Dear Dr. Keita,

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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We look forward to receiving your revised manuscript.

Kind regards,

Jordan Llego, PhD ELM, D. Hon. Ex., PhDN, RN

Academic Editor

PLOS ONE

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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?

Reviewer #1: Partly

Reviewer #2: Yes

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

Reviewer #1: N/A

Reviewer #2: No

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3. Have the authors made all data underlying the findings in their manuscript fully available??>

The PLOS Data policy

Reviewer #1: Yes

Reviewer #2: Yes

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4. Is the manuscript presented in an intelligible fashion and written in standard English??>

Reviewer #1: Yes

Reviewer #2: Yes

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Reviewer #1: Thank you for submitting your manuscript. The manuscript "Quality of Life in Older Immigrant Adults on Hemodialysis" explores an important and under-researched area, namely the quality of life of older immigrant adults living with stage 5 Chronic Kidney Disease (CKD) on hemodialysis. Overall, the manuscript presents a clear and thoughtful analysis of the experiences of this population. Below are my detailed comments and suggestions for improvement:

Sample Size Justification (p. 19): The authors state that 10-12 participants were anticipated, but no clear rationale for this sample size is provided. A more explicit explanation of how the sample size was determined based on the study's information power would strengthen the manuscript.

Data Availability (p. 28): The manuscript indicates that the data are available upon request and outlines privacy concerns that might restrict full public availability. While the authors make an effort to ensure data privacy, it would be helpful to include additional details about where the data can be accessed (e.g., whether it will be available in a public repository once ethical and privacy concerns are addressed). A more comprehensive data-sharing plan could further align the manuscript with open data policies and increase its transparency and reproducibility.

Discussion of Cultural Practices and Health (p. 23): The authors could provide a clearer exploration of the intersection between QoL and cultural practices, especially regarding specific cultural rituals like Ramadan fasting. A deeper dive into the complexities of balancing religious and health needs would provide a more nuanced understanding of this population.

Health and Illness Perceptions (p. 17): The section on "health and illness perceptions" would benefit from further elaboration. It would be valuable to expand this section by offering insights into how participants' perceptions of CKD and dialysis treatment align with their cultural beliefs. This would enhance the cultural competence of healthcare interventions suggested by the study.

Use of Direct Participant Quotes (p. 32): Some participants' direct quotations would enrich the narrative and provide deeper insights into the lived experiences of participants. For example, a participant’s emotional response is mentioned, but the accompanying quote is too generalized. A more detailed participant quote could better illustrate how emotional responses differ among participants.

Clinical Implications of Findings (p. 50): The manuscript could expand on how the findings can be applied to clinical practice. While the authors touch on recommendations for culturally competent care, providing specific, actionable suggestions for healthcare providers could make the study more practical for healthcare policy development.

Reviewer #2: The analyzed study aims to describe the sensations and perceptions of elderly immigrants with stage 5 chronic kidney disease undergoing hemodialysis, as well as the direct impact of this treatment on their quality of life, considering factors such as family and social support, independence, cultural and religious practices, and other aspects of daily living. The topic is highly relevant and timely, especially in contributing to the development of culturally sensitive clinical practices and care strategies within the healthcare system.

The results section is particularly strong and well-developed, with a clear presentation and effective discussion of the findings in line with the research objectives. However, the manuscript as a whole would benefit greatly from structural and formatting revisions to ensure compliance with the journal’s publication standards and to improve the clarity and coherence of the text.

Formatting and Structure:

It is recommended that the authors consult the journal’s submission guidelines in detail. While it is evident that the manuscript is derived from a doctoral dissertation, its current format deviates significantly from the journal's editorial requirements. Specifically:

The journal allows a maximum of three levels of headings, while the manuscript contains four chapters, each with an average of 4 to 11 sub-sections;

Continuous line numbering must be applied throughout the manuscript;

References should follow the Vancouver style and be numbered according to their order of appearance in the text;

The acknowledgments section should include only individuals who contributed to the work without meeting authorship criteria, along with a description of their specific roles.

Abstract:

The abstract lacks clarity and fails to present essential elements such as a concise description of the methodology and key findings. A revision is necessary to improve the informativeness and structure of this section.

Keywords:

Of the five keywords provided, three are not indexed in the MeSH database. The use of standardized descriptors is important for indexing and should be revised accordingly.

Chapters 1 and 2 – Introduction and Literature Review:

The sections provide relevant background information that supports the research rationale. However, there is a noticeable degree of repetition, which affects the flow and clarity of the text. A more concise and focused revision is recommended.

Chapter 3 – Method:

This section includes theoretical definitions (e.g., dependability, credibility, transferability, and confirmability) that might be better positioned in the theoretical framework or discussion. Additionally, some content is repeated—such as the definition of the sample, which appears both under “Sampling and Recruitment” (p. 21) and “Ethical Statement” (p. 29). The tables, while functional, are overly simplistic and could be better developed to enhance the depth and quality of the analysis.

The manuscript addresses an important topic and demonstrates potential for publication. However, substantial revisions are necessary to meet the journal’s formatting standards and to improve the structure, clarity, and consistency of the content. I encourage the authors to revise the manuscript thoroughly, and carefully review the content throughout the manuscript, avoiding unnecessary repetition of information.

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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

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Quality of Life in Older Immigrant Adults on Hemodialysis

PONE-D-25-14166R1

Dear Dr. Keita,

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.

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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,

Jordan Llego, PhD ELM, D. Hon. Ex., PhDN, RN

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Thank you for submitting your revised manuscript to PLOS ONE. We appreciate the time and effort you dedicated to addressing the reviewers' comments and strengthening the overall quality of your manuscript.

After careful review of your revised submission and the comprehensive responses to reviewer feedback, we are pleased to inform you that your manuscript has been accepted for publication in PLOS ONE.

We commend you on conducting a study of significant cultural and clinical relevance. Your work makes a valuable contribution to the growing body of literature that addresses health disparities and promotes holistic, patient-centered care for immigrant populations living with chronic illness.

Our production team will now proceed with preparing your manuscript for publication. You may be contacted for final proofs and typesetting.

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

Reviewer #1: All comments have been addressed

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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: N/A

**********

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

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Reviewer #1: Thank you for your careful and thoughtful revision of the manuscript. The revised version shows significant improvements across multiple dimensions:

Sample Size Justification: You have adequately explained your rationale using the concept of “information power,” which is appropriate for qualitative inquiry. This strengthens the methodological transparency of your work.

Data Availability: Your update to the Data Availability Statement—indicating that data will be deposited in a public repository, subject to ethical restrictions—is consistent with PLOS ONE’s data policy and commendable in addressing participant privacy.

Thematic Depth and Cultural Context: The expanded discussion on cultural health practices (e.g., Ramadan fasting) and illness perceptions now offers greater contextual insight into the lived experiences of older immigrant adults on hemodialysis. This enriches the cultural and clinical relevance of your findings.

Use of Participant Quotations: The inclusion of detailed and representative participant narratives adds credibility and emotional resonance to the themes, elevating the quality of the qualitative analysis.

Clinical Implications: The revised discussion provides practical, actionable recommendations for culturally competent care, enhancing the impact of the research for healthcare providers and policymakers.

Formatting and Clarity: Structural improvements, standard English, appropriate referencing, and adherence to submission guidelines have further improved the readability and professionalism of the manuscript.

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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

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