Real-world clinical practice of Diabetic Foot Ulcer prevention and care in Singapore: A qualitative inquiry with healthcare professionals

Anita Pienkowska; Josip Car; James Best; Choon Huat Gerald Koh; Lorainne Tudor Car; Kavita Venkataraman; Bernhard O. Boehm; Huiling Liew; Elaine Tan; Harvinder R.S. Sidhu; Tavintharan Subramaniam; Rosalind Siah Chiew Jiat; Naren K. Surendra; Kelley Fann Ing Goh; Nandika Lodh; Andy Hau Yan Ho

doi:10.1371/journal.pone.0328637

Peer Review History

Original SubmissionApril 7, 2025
5 May 2025 Decision Letter - Fredirick mashili, Editor Dear Dr. Ho, Please revise the manuscript addressing all the comments from the two reviewers The manuscript requires a minor revision Remember to adhere to all formatting and styling requirements accordingly. 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 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, Fredirick Lazaro mashili, MD, 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. Thank you for stating the following in the Acknowledgments Section of your manuscript: “This research is supported by the Singapore Ministry of Health’s National Medical Research Council under the Health Services Research Grant (HSRG-DB17Nov002).“ We note that you have provided funding information that is currently declared in your Funding Statement. However, funding information should not appear in the Acknowledgments section or other areas of your manuscript. We will only publish funding information present in the Funding Statement section of the online submission form. Please remove any funding-related text from the manuscript and let us know how you would like to update your Funding Statement. Currently, your Funding Statement reads as follows: “This study was funded by the Singapore Ministry of Health’s National Medical Research Council under the Health Services Research Grant (HSRG-DB17Nov002), awarded to JC and AHYH. The funder nad no role in the study design, data collection and analysis.” Please include your amended statements within your cover letter; we will change the online submission form on your behalf. 3. In the online submission form, you indicated that [Deidentified interview data are available on request. Researchers who wish to obtain further details may contact the corresponding author with a methodologically sound proposal.]. 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. 4. Please amend your manuscript to include your abstract after the title page. 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. 6. 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. Additional Editor Comments: Please revise and address all the comments from both the reviewers. [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 Reviewer #2: Yes ******** 2. Has the statistical analysis been performed appropriately and rigorously? -->?> Reviewer #1: Yes Reviewer #2: Yes ****** 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 ****** 4. Is the manuscript presented in an intelligible fashion and written in standard English??> Reviewer #1: Yes Reviewer #2: Yes ****** Reviewer #1: Abstract: Well written, though a need to indicate on study design, further while you elaborated how you collected a brief indication of how participants were recruited, how you attained saturation and how transcription was done might improve the flow. Introduction Oky, as it has provide justification for the study Methodology Study design well written and justified Add a brief rationale for selecting the specific healthcare clusters also consider clarifying how they data collector agreed upon saturation. Additionally, as qualitative research rely on physical cues and expressions and you conducted interviews via zoom how were you able to capture these important aspect of the study Results Well written with a good flow of ideas Expand just slightly on findings related to footwear education, what does it signify as most participant didn't mention it Discussion Okey. Though consider shortening slightly; some arguments (e.g., role delineation) are repeated. while noting out repeated screening having significant implication in the effectiveness of quality of care for both caregivers and patients you can enhance it by linking it with specific data from result as it points out a major weakness in service provision (fragment care) Conclusion, Its aligns with findings and discussion. But you also add actionable recommendations for guideline makers and policy makers General comment The paper is well written and significant in improving clinical practice specifically on the field of diabetic foot ulcer thus recommended for submission after comments being addressed Reviewer #2: The results are presented in a structured and logically organized way, using categories that reflect the study’s framework — namely clinical guideline components. The findings are rich, well contextualized, and supported by participant quotes. However, I encourage the authors to refine their theme labels to reflect analytical insight, not just descriptive domains (suggestions, “Assessment: consistency and limitations in screening practice”, patient education: high value but varied depth, guidelines: selective application and gaps in utility”). Also, to more explicitly demonstrate how the framework guided the structure and interpretation of findings (Suggestion: In results or methods, briefly mention how each theme maps onto the clinical guideline components (e.g., ACE, IWGDF)—this helps anchor the analysis in the stated framework method). Additional participant quotations in later sections, particularly “Wound Care,” would strengthen the balance across themes (Suggestion: Add one or two direct quotes in wound care and referral sections — particularly where the discussion includes logistics, cost, or health systems barriers. ****** 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: Yes: Fredirick mashili ******** [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 https://doi.org/10.1371/journal.pone.0328637.r001
Revision 1
13 Jun 2025 Author Response Dear Reviewers, Thank you for considering our manuscript and for taking the time to review it. Please find below answers to the review comments. Thank you for inviting us to revise the manuscript for your further consideration. Response to 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 =>We appreciate your feedback. ________________________________________ 2. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: Yes Reviewer #2: Yes =>We appreciate your feedback. ________________________________________ 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 =>We appreciate your feedback. ________________________________________ 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 =>We appreciate your feedback. ________________________________________ 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: Abstract: Well written, though a need to indicate on study design, further while you elaborated how you collected a brief indication of how participants were recruited, how you attained saturation and how transcription was done might improve the flow. =>Thank you for highlighting the need to improve the abstract’s flow. We have revised it to include clearer information on the study design, sampling and transcription process. "A qualitative study design involving focus group discussions was used to explore practices in the prevention and treatment of DFUs. Verbatim transcripts from eight discussions involving 19 HCPs, purposively sampled, were analyzed using the framework method. Coding was guided by a DFU model of care developed from international and local clinical guidelines. Introduction" Oky, as it has provide justification for the study =>Thank you for your kind and encouraging review. Methodology Study design well written and justified Add a brief rationale for selecting the specific healthcare clusters also consider clarifying how they data collector agreed upon saturation. Additionally, as qualitative research rely on physical cues and expressions and you conducted interviews via zoom how were you able to capture these important aspect of the study =>Thank you for this helpful comment. We have added a brief rationale for the selection of specific healthcare clusters "Participant recruitment was conducted at five major public hospitals and medical clinics in Singapore covering two out of three healthcare clusters. The initial study design included all three clusters to capture a broad spectrum of service settings and ensure diverse perspectives on DFU prevention and treatment. However, one cluster opted not to participate further due to differing institutional policies related to data sharing considerations for a connected sub-project." and further clarified how data saturation was determined. "Preliminary analysis of the verbatim transcripts was conducted during the data collection phase. Preliminary analysis of the verbatim transcripts was conducted concurrently with data collection. JC and AHYH engaged in iterative discussions and based on emerging patterns and recurring themes jointly concluded that data saturation had been reached after 19 participants were interviewed." =>Regarding the use of Zoom for focus group discussions, we acknowledge that non-verbal cues can significantly enrich qualitative data. While non-verbal cues were not systematically recorded for analysis, the interviewers were attentive to participants’ expressions and reactions during the sessions and responded accordingly in real time. Given the nature of our research, which centers on clinical practices rather than emotional or behavioral nuances, we believe that the absence of formal non-verbal analysis does not significantly affect the robustness of our findings. Results Well written with a good flow of ideas Expand just slightly on findings related to footwear education, what does it signify as most participant didn't mention it =>Thank you for your helpful suggestion and supportive comments. Regarding the findings on foot care education, we have expanded the section to include the number of participants who mentioned each topic, to illustrate the distribution of focus across different areas. We also clarified the statement concerning guideline-recommended topics that were not mentioned and discussed possible reasons for their omission. "Footcare education provided by the study participants primarily focused on topics such as footwear (9/19 participants), including shoe shape and size or the use of socks; general diabetes education (8/19); wounds (8/19); inspection (4/19); hygiene (3/19); nails (3/19); and moisturizing (2/19). However, several specific recommendations outlined in clinical guidelines—such as inspecting shoes before wearing them, ensuring sole flexibility, using breathable materials, adjustable fastenings, or low heels—were not mentioned. This may suggest that these elements are either not perceived as immediately relevant in the context of this patient population or that there is a need to enhance the communication of guideline-based recommendations. Notably, we observed inconsistent recommendations about CrocsTM, alternating between endorsing and advising against their use." Discussion Okey. Though consider shortening slightly; some arguments (e.g., role delineation) are repeated. while noting out repeated screening having significant implication in the effectiveness of quality of care for both caregivers and patients you can enhance it by linking it with specific data from result as it points out a major weakness in service provision (fragment care) =>Thank you for your careful review. We have adjusted the flow of the discussion section to minimize repetitions. Conclusion, Its aligns with findings and discussion. But you also add actionable recommendations for guideline makers and policy makers =>We appreciate your supportive review. General comment The paper is well written and significant in improving clinical practice specifically on the field of diabetic foot ulcer thus recommended for submission after comments being addressed =>Thank you for your supportive review. All comments have been addressed. Reviewer #2: The results are presented in a structured and logically organized way, using categories that reflect the study’s framework — namely clinical guideline components. The findings are rich, well contextualized, and supported by participant quotes. However, I encourage the authors to refine their theme labels to reflect analytical insight, not just descriptive domains (suggestions, “Assessment: consistency and limitations in screening practice”, patient education: high value but varied depth, guidelines: selective application and gaps in utility”). Also, to more explicitly demonstrate how the framework guided the structure and interpretation of findings (Suggestion: In results or methods, briefly mention how each theme maps onto the clinical guideline components (e.g., ACE, IWGDF)—this helps anchor the analysis in the stated framework method). Additional participant quotations in later sections, particularly “Wound Care,” would strengthen the balance across themes (Suggestion: Add one or two direct quotes in wound care and referral sections — particularly where the discussion includes logistics, cost, or health systems barriers. =>We appreciate your supportive review and are grateful for your insightful and helpful comments. The subheadings in the findings section have been revised to reflect analytical insights rather than merely descriptive content. For the sections on assessment, patient education, and guidelines, we adopted your insightful suggestions: Assessment: consistency and limitations in screening practice, Patient education: high value but varied depth, and Guidelines: selective application and gaps in utility. For the remaining sections, we used the following titles: Referrals: interprofessional care amid systemic pressures and Wound care: combining therapeutic strategies and medical procedures. Thank you for suggesting that we explicitly demonstrate how the framework guided the structure and interpretation of our findings. We have expanded the description of the model’s development and clarified how the data informed and shaped the final codebook. "The research team (NKS and AP) developed a high-level model of care, outlining essential components visualized in Fig 1. Key guidelines such as ACE (10), IWGDF (6-8), and Diabetic Foot Ulcer Care in the Asia-Pacific region International Consensus Document (9) were iteratively analyzed to glean recurring and emphasized elements of DFU prevention and care. We began with iteratively drafting a decision flow diagram representing patient journey through different healthcare professionals, based on outcomes from various assessment, investigations and treatment strategies criteria (e.g. presence or absence of an active ulcer) drawn from the guidelines. To enhance clarity and simplify the diagram, we examined the main sections of each guideline to identify priority areas. The ACE guideline emphasizes foot assessment (including active DFU presentation, risk stratification, other contributing factors, and referrals) and patient education. The IWGDF guidelines cover pathophysiology, prevention, assessment and treatment, active Charcot neuro-osteoarthropathy, and organization of care. The Asia-Pacific consensus document highlights assessment, investigations, infection management, clinical treatment, and strategies for improving outcomes, such as multidisciplinary care, patient-centered approaches, self-care, telemedicine, and caregiver involvement. Based on this synthesis, we grouped the previously mapped steps into three interdependent domains—assessment, referral, and specialist care—with patient education as a cross-cutting element. […] The high-level model of care (Fig. 1) guided our iterative coding process. Insights from the FGD transcripts influenced its structure, resulting in a codebook which organizes data on “specialist care” under two categories: wound care and guidelines and offers more nuanced codes for patient education and referrals – the diverse information provided by participants impacted the granularity of codes for educational formats and topics, as well as additional codes for organizing care. In addition, we created a distinct category for guideline use and wound care practices across specialties (Fig. 2) to capture the declared adherence to clinical guidelines and the range of therapeutic and treatment strategies." 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. Yes Regards, Prof. Andy Ho Anita Pienkowska Attachments Attachment Submitted filename: 20250604_Response to Reviewers-updated.pdf https://doi.org/10.1371/journal.pone.0328637.r002
4 Jul 2025 Decision Letter - Fredirick mashili, Editor Real-world clinical practice of Diabetic Foot Ulcer prevention and care in Singapore: A qualitative inquiry with healthcare professionals PONE-D-25-17596R1 Dear Dr. Ho, 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, Fredirick Lazaro mashili, MD, PhD Academic Editor PLOS ONE Additional Editor Comments (optional): All the previous comments and concerns have been sufficietly addressed 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: Yes ****** 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: The study has been well written and add up t the body of knowledge linking up knowledge and practices through a well narrated design. Thus, i would offer t for publication Reviewer #2: The authors have sufficiently addressed all the previous comments raised. This manuscript can now be accepted for publication ****** 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: Yes: Fredirick mashili ******** https://doi.org/10.1371/journal.pone.0328637.r003
Formally Accepted
Acceptance Letter - Fredirick mashili, Editor PONE-D-25-17596R1 PLOS ONE Dear Dr. Ho, 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 You will receive further instructions from the production team, including instructions on how to review your proof when it is ready. Please keep in mind that we are working through a large volume of accepted articles, so please give us a few days 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. You will receive an invoice from PLOS for your publication fee after your manuscript has reached the completed accept phase. If you receive an email requesting payment before acceptance or for any other service, this may be a phishing scheme. Learn how to identify phishing emails and protect your accounts at https://explore.plos.org/phishing. 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 Dr. Fredirick Lazaro mashili Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0328637.r004

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 .