamed to “measurement”

Results

The results are presented clearly, with appropriate use of statistical analysis to identify significant predictors of internalized stigma. The prevalence data and associations with factors like education level, suicidal ideation, and substance use are reported effectively. However, some sections could be enhanced with visual aids, such as charts or graphs, to better illustrate the relationships among variables. Additionally, discussing the clinical implications of the findings, especially for healthcare providers in Ethiopia, would add practical value.

Discussion

The discussion section successfully interprets the results in the context of existing literature, noting consistencies and differences with previous studies. It provides plausible explanations for the observed associations and acknowledges cultural factors that may influence internalized stigma. However, the discussion could be enriched by addressing the implications for policy and service development, particularly regarding mental health education and support systems. The limitations are acknowledged, but a deeper exploration of potential confounding variables would strengthen this section.

Conclusion

The conclusion effectively summarizes the key findings and reinforces the need for anti-stigma efforts in Ethiopia. It provides clear recommendations, such as early outpatient support and drug adherence interventions, but could be further strengthened by suggesting specific anti-stigma strategies tailored to the Ethiopian cultural context. Additionally, highlighting areas for future research, such as longitudinal studies to explore causality, would offer a more forward-looking perspective.

Reviewer #2: the authors did not obtain prior informed consent from the participants or their legal guardians before including them in the study. This omission violates the essential principles of ethical research involving human subjects and cannot be overlooked

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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

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Attachments

Attachment

Submitted filename: PONE-D-24-17598_comments.docx

PONE-D-24-17598R1Predictors of Internalised Stigma Among People with Mental Illness Attending a Psychiatry Outpatient Clinic in Ethiopia: Institution Based Cross Sectional study.PLOS ONE

Dear Dr. Getinet,

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: After a careful review was undertaken by reviewers, I finally recommend you revise the document, focusing on the issues raised by the reviewers.

Please submit your revised manuscript by Mar 17 2025 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,

Yadeta Alemayehu

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.

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

Reviewer #2: (No Response)

Reviewer #3: (No Response)

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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

Reviewer #2: Yes

Reviewer #3: Yes

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

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

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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

Reviewer #3: Yes

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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: No

Reviewer #2: (No Response)

Reviewer #3: Yes

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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: Appreciate to the author for incorporating all the revisions based on the reviewer's comments and providing explanations for each change. The revised manuscript demonstrates improved design and writing, with a clear and cohesive introduction and discussion section. Overall, the revised manuscript meets the criteria for acceptance.

Reviewer #2: (No Response)

Reviewer #3: In the statistical analysis, it is better to add units of measurement on Age.

My additional comments are;

Regarding ethical standard as the study involves human subjects, it is better to provide ethical statement.

And on submission guidelines, the abstract should be within the limited range, it shouldn't beyond 300 words.

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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

Reviewer #3: Yes:  MY name is Ziyad Towfik Abdella

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[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.

Predictors of Internalised Stigma Among People with Mental Illness Attending a Psychiatry Outpatient Clinic in Ethiopia: Institution Based Cross Sectional study.

PONE-D-24-17598R2

Dear Dr. Wondale,

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.

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Kind regards,

Yadeta Alemayehu

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments: