Predictive factors for limited health literacy among persons with cirrhosis: A Swedish explorative cross-sectional study

Maria Hjorth; Anna Forsberg

doi:10.1371/journal.pone.0321780

Peer Review History

Original SubmissionNovember 28, 2024
28 Nov 2024 Author Response https://doi.org/10.1371/journal.pone.0321780.r001
23 Jan 2025 Decision Letter - Isabelle Chemin, Editor Dear Dr. Hjorth, 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. 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, Isabelle Chemin, 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. In the online submission form, you indicated that [Data are available from Region Dalarna upon reasonable request (e-mail: forsknings.utlamnande@regiondalarna.se) provided that the data can be made available in accordance with applicable data protection and privacy regulations.]. All PLOS journals now require all data underlying the findings described in their manuscript to be freely available to other researchers, either 1. In a public repository, 2. Within the manuscript itself, or 3. Uploaded as supplementary information. This policy applies to all data except where public deposition would breach compliance with the protocol approved by your research ethics board. If your data cannot be made publicly available for ethical or legal reasons (e.g., public availability would compromise patient privacy), please explain your reasons on resubmission and your exemption request will be escalated for approval. [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? Reviewer #1: Yes ******** 2. Has the statistical analysis been performed appropriately and rigorously? -->?> Reviewer #1: Yes ****** 3. Have the authors made all data underlying the findings in their manuscript fully available??> The PLOS Data policy Reviewer #1: Yes ****** 4. Is the manuscript presented in an intelligible fashion and written in standard English??> Reviewer #1: Yes ****** Reviewer #1: The authors are commended for conducting the first study of health literacy in a Swedish cirrhosis population. Health literacy is not adequately studied in patients with cirrhosis. In order for the manuscript to be strengthened the following need to be addressed. 1. It is unclear if the patients were counseled by their hepatologists during the recruitment phase of the study spread over 24 months, introducing a bias in the assessment of HL. 2. The inclusion and exclusion criteria need to clearly stated. 3. The methods particularly the Royal Free Hospital – Nutritional Prioritizing Tool (RFH-NPT) section need to be revised for clarity. A correlation between the Royal Free Hospital – Nutritional Prioritizing Tool (RFH-NPT), and HL is not linear, multiple confounders may impact the association, and needs to be justified. 4. Additionally, 70% higher risk of limited health literacy was exhibited in patients with covert hepatic encephalopathy, indicating a significant gap in the management of hepatic encephalopathy despite their symptoms. 5. It will be interesting to know if the same pattern pf limited HL was shown by patients with other GI disease. ****** 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: Satish Chandrasekhar Nair ******** [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.0321780.r002
Revision 1
5 Feb 2025 Author Response We thank you and the Editor and Reviewer for constructive comments on our manuscript, which have helped us to improve the text. In addition to the received comments, we have clarified that our analysis concerned previous events of hepatic encephalopathy and not presence of hepatic encephalopathy as we previously stated in the manuscript (page 9, row 162). We have reviewed all comments and suggestions thoroughly. Below we address them point by point. According to the instructions, the revised manuscript is uploaded in two examples 'Revised Manuscript with Track Changes' and ‘Manuscript’, without tracked changes. In line with the made changes, the supporting information have been revised, please see Appendix S1 and S2. We hope you will find our revisions satisfactory. Kind regards, The Authors Editor: - Thank you for the suggestion for deposit a laboratory protocol. This manuscript thus refers to clinical patient data and do not include any laboratory data. Therefore we find this recommendation not applicable. Reviewer: Comment 1. We have added information about each participant regular hepatology consultations, which started at the time of cirrhosis diagnosis (page 5, row 94 to page 6, row 96). This study had a cross sectional design, collecting data at one single time point per patient, we therefore deem the risk of bias due to hepatology consultations being limited. Reviewer: Comment 2. Inclusion and exclusion criteria have been clarified with predefined comorbidities that resulted in exclusion. The information have been summarized in a new added table (Table 1), which is placed in the paragraph ‘Participant and setting’. Accordingly the text in the paragraph has been revised. Please see page 5, row 91 to page 6, row 106. Due to the new added table, the number for the following tables in the manuscript have been revised (Page 10, row 184; page 10, row 190; and page 11, row 198) Reviewer: Comment 3. After consideration we have decided to exclude RFH-NPT form the analysis. Consequently, we agree there is a high risk for confounders for this factor. This change has resulted in the following adjustment in the manuscript: • The paragraph that described the RFH-NPT has been removed from the data collection section (page 8, rows 143-151). • Risk for malnutrition has been removed from the statistical analysis section (page 9, rows 163-164). • Risk ratio and confidence intervals for the second generalized logistic regression model have been adjusted in line with the new analysis (page 11, row 196 and Table 4). • The new analysis revealed a 54 % higher risk for limited health literacy following covert hepatic encephalopathy, instead of previously reported 70 %, (page 11, row 204). • Reference 28 has been removed, which is visible in the manuscript without track changes. Reviewer: Comment 4. We agree that there is a gap in the management of hepatic encephalopathy. Without systematic screening for hepatic encephalopathy, the symptom may not be identified, which is one of our important reported findings in this study. We have revised the text to clarify the problematic situation without screening routines for hepatic encephalopathy (page 12, row 206-207). Reviewer: Comment 5. According to Kaps et al 2022 (Reference 12). Health literacy in patients with cirrhosis is reported to be lower than for patients with gastrointestinal cancer or inflammatory bowel disease. In line with this comment, we have elaborated the text for clarification. Please, see page 13, rows 234-236. Attachments Attachment Submitted filename: Response letter_Hjorth and Forsberg.docx https://doi.org/10.1371/journal.pone.0321780.r003
11 Mar 2025 Decision Letter - Isabelle Chemin, Editor Predictive factors for limited health literacy among persons with cirrhosis: A Swedish explorative cross-sectional study PONE-D-24-54410R1 Dear Dr. Hjorth, 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, Isabelle Chemin, PhD Academic Editor PLOS ONE Additional Editor Comments (optional): Reviewers' comments: Reviewer's Responses to Questions Comments to the Author Reviewer #1: All comments have been addressed ******** 2. Is the manuscript technically sound, and do the data support the conclusions??> 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 Reviewer #1: Yes ****** 5. Is the manuscript presented in an intelligible fashion and written in standard English??> Reviewer #1: Yes ****** Reviewer #1: The manuscript is significantly strengthened The queries have been successfully addressed. No further concerns. ****** 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: Satish Chandrasekhar Nair ******** https://doi.org/10.1371/journal.pone.0321780.r004
Formally Accepted
Acceptance Letter - Isabelle Chemin, Editor PONE-D-24-54410R1 PLOS ONE Dear Dr. Hjorth, 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 Mrs Isabelle Chemin Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0321780.r005

Open letter on the publication of peer review reports

PLOS recognizes the benefits of transparency in the peer review process. Therefore, we enable the publication of all of the content of peer review and author responses alongside final, published articles. Reviewers remain anonymous, unless they choose to reveal their names.

We encourage other journals to join us in this initiative. We hope that our action inspires the community, including researchers, research funders, and research institutions, to recognize the benefits of published peer review reports for all parts of the research system.

Learn more at ASAPbio .