Dear Dr. Nepal,

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Veincent Christian Pepito

Academic Editor

PLOS ONE

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Additional Editor Comments:

Dear authors,

Thank you very much for taking on the burden of doing implementation research for leprosy in Nepal. The paper is good in theory but needs to be revised so it is more faithful to the title. Please see my comments below:

1. The paper talks about implementation fidelity but does not bother comparing and contrasting with country clinical practice guidelines or leprosy control program operations manual or WHO best practices for leprosy. How are you able to conclude that there was implementation fidelity (or there was none)? Please consider adapting the methodology used here where we compared what the facilities found with what is the recommended practice by our ministry of health and the World Health Organization: https://actamedicaphilippina.upm.edu.ph/index.php/acta/article/view/409

2. What is the theoretical framework used in analyzing the study? How were the themes generated and what is the basis for presenting these themes?

3. What is the reflexivity and positionality of the authors as they did this study? Please add this to the manuscript.

4. While you are discussing adherence to protocols, can you also discuss treatment extension, fidellity of healthcare providers in keeping with treatment guidelines, and its effect on patient adherence to medication?

https://www.cell.com/heliyon/fulltext/S2405-8440(21)01382-7

5. Discussing self-care for leprosy is good but I think there is a need to be cautious about what self-care practices are good and what self-care practices are bad:

https://academic.oup.com/heapol/article/38/2/205/6798855?login=false

https://www.emerald.com/insight/content/doi/10.1108/ijhg-01-2023-0008/full/html

6. While it was done in passing, can you please give a more detailed description of Nepal's healthcare system and the provision of leprosy services to familiarize the international reader about the paper? Specifically, please mention how long is the travel time from you to referral hospitals and other context to fully appreciate the issues that you have discussed, or if you are from an urban area or a rural area?

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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: Yes

Reviewer #2: N/A

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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: Implementation fidelity in leprosy care and support for disability prevention and

management in Rupandehi, Nepal: A qualitative study

<abstract>

Background

Your background section emphasizes the importance of implementation fidelity but lacks a clear rationale for studying it in the context of leprosy care in Nepal. To strengthen the justification, briefly explain why exploring implementation fidelity is crucial for improving leprosy care in Nepal. Also, a shorthand definition to implantation fidelity, could be beneficial to the readers unfamiliar to the topic.

Methodology

Your methodology section effectively outlines a numerous qualitative methods used, but specifying the number of participants would enhance clarity. Also, if applicable, please rearrange your sentences in the sequences the event takes place. For example, if sampling design is conducted prior to data collection. Also, mention the timeline the study was conducted.

Although ‘thematic data analysis’ is a used frequently, I think the correct term for qualitative research method is ‘thematic analysis.’

Results & Conclusions

As per author guidelines, you are discouraged to use abbreviation in the abstract. Please revise accordingly.

After reading your results and conclusions section in the abstract, I would like to suggest that you should consider revising the title of your study. Is your study specific to the role of healthcare providers in leprosy prevention and management or is it about overall implementation fidelity in leprosy care?

Please ensure the consistency of ‘tense’ in your sentences.

Overall

Please refer to the PLOS ONE author guidelines. Your abstract is at least 23 words above the permitted word limit. Your abstract is comparatively well-written in the introduction and methods section, while you may consider tightening your sentences in the results and conclusions sections, particularly focusing to reduce redundancy. Otherwise, this is a good abstract.

Introduction

First paragraph

Please cite a source that listed 22 prioritized countries on leprosy. As Nepal does not locate under Southeast Asia, replacing the regional prevalence of Southeast Asia to South Asia would be helpful. If this dataset is not available, you may cite the prevalence in neighboring and some South Asian countries. The sociocultural context of Southeast Asia may not closely resemble that in South Asia. Also, please quantify to what extent the cases of leprosy was reduced during the COVID-19 pandemic. Then, what’s the post-pandemic status of leprosy reporting?

Second paragraph

Please begin with presenting leprosy as a significant health problem in the history of Nepal, and then what the current status is. While you present the facts and figures, please make it comprehensible for the readers. For example, first clarify if leprosy is a disability? Disability and disease are different constructs. Then, explain the meaning of MDT. How severe are cases of leprosy of Grade 2 Disability and how is it different than other Grades?

It is evident that since 2010 leprosy was not a significant health problem at national level. However, how was/is the burden of leprosy in Rupandehi, Nepal? If this is not at a significant level, what is the significance of this study? Or, was/is the prevalence of leprosy in the study area underestimated? If yes, for what factors?

Third paragraph

Explain what health post in Nepal is. Is it the lowest level of healthcare access to Nepali populations?

<suggestion> In the second paragraph, it is better for readers to explicitly specify how many times the data was collected or what months the data was collected. The current version needs to be clarified regarding when the enrolment started.

Overall

The introduction section has important information but lacks proper flow and some important background information. For example, it lacks regional nation vs region-specific information on leprosy. Adding a context of history of leprosy in Nepal and connecting it to the current status of leprosy can be helpful. Also, socio-cultural environment of Nepal has interplayed an important role on leprosy care and management, which was lacking. To streamline the flow, I suggest you consider revising your introduction as below:

- Present leprosy as a significant public health problem in Nepal’s history, and how why studying leprosy care and management is still important in the current context in spite of its lower prevalence?

- Discuss leprosy care and management from the light of socio-cultural context in Nepal and specific to your study area.

- Discuss how leprosy care is available and what are the major barriers to its prevention and treatment.

- Provide a strong rationale why your study is important given the current scenario of leprosy in the study area. How does your study in a local context be useful to the national level and what are its relevance to the global society? Mentioning that leprosy care and support implementation fidelity is discussed only in grey literature does not provide a strong rationale for your study. Contextualize it in a more robust way.

- One major limitation in the introduction was the unclear delivery of what the term ‘implementation fidelity’ is. If you think that your study is more about ‘implementation fidelity,’ you will need to clarify this jargon to the readers and centralize your introduction under this term.

Methods

Ethics statement

Please use proper punctuation. For example, reference no should follow with ‘:’ rather than ‘;’. You don’t need to abbreviate any term you have not used more than three times in your manuscript. Also, explicitly specify which health office in Rupandehi did you seek consent from? Is it the provincial health office, or any ministry or something else? Did you provide a copy of informed consent to the participants? And, did you receive consent before recording the interview? Were there any renumeration or benefits provided to the participants in exchange for their time and contribution to your research? Was proxy permitted? As you have integrated several data collection methods, were the approaches to ethical considerations similar or different to each specific method?

Study setting

Provide a citation to justify your statement that Rupandehi is one the of the leprosy-endemic districts of Nepal. When you specify the borders, be explicit to differentiate the national versus international borders. It might also be insightful to consider inserting map depicting the study area. While you have specified 1.2/10,000 prevalence, there are two important pieces of information missing: a) to be considered a rate, you need a time variable; prevalence and prevalence rates are two different ideas in epidemiology; and b) which year is this prevalence of?

Also the following sentences – The government of Nepal (GON) …………milestones of NLEP is not relevant under this subheading.

Study design and participant selection

I believe you do not require this subheading.

Study design

Correct the case from title to sentence case and be consistent throughout your manuscript.

Please simplify when you explain your study design – qualitative implementation research methodology using a multi-source, multimethod case study design – is very vague. Rather specify the exact approach of qualitative research you implemented, such as case study design, grounded theory, narrative study or something else. Please elaborate the method you used for data collection.

Participant selection

No comments.

Table 1

Please add a table note specifying the standard used for leprosy categorization. Interestingly, 100% of cases are multi-bacillary. Are all cases of leprosy Multi-Bacillary in Nepal or in the study area? If not, why did you lack variability in your study?

Study tool and data collection

Please detail out if your tools were designed in English or Nepali language? How did you confirm the validity of the translation? You have mentioned that the tools were pre-tested but did not detail out how and when? Please add these details and describe what changes were made following the pre-test? Did you utilize any software for transcribing the script?

Data analysis

Please cite the software. Also, explain whether you used Nepali or English (if translated) version for the data analysis. Specify what specific methods were used for focused group vs. KII vs. observation. If all of them were analyzed using same approach, explicitly mention it.

Results

Adherence to leprosy protocols and guidelines

Interestingly, no detail of what standard protocol (national/international/WHO) used to treat leprosy was provided. Any thoughts?

Also, it was mentioned that the skin smear test was not possible due to the unavailability of a lab technician. Elaborating this in discussion could be insightful. Does this mean that these local health units in Nepal have necessary pre-requisites, but only lack the specific experts?

Follow-up and monitoring of case registration

Please integrate some points on how leprosy registration in Nepal is performed and whether or not there is a practice of universal or centralized record for leprosy in Nepal.

The only significant comment I have for results section is it’s a bit lengthy. Try to shorten it.

Discussion

Good start, particularly the first paragraph.

My suggestion is that the cases during COVID-19 are different to those in normal period. So, exclude discussing COVID-19 as your study was conducted in 2024, unless you specifically want to discuss a section on leprosy care management during the pandemic. Similarly, avoid having references relevant to the COVID-19 period accordingly as the scenario would be very different in COVID-19 period.

Discussions are well-detailed out. However, it would be more relevant to discuss your points referencing literature relevant to countries, preferably South Asia,, with similar healthcare and sociocultural systems. Integrate some major constructs, such as age, urban/rural differentials may also play important factor in diagnosis and treatment to leprosy. Also, integrate some important policy measure improvements.

References

Please refer to the author guidelines to format your references in an appropriate way.

Please be very specific when you have headings, subheadings in your study. Follow author guidelines to correctly represent the cases and levels of headings/sub-headings.

Overall

Leprosy has traditionally been an important public health concern in Nepal, particularly in rural context. This study needs a revised title; otherwise, the study represents an important work, reflecting the gaps in diagnosing and treating leprosy in Nepal. Methodology is appropriate with different methods to cross-validate the information obtained. The introduction can be framed better with suggested improvements, while results and discussion sections seem too lengthy and need tightening.</suggestion></abstract>

Reviewer #2: Very well written paper. No obvious comments to add. Just to make clarification in the manuscript- the basic procedures like VMT/ST and skin smear tests are not performed in government health facilities in Nepal. This makes diagnosis of leprosy delayed. This can be accepted for publication.

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Reviewer #1: No

Reviewer #2: No

**********

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Dear Dr. Nepal,

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 Jul 12 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.

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• 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'.
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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.

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,

Veincent Christian Pepito

Academic Editor

PLOS ONE

Additional Editor Comments:

Dear Author, thank you very much for your revision. Both reviewers have recommended acceptance, but I still have some issues with the paper. Kindly address this so we can move soon to acceptance and publication:

1. Tables 1 and 2, which are respondent profiles, can be transferred to the supplementary appendix. A brief description of who they are, referencing the supplementary appendix, would be sufficient.

2. The reflexivity statement should be rewritten and improved. Reflexivity statement is not just about reflection or critical assessment of biases, etc. It is more about how your backgrounds, beliefs and experiences played a part in the interpretation and development of themes and subthemes. There are many good reflexivity statements from previously published papers; please pattern your statement from it. I want to know what your backgrounds and experiences are and how these have affected the analyses and the generation of themes.

3. I want Supplementary Tables 1 and 2 to be put into the main paper and replace Table 3 as it stands now. I want the comparisons to the guidelines be more explicit in the presentation of Results, similar to the Acta Medica Philippina paper I sent to you in the previous round. You are talking about implementation fidelity so what is done should be compared to what is ideal or in the guidelines. I am fine with the framework used; it just needs to be more harmonized and streamlined. Like, for theme 1 healthcare provider's adherence to leprosy services. There should be a comparison to what is in the guidelines, then how reality is different or similar to it. As it stands, you are only presenting what is currently being done, which does not tell us anything about implementation fidelity.

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

Reviewer #1: All comments have been addressed

Reviewer #2: All comments have been addressed

**********

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

Reviewer #1: Yes

Reviewer #2: Yes

**********

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

Reviewer #1: Yes

Reviewer #2: N/A

**********

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

The PLOS Data policy

Reviewer #1: Yes

Reviewer #2: Yes

**********

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

Reviewer #1: Yes

Reviewer #2: Yes

**********

Reviewer #1: Thank you for addressing and incoporating my feedback. I hope my comments have helped to enhance the quality of your work.

Reviewer #2: I want to confirm that this paper has been well written and can be accepted for publication. NO further comments from me.

**********

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.

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Reviewer #1: No

Reviewer #2: No

**********

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Implementation fidelity in leprosy care and support for disability prevention and management in Rupandehi, Nepal: A qualitative study

PONE-D-25-09075R2

Dear Dr. Nepal,

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,

Veincent Christian Pepito

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments: